Showing papers in "Ultraschall in Der Medizin in 2017"

EFSUMB Guidelines and Recommendations on the Clinical Use of Liver Ultrasound Elastography, Update 2017 (Long Version)

Abstract: We present here the first update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography with a focus on the assessment of diffuse liver disease. The short version provides clinical information about the practical use of elastography equipment and interpretation of results in the assessment of diffuse liver disease and analyzes the main findings based on published studies, stressing the evidence from meta-analyses. The role of elastography in different etiologies of liver disease and in several clinical scenarios is also discussed. All of the recommendations are judged with regard to their evidence-based strength according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence. This updated document is intended to act as a reference and to provide a practical guide for both beginners and advanced clinical users.

Contrast Enhanced Ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS®): the official version by the American College of Radiology (ACR).

Abstract: Author(s): Kono, Yuko; Lyshchik, Andrej; Cosgrove, David; Dietrich, Christoph F; Jang, Hyun-Jung; Kim, Tae Kyoung; Piscaglia, Fabio; Willmann, Juergen K; Wilson, Stephanie R; Santillan, Cynthia; Kambadakone, Avinash; Mitchell, Donald; Vezeridis, Alexander; Sirlin, Claude B

Modified Lung Ultrasound Score for Assessing and Monitoring Pulmonary Aeration.

Abstract: Purpose Lung Ultrasound Score (LUSS) is a useful tool for lung aeration assessment but presents two theoretical limitations. First, standard LUSS is based on longitudinal scan and detection of number/coalescence of B lines. In the longitudinal scan pleura visualization is limited by intercostal space width. Moreover, coalescence of B lines to define severe loss of aeration is not suitable for non-homogeneous lung pathologies where focal coalescence is possible. We therefore compared longitudinal vs. transversal scan and also cLUSS (standard coalescence-based LUSS) vs. qLUSS (quantitative LUSS based on % of involved pleura). Materials and methods 38 ICU patients were examined in 12 thoracic areas in longitudinal and transversal scan. B lines (number, coalescence), subpleural consolidations (SP), pleural length and pleural involvement (> or ≤ 50 %) were assessed. cLUSS and qLUSS were computed in longitudinal and transversal scan. Results Transversal scan visualized wider (3.9 [IQR 3.8 – 3.9] vs 2.0 [1.6 – 2.5] cm, p 50 % was observed in 17 % and coalescence in 33 % of cases. Focal coalescence accounted for 52 % of cases of coalescence. qLUSS-transv generated a different distribution of aeration scores compared to cLUSS-long (p Conclusion In unselected ICU patients, variability of pleural length in longitudinal scans is high and focal coalescence is frequent. Transversal scan and quantification of pleural involvement are simple measures to overcome these limitations of LUSS.

EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound - Part 1: Examination Techniques and Normal Findings (Long version).

Abstract: In October 2014 the European Federation of Societies for Ultrasound in Medicine and Biology formed a Gastrointestinal Ultrasound (GIUS) task force group to promote the use of GIUS in a clinical setting. One of the main objectives of the task force group was to develop clinical recommendations and guidelines for the use of GIUS under the auspices of EFSUMB. The first part, gives an overview of the examination techniques for GIUS recommended by experts in the field. It also presents the current evidence for the interpretation of normal sonoanatomical and physiological features as examined with different ultrasound modalities.

American College of Radiology Contrast Enhanced Ultrasound Liver Imaging Reporting and Data System (CEUS LI-RADS) for the diagnosis of Hepatocellular Carcinoma: a pictorial essay.

Abstract: Author(s): Piscaglia, Fabio; Wilson, Stephanie R; Lyshchik, Andrej; Cosgrove, David; Dietrich, Christoph F; Jang, Hyun-Jung; Kim, Tae Kyoung; Salvatore, Veronica; Willmann, Juergen Karl; Sirlin, Claude B; Kono, Yuko

EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound.

Abstract: In October 2014 the European Federation of Societies for Ultrasound in Medicine and Biology formed a Gastrointestinal Ultrasound (GIUS) task force group to promote the use of GIUS in a clinical setting. One of the main objectives of the task force group was to develop clinical recommendations and guidelines for the use of GIUS under the auspices of EFSUMB. The first part, gives an overview of the examination techniques for GIUS recommended by experts in the field. It also presents the current evidence for the interpretation of normal sonoanatomical and physiological features as examined with different ultrasound modalities.

Characterization of Focal Liver Lesions using CEUS and MRI with Liver-Specific Contrast Media: Experience of a Single Radiologic Center.

Abstract: Aim The purpose of this study was to compare contrast-enhanced ultrasound (CEUS), magnetic resonance imaging (MRI) using liver-specific contrast agent and a combination of both for the characterization of focal liver lesions (FLL). Methods 83 patients with both benign and malignant liver lesions were examined using CEUS and MRI after the intravenous administration of liver-specific contrast media. All patients had inconclusive results from prior imaging examinations. Histopathological specimens could be obtained in 53 patients. Ultrasound was performed using a multi-frequency curved probe (1 – 6 MHz) after the injection of 1 – 2.4 ml ultrasound contrast media. The sensitivity, specificity, positive predictive value and negative predictive value of CEUS, MRI and a combination of both (CEUS + MRI) were compared. Results The sensitivity, specificity, positive and negative predictive values regarding lesion classification were 90.9 %, 70.6 %, 92.3 % and 66.6 %, respectively, for CEUS; 90.9 %, 82.4 %, 95.2 % and 70.0 %, respectively, for MRI; and 96.9 %, 70.6 %, 92.7 % and 85.7 % respectively, for CEUS + MRI. There were no statistically significant differences. 6 malignant lesions were missed using CEUS or MRI alone (false negatives). The use of both modalities combined reduced the false-negative results to 2. Conclusion CEUS and MRI with liver-specific contrast media are very reliable and of equal informative value in the characterization of focal liver lesions. The number of false-negative results can be decreased using a combination of the two methods.

Transient Elastography to Assess the Cervical Ripening during Pregnancy: A Preliminary Study.

Abstract: Purpose To explore the feasibility of transient elastography (TE) to quantify cervical stiffness changes during normal pregnancy and its spatial variability. Materials and Methods TE was used to quantify the cervical stiffness in four anatomical regions. 42 women between 17 and 43 years of age and at 6 – 41 weeks of gestation were studied. The stiffness was related to gestational age at the time of examination, interval from ultrasound examination to delivery and cervical length to evaluate the potential of TE to assess cervical ripening. In addition, a sensitivity analysis based on Cronbach’s alpha coefficient was carried out to assess the concordance between inter/intra-operator measurements. Results There were significant correlations between cervical stiffness measured in the four regions with gestational age and the remaining time for delivery. Results confirm stiffness variability within the cervix. No significant association was found between cervical length and stiffness in the four ROIs. Associations between gestational age and remaining time for delivery with cervical length present weaker correlations than with cervical stiffness. The external part of the cervix was significantly softer than the internal one, and these stiffness values vary significantly in the anterior compared to the posterior cervix. The measurements taken by the same and by two different observers for different regions in the cervix were reliable and reproducible. Conclusion It is feasible to objectively quantify the decrease of cervical stiffness correlated to gestational age. Transient elastography is a valuable promising tool to provide additional information on the process of cervical effacement to that obtained from digital examination and conventional ultrasound. Further studies are needed to assess the feasibility of the technique in obstetric clinical applications, such as prediction of preterm birth or success in labor induction.

Percutaneous Treatment of Malignant Liver Lesions: Evaluation of Success Using Contrast- Enhanced Ultrasound (CEUS) and Perfusion Software.

Abstract: Aim Using new perfusion software for evaluation of the success of percutaneous treatments of malignant liver tumors with CEUS. Materials and Methods Retrospective analysis of 88 patients (74 male, 14 female; 30 – 84 years) with 165 malignant liver lesions. The lesions were 57 metastases and 108 HCCs. The success of interventional treatment (IRE n = 47; RFA n = 38; MWA n = 44; TACE n = 36) was evaluated by CEUS and perfusion software (VueBox®). CEUS was performed after injection of 1 – 2.4 ml of sulfur hexafluoride microbubbles (SonoVue®) using a 1 – 5 MHz convex probe. DICOM loops up to 1 min. in the ablation area were stored digitally in the PACS. Regions of interest (ROI) were manually placed in the center, the margins of the lesions as well as in the surrounding tissue. Using VueBox® peak, time to peak (TTP), mean transit time (mTT), rise time (RT), the wash-in and wash-out rate were calculated for the regions, in order to evaluate the success of the percutaneous treatment after the ablation in comparison to the ceCT/ceMRI up to 6 months after the treatment. Results There were significant differences in all cases between the center compared to the margins for the main perfusion parameters (peak, mTT, RT) (p Conclusion A combination of CEUS with perfusion imaging enables critical assessment of successful treatment after percutaneous interventional procedures for a malignant liver lesion.

Transperineal Ultrasound for Perianal Fistulas and Abscesses - A Systematic Review and Meta-Analysis.

Abstract: Purpose Transperineal ultrasound (TPUS) is a practical tool for assessing perianal inflammatory lesions. We systematically review its accuracy for detecting and classifying perianal fistulae and abscesses. Method The National Library of Medicine and Embase were searched for articles on TPUS for the assessment of idiopathic and Crohn’s perianal fistulae and abscesses. Two reviewers independently reviewed eligible studies and rated them for quality using the QUADAS tool. The primary outcome measure was the accuracy of TPUS as measured by its sensitivity and positive predictive value (PPV) in detecting and classifying perianal fistulae, internal openings and perianal abscesses. Results We included 12 studies (565 patients). Overall, the methodological quality of the studies was suboptimal. 3 studies were retrospective and 4 showed significant risks of bias in the application of the reference standard. The sensitivity of TPUS in detecting perianal fistulae on a per-lesion basis was 98 % (95 % CI 96 – 100 %) and the PPV was 95 % (95 % CI 90 – 98 %). The detection of internal openings had a sensitivity of 91 % (95 % CI 84 – 97 %) with a PPV of 87 % (95 % CI 76 – 95 %). The classification of fistulae yielded a sensitivity of 92 % (95 % CI 85 – 97 %) and a PPV of 92 % (95 % CI 83 – 98 %). TPUS had a sensitivity of 86 % (95 % CI 67 – 99 %) and PPV of 90 % (95 % CI 76 – 99 %) in the detection of perianal abscesses. Conclusion The current literature on TPUS illustrates good overall accuracy in the assessment of perianal fistulae and abscesses. However, many studies had methodological flaws suggesting that further research is required.

Prediction of Pathological Complete Response to Neoadjuvant Chemotherapy for Primary Breast Cancer Comparing Interim Ultrasound, Shear Wave Elastography and MRI.

Abstract: Background Prediction of pathological complete response (pCR) of primary breast cancer to neoadjuvant chemotherapy (NACT) may influence planned surgical approaches in the breast and axilla. The aim of this project is to assess the value of interim shear wave elastography (SWE), ultrasound (US) and magnetic resonance imaging (MRI) after 3 cycles in predicting pCR. Methods 64 patients receiving NACT had baseline and interim US, SWE and MRI examinations. The mean lesion stiffness at SWE, US and MRI diameter was measured at both time points. We compared four parameters with pCR status: a) Interim mean stiffness ≤ or > 50 kPa; b) Percentage stiffness reduction; c) Percentage US diameter reduction and d) Interim MRI response using RECIST criteria. The Chi square test was used to assess significance. Results Interim stiffness of ≤ or > 50 kPa gave the best prediction of pCR with pCR seen in 10 of 14 (71 %) cancers with an interim stiffness of ≤ 50 kPa, compared to 7 of 50 (14 %) of cancers with an interim stiffness of > 50 kPa, (p 30 % (sensitivity 50 % and specificity 79 %, p = 0.03) and % reduction in US diameter (sensitivity 47 %, specificity 81 %, p = 0.03). Similar results were obtained from ROC analysis. Conclusion SWE stiffness of breast cancers after 3 cycles of NACT and changes in stiffness from baseline are strongly associated with pCR after 6 cycles.

Biopsy of Liver Target Lesions under Contrast-Enhanced Ultrasound Guidance - A Multi-Center Study.

Abstract: Purpose To retrospectively characterize the prevalence and impact of contrast-enhanced ultrasound (CEUS) as a guidance technique for the biopsy of liver target lesions (LTLs) at six interventional ultrasound centers. Materials and Methods The six participating centers retrospectively selected all patients in whom biopsy needles were positioned in LTLs during CEUS. The prevalence of CEUS-guided biopsies at each center between 2005 and 2016, contrast agent consumption, procedure indications, diagnostic yield and complications were assessed. Informed consent was obtained for all patients. Results CEUS-guided biopsy of LTLs was carried out in 103 patients (68 M/35 F, median age: 69 yrs) with 103 liver target lesions (median size: 20 mm) using cutting needles (18 – 20 g) in 94 cases (91.2 %). CEUS-guided biopsy represented 2.6 % (range: 0.8 – 7.7 %) of 3818 biopsies on LTLs carried out at the participating centers. Indications to CEUS-guided biopsy were: a target lesion not visible on non-enhanced US (27.2 %), improvement of conspicuity of the target (33 %), choice of non-necrotic area inside the target (39.8 %). 26 patients (25.2 %) had a previously non-diagnostic cyto-histological exam. The diagnostic accuracy of the technique was 99 %. No major complications followed infusion of contrast agent or biopsy performance. Conclusion The indications for CEUS-guided biopsy for LTLs are limited, but CEUS can be useful in challenging clinical scenarios, e. g. poorly visualized or invisible lesions or sampling of non-necrotic areas in the target lesions. There is also a potential advantage in using CEUS to guide repeat biopsies after unsuccessful sampling performed using the standard ultrasound technique.

Erratum: EFSUMB Guidelines and Recommendations on the Clinical Use of Liver Ultrasound Elastography, Update 2017 (Long Version) : (Ultraschall in der Medizin (Stuttgart, Germany : 1980) (2017) 38 4 (e16-e47))

Abstract: This is to clarify that in the published EFSUMB Guidelines and Recommendations on the Clinical Use of Liver Ultrasound Elastography, Update 2017 (Long Version) in Figure 1 (“The types of elastography described in this paper”) the availability of Easaote SpA point shear wave technology (pSWE) was not mentioned. Herewith we present the corrected figure.

Ultrasound of the Major Salivary Glands is a Reliable Imaging Technique in Patients with Clinically Suspected Primary Sjögren's Syndrome.

Abstract: Objective To assess the inter- and intraobserver reliability of ultrasound of major salivary glands in patients clinically suspected of having primary Sjogren’s syndrome (pSS) as well as to assess sources of variation in outcomes of ultrasonographic evaluation. Methods 80 consecutive outpatients with clinically suspected pSS underwent ultrasound evaluation. The following ultrasound variables of the parotid and submandibular salivary glands were assessed: echogenicity, parenchymal homogeneity, presence of hypoechogenic areas, hyperechogenic reflections and clearness of posterior glandular border, according to the scoring system of Hocevar et al. (total score range: 0 – 48). Images were scored independently by three blinded observers in two sessions. Results The intraobserver reliability of the total ultrasound score was excellent, with an intraclass correlation (ICC) ranging from 0.89 to 0.96. The interobserver reliability was good to excellent, with ICCs of 0.84 and 0.76 for the total ultrasound score in the two sessions. The kappa value ranged from 0.60 to 0.83 depending on the applied cut-offs (cut-off score ≥ 15 and ≥ 17). Hypoechogenic areas and homogeneity of parotid glands showed the highest interobserver reliability. The median kappa for echogenicity was low. The total ultrasound scores varied more between observers in patients with higher ultrasonographic scores (approximately scores ≥ 20). Conclusion Ultrasound of major salivary glands is a reliable imaging technique for patients with clinically suspected pSS. Discrepancies between observers in assessing the severity of ultrasound findings may interfere with detecting ‘true’ changes over time. When monitoring the progression of pSS or treatment efficacy, it is advised that a particular patient be scored by the same ultrasonographer at every time point.

Prenatal Diagnosis of Agenesis of Ductus Venosus: A Retrospective Study of Anatomic Variants, Associated Anomalies and Impact on Postnatal Outcome.

Abstract: Purpose To assess the anatomic variants, associated anomalies and postnatal outcome of fetuses with a prenatally diagnosed agenesis of ductus venosus (ADV). Materials and Methods Retrospective study of 119 cases with agenesis of ductus venosus diagnosed by prenatal ultrasound in two tertiary referral centers from 2006 to 2014. The type and location of the umbilical venous drainage site was noted. Charts were reviewed for associated structural or chromosomal anomalies, pregnancy outcome and postnatal course. Results In 24 cases (20.2 %) ADV was an isolated finding, while 95 cases (79.8 %) had associated anomalies. We identified 84 cases (70.6 %) with intrahepatic and 35 cases (29.4 %) with extrahepatic drainage of the umbilical vein. 58.8 % of neonates were alive at follow-up. There was no statistical association between drainage site and associated anomalies or outcome. Postnatal outcome was determined by the presence and severity of associated anomalies. There was no adverse outcome in the isolated group related to ADV. Overall, there were 6 persistent portosystemic shunts, 3 of them with a spontaneous closure, and one total agenesis of the portal venous system with lethal outcome. Conclusion Postnatal outcome in cases with ADV mainly depends on the presence of associated anomalies. In isolated cases the prognosis is generally good, but neonates with a prenatally diagnosed portosystemic shunt should be followed until its occlusion. Portal venous system agenesis is rare but should be ruled out on prenatal ultrasound.

Diagnosis of Hepatocellular Carcinoma with Non-Invasive Imaging: a Plea for Worldwide Adoption of Standard and Precise Terminology for Describing Enhancement Criteria

Abstract: Hepatocellular carcinoma in cirrhosis is unique in oncology since a definitive diagnosis based on non-invasive imaging can be used without biopsy confirmation to determine even the most radical therapies such as liver transplantation. Given the enormous responsbility assigned to non-invasive imaging in guiding HCCmanagement one would expect that there would be standardized terminology in use throughout the world for describing the diagnostic imaging criteria. Surprisingly, this is not the case. Different guidelines have adopted different terminology for assessing the temporal enhancement characteristics of HCC. The adoption of different terminology by different guidelines, even if intended to have similar meaning, contributes to inconsistency in clinical care, causes confusion in research, and is a barrier to progress in the field. It is time to standardize the terminology for describing temporal enhancement criteria, which will be suggested at the end of the present editorial in line with recently published relevant documents in this field. A summary of the current guidelines and of the variance of the terminology is useful to understand the potential causes of variability and misunderstandings. Guidelines released by the AASLD in 2005 [1] recognized the need to incorporate imaging features from both the arterial phase and the subsequent venous/delayed phase. This was done to help avoid false-positive diagnosis of perfusion disturbances caused by arterioportal shunting which also can manifest with hyperenhancement in the arterial phase. The criteria for the diagnosis of HCC was a lesion showing “arterial hypervascularity that washes out in the early or delayed venous phase” [1]. The update of these guidelines in 2011 adopted the wording of “intense arterial uptake followed by wash out in the venous-delayed phases” [2]. Although the AASLD guidelines should be lauded for recognizing the importance of “washout”, the terminology advocated by the AASLD is suboptimal. The term “hypervascularity” is ambiguous as it encompasses multiple different pathophysiological alterations – including number and size of vessels, type of vessels, quality of their walls (fenestrated or not fenestrated sinusoids, capillarization), degree of vascular tone, etc. – most of which cannot be assessed reliably by imaging. A descriptive term would be more appropriate. In this sense, the usage of “intense arterial uptake” in the 2011 update is an improvement [2], but remains suboptimal for several reasons. In a liver with only arterial inflow and no portal perfusion (e. g. a patient with reversal of portal flow due to portal hypertension or TIPS), any part of the liver, including benign parenchyma, has intense arterial “uptake”. Moreover, no cancer and no part of the liver, literally takes up contrast agents in the arterial phase. Even contrast agents that eventually are transported into liver cells via membrane transporters do not enter cells in any meaningful concentration during the arteial phase. Thus the wording, “intense arterial uptake”, is pathophysiolgicaly incorrect and cannot be considered appropriate. The EASL 2012 guidelines [3] as well as the Spanish guidelines [4] utilized similar imperfect terminology as the AASLD guidelines Fabio Piscaglia Masatoshi Kudo Kwang-Hyub Han Claude Sirlin Editorial

Authors' Reply to Letter: Role of Contrast-Enhanced Ultrasound (CEUS) in Paediatric Practice: An EFSUMB Position Statement

Abstract: We thank the author for the interest in recent statement on use of contrast-enhanced ultrasound (CEUS) in the paediatric population [1], and note the number of concerns raised. The author makes numerous valid points with regards to the use of CEUS in the paediatric patient and highlights, quite correctly, the large number of limitations of CEUS.We believe the point of the position statement has been “missed”; CEUS will not replace CT and MR imaging but should be seen as an additional, problem solving or alternative child friendly diagnostic tool that is safe and easily repeatable in a clinical setting. The authors do not claim to be able to considerably reduce CT and MR imaging in clinical practice but advocate that there is potential for reduction with the use of CEUS. There will always be the need for CT and MR imaging, but very often, and this is true both in the adult and paediatric population, physicians and radiologists are all too eager to “press-the-button” to invoke the use of more expensive and often harmful imaging prior to exhausting the potential of the least harmful imaging modality, i. e. ultrasound. Of course assessment for staging of malignant disease will need CT imaging, but is CT imaging really needed when an incidental focal lesion is present on a baseline ultrasound [2]? Is CT follow-up really necessary when there is an isolated spleen injury following blunt abdominal trauma [3]? The ability to characterise a liver lesion immediately and accurately reduces parent anxiety particularly when the likelihood of malignancy is low. No doubt the addition of CEUS to an ultrasound examination requires valuable physician or radiologist time, but reduces potential patient morbidity considerably; the patient, in this case the child, is paying for the idleness of the physician or radiologist. It is far too easy to “order” a CT or MR examination, and report remotely at physician or radiologist convenience. Our statement is designed to encourage the paediatric imaging community to move forward and embrace this technique for the benefit of their clients, and highlights areas to consider where CEUS usefulness may be further explored. It is important to appreciate that the statement follows the introduction of SonoVueTM/LumasonTM (Bracco, SpA, Milan) for liver application in the paediatric population in the United States of America, licenced for use by the Food and Drug Administration (FDA) following approval without any prior conducted dedicated clinical trial. The reason for this is undoubtedly the need to reduce the medical radiation burden carried by the American child, carried into adulthood increasing the risk of later life cancer, based on real data [4]. The actuality of a CEUS examination is that licencing was restricted to adults (until recent FDA approval) for intravenous use, and then only to the heart, liver, breast and peripheral vessels. This has not hampered the adult physician and radiologist from dutifully exploring many other areas, and generally establishing the potency of CEUS in the diagnosis and management of many disease processes with numerous publications in the literature, summarised in EFSUMB guidelines [5]. Without this pioneering work by numerous practitioners in Europe the current status of CEUS would not be acknowledged as significant. This is pertinent to the point raised by the author with regards to the statement that conclusions are from a radiological culture based on adults. The many authors of the EFSUMB statement are drawn from a variety of backgrounds, all with extensive experience of CEUS both in adults and children, and many are paediatric practitioners; all driven by their vision of improving imaging care for the child using CEUS.Without the skill and observations of this group and many other unheralded practitioners across Europe, this position statement would not have been possible. The lead needs to be taken by paediatric practitioners, who to date, are unfortunately few in number. We believe the problem lies elsewhere; there is no ideal imaging method for children and any addition that resolves a problem should be welcomed. However, the rigid implementation of CT and MR imaging in many clinical protocols precludes the introduction of CEUS as a problem solving tool. This is clearly highlighted by the author’s statement that the recent guidelines issued by ESGAR/ESPR [6], excludes the use of CEUS in inflammatory bowel disease in children; has this been extensively investigated? The probability is that it has not and without encouragement will never be, driven by vested interests in existing techniques to the detriment of the child. Extensive literature exists in the adult [7] and this should be extended to the child; surely a rapid, safe, cost-effective and child friendly examination is a mandatory requirement in this young population with a potential lifelong disease. We hope this reply as well as the position statement will overcome reactionary attitudes to the more widespread use of CEUS in children and allow for the safe care of all our children.

Contrast-Enhanced Ultrasound in the Follow-Up of Endoleaks after Endovascular Aortic Repair (EVAR)

Abstract: Endovascular aortic repair (EVAR) has become established in the treatment of abdominal aortic aneurysms and shows potential benefits such as a low perioperative morbidity and a short hospitalization duration. The follow-up after EVAR primarily consists of lifelong postinterventional imaging of the aneurysm size in order to detect complications such as endoleaks or stent dislocation. Computed tomography angiography, an imaging modality that uses ionizing radiation and that relies on a contrast medium which is dependent on thyroid and renal function, is widely used for follow-up. Meanwhile, contrast-enhanced ultrasound (CEUS) has been established as a viable, fast and cost-effective imaging alternative for the follow-up and the detection of endoleaks after EVAR with the additional benefit of being a real-time non-ionizing radiation examination and having comparable or even superior diagnostic performance. This review describes the use of CEUS for follow-up after EVAR and describes the most common pathologies. Die endovaskulare Aortenreparatur (EVAR) hat sich in der Versorgung von abdominellen Aortenaneurysma etabliert und zeigt als Vorteile eine niedrige perioperative Morbiditat und Mortalitat sowie kurzere Zeiten des Krankenhausaufenthaltes. Im Follow-up sind regelmasige, letztlich lebenslange Kontrolluntersuchungen mittels Bildgebung erforderlich, um die Grose des Aneurysmasacks im Verlauf zu uberwachen und zudem postinterventionelle Komplikationen wie Endoleaks oder Stentgraft-Migration und -Bruche zu detektieren. Weit verbreitetet zeigt sich die kontrastmittelverstarkte Computertomografie-Angiografie (CT-A) als Bildgebung nach EVAR, diese Methode beinhaltet jedoch die Anwendung von ionisierender Strahlung und jodhaltigem Kontrastmittel, welches abhangig von Nierenfunktion und Schilddrusenstoffwechsellage nicht uneingeschrankt genutzt werden kann. Zwischenzeitlich hat sich der Kontrastverstarkte Ultraschall (CEUS) als leistungsfahige und kosteneffektive Schnittbildgebungsalternative fur Follow-up-Untersuchungen nach EVAR etabliert mit den Vorteilen einer dynamischen Untersuchung und ohne Risiko fur eine Nierenfunktionseinschrankung oder Strahlenbelastung. Hierbei zeigt sich der kontrastverstarkte Ultraschall ebenburtig in der Detektionsrate und der Charakterisierung von Endoleaks im Vergleich zur CT-A. In diesem Review geben wir eine Ubersicht uber die Anwendung von CEUS in Rahmen des Follow-up nach EVAR und erlautern die Detektion und Charakterisierung der wichtigsten Pathologien.

Inter-Rater Reliability of Air/Saline HyCoSy, HyFoSy and HyFoSy Combined With Power Doppler for Screening Tubal Patency.

Abstract: Purpose To estimate the inter-observer reliability and agreement of offline analyses of three different ultrasound techniques for assessing tubal patency. Methods 100 tubes (n = 100) in 50 women were evaluated for tubal patency between November 2013 and July 2015 using ultrasound as index tests and laparoscopy as the reference standard. Three different ultrasound techniques were applied: two-dimensional grayscale ultrasound using air + saline as the contrast media (2D-HyCoSy); two- and three-dimensional grayscale ultrasound using foam as the contrast media (2 D/3D-HyFoSy); and the same technique but adding bi-directional power Doppler (2 D/3D-Doppler-HyFoSy). The videos containing full standardized exams using these three techniques were split into three parts, anonymized, encoded, randomized and reassessed in Nov. 2015 by two observers who assessed tubal patency using standardized criteria. These observers were blinded to any clinical information and each other’s results. Proportions of observed agreement (po) and Cohen's Kappa (κ) including the 95 % confidence intervals (CI) were calculated. Results The inter-observer reliability/agreement in 2 D/3D-Doppler-HyFoSy (po = 0.99, κ = 0.95, 95 % CI: 0.93 – 0.97) was higher compared to 2D-air/saline-HyCoSy (po = 0.83, κ = 0.55, 95 % CI: 0.40 – 0.68) and 2 D/3D-HyFoSy (po = 0.92, κ = 0.67, 95 % CI: 0.54 – 0.76). Conclusion The inter-observer reliability and agreement of the diagnosis of tubal patency evaluating stored videos are improved when foam and power Doppler are used during acquisition. Therefore, this technique may be preferred to minimize misclassification and misdiagnosis.

Simple Rules, Not So Simple: The Use of International Ovarian Tumor Analysis (IOTA) Terminology and Simple Rules in Inexperienced Hands in a Prospective Multicenter Cohort Study.

Abstract: Objectives To analyze how well untrained examiners – without experience in the use of International Ovarian Tumor Analysis (IOTA) terminology or simple ultrasound-based rules (simple rules) – are able to apply IOTA terminology and simple rules and to assess the level of agreement between non-experts and an expert. Methods This prospective multicenter cohort study enrolled women with ovarian masses. Ultrasound was performed by non-expert examiners and an expert. Ultrasound features were recorded using IOTA nomenclature, and used for classifying the mass by simple rules. Interobserver agreement was evaluated with Fleiss’ kappa and percentage agreement between observers. Results 50 consecutive women were included. We observed 46 discrepancies in the description of ovarian masses when non-experts utilized IOTA terminology. Tumor type was misclassified often (n = 22), resulting in poor interobserver agreement between the non-experts and the expert (kappa = 0.39, 95 %-CI 0.244 – 0.529, percentage of agreement = 52.0 %). Misinterpretation of simple rules by non-experts was observed 57 times, resulting in an erroneous diagnosis in 15 patients (30 %). The agreement for classifying the mass as benign, malignant or inconclusive by simple rules was only moderate between the non-experts and the expert (kappa = 0.50, 95 %-CI 0.300 – 0.704, percentage of agreement = 70.0 %). The level of agreement for all 10 simple rules features varied greatly (kappa index range: -0.08 – 0.74, percentage of agreement 66 – 94 %). Conclusion Although simple rules are useful to distinguish benign from malignant adnexal masses, they are not that simple for untrained examiners. Training with both IOTA terminology and simple rules is necessary before simple rules can be introduced into guidelines and daily clinical practice.

Cost-Effectiveness of Mobile App-Guided Training in Extended Focused Assessment with Sonography for Trauma (eFAST): A Randomized Trial.

Abstract: Purpose Ultrasound training is associated with a long learning curve and use of substantial faculty resources. Self-directed ultrasound training may decrease the need for faculty-led teaching. Mobile apps seem promising for use in self-directed ultrasound training, but no studies have examined the cost-effectiveness of mobile app-guided training versus traditional formats such as textbook-guided training. This study evaluated the cost-effectiveness of mobile app-guided versus textbook-guided ultrasound training. Material and methods First-year residents (n = 38) with no previous ultrasound experience were randomized into mobile app-guided versus textbook-guided self-directed ultrasound training groups. Participants completed a transfer test involving four patient cases and a theoretical test on diagnostic accuracy. Two ultrasound experts assessed the residents’ performance using the Objective Structured Assessment of Ultrasound Skills (OSAUS) scale. The costs of developing mobile app and textbook material were calculated and used for the analysis of cost-effectiveness. Results 34 participants completed the transfer test. There was no statistically significant difference in test performance or diagnostic accuracy between the mobile app-guided (mean-OSAUS 42.3 % [95 %CI38.5 – 46.0 %]) and textbook-guided groups (mean-OSAUS 45.3 % [95 %CI39.3 – 51.3 %]) (d.f. [1.33] = 0.45, p = 0.41). However, development costs differed greatly for each instructional format. Textbook-guided training was significantly more cost-effective than mobile app-guided training (Incremental Cost Effectiveness Ratio -861 967 [95 %CI-1071.7 to-3.2] USD/pct. point change in OSAUS score). Conclusion Mobile app-guided ultrasound training is less cost-effective than textbook-guided self-directed training. This study underlines the need for careful evaluation of cost-effectiveness when introducing technological innovations for clinical skills training.

Short-Time Impact of Laser Ablation of Placental Anastomoses on Myocardial Function in Monochorionic Twins with Twin-to-Twin Transfusion Syndrome.

Abstract: Purpose To evaluate pre- and post-procedure myocardial function in monochorionic twins with TTTS who underwent laser ablation of placental anastomoses using pulsed wave tissue Doppler imaging (pw TDI) Materials and Methods 20 monochorionic twin gestations with TTTS were included and underwent laser ablation at our center between 2011 and 2014 Prior to and after the intervention, cardiac function was assessed by measuring the mitral annular plane systolic excursion (MAPSE), the tricuspid annular plane systolic excursion (TAPSE), Tei index, isovolumetric contraction time (ICT), ejection time (ET), isovolumetric relaxation time (IRT) for the left ventricle in pulsed wave Doppler (pw D) ultrasound as well as ICT, ET, IRT and Tei index in pw TDI for the left and right ventricle E-, A-, E´- and A´-wave peak velocity and the systolic downward motion (S´) were measured for both ventricles and the E/A, E/E´ and E´/A´ ratios were calculated In a mean of 13 (SD 06) days after laser ablation, this measurement protocol was repeated Results Pre-intervention recipients had longer ICT, ET and IRT in pw D and pw TDI compared to donors not reaching statistical significance for most parameters Statistically significant were prolonged ICT in pw D (p 001) and ET (p 001) in pw TDI in recipients In donor fetuses preoperative myocardial function did not differ significantly from postoperative myocardial function except in increased left ventricular ejection time of the left ventricle in pw TDI (p 004) and an increased E´/A´ratio (p 001) After laser coagulation, myocardial function was slightly altered in recipients as ICT and IRT shortened and Tei indices decreased but only reaching statistical significance in shortened IRTs in pw TDI for both ventricles Conclusion Laser ablation of placental anastomoses in TTTS might influence myocardial function in the postoperative period Shortened IRT intervals may reflect an improvement of diastolic function in recipients

Value of Contrast-Enhanced Ultrasound Quantification Criteria for Identifying Patients not Responding to Bevacizumab-Based Therapy for Colorectal Liver Metastases

Abstract: Purpose To evaluate changes in tumor vascularization parameters based on contrast-enhanced ultrasound (CEUS) quantification criteria of at least one visible liver metastasis as an early predictor of non-response to chemotherapy, including bevacizumab for colorectal cancer (CRC) liver metastases. Materials and Methods This multicenter prospective study included patients who received first-line bevacizumab-based chemotherapy. Tumor enhancement measured using CEUS within one liver metastasis and in relation to the surrounding healthy liver was quantified within 8 days before the first infusion of bevacizumab (E0), 24 hours after the end of the first infusion of bevacizumab (E1), in the 24 hours before the 2nd and 3 rd infusion of bevacizumab on day 15 (E2) and day 30 (E3), respectively, and after 2 months of treatment (E4). Endpoints were tumor response using RECIST criteria at 2 months, progression-free survival (PFS) and overall survival (OS). Results Among the 137 patients included in this study, 109 were analyzed. Only CEUS parameters calculated in relation to healthy liver were significant. High wash-in and wash-out rates at baseline were significantly associated with a better tumor response. Increases over time E2-E0 and E3-E0 for peak enhancement were significantly associated with shorter progression-free survival. Increases over time E2-E0 and E3-E0 for peak enhancement and wash-in area under the curve were significantly associated with a shorter overall survival. Conclusion This large study demonstrated that early dynamic changes in the vascularity of liver metastases evaluated by quantified CEUS are associated with outcome in patients receiving first-line bevacizumab-based treatment for metastatic CRC.

Ultrasound-Guided Corticosteroid Injection in Patients with Carpal Tunnel Syndrome: Efficacy of Intra-Epineurial Injection

Abstract: Purpose To identify the ultrasound (US) findings of intra-epineurial corticosteroid injection during US-guided hydrodissection in patients with carpal tunnel syndrome (CTS), and to determine their clinical relevance in relation to treatment outcomes. Materials and Methods We performed 101 US-guided hydrodissections and corticosteroid injections in 101 patients with CTS, and evaluated their pre- and post-injection US findings. We categorized these injections into two groups based on the occurrence of intra-epineurial injection. We also recorded clinical data including sex, age, side of injection, BMI, and the duration of pre-injection CTS-related discomfort. The outcomes were measured using the Likert satisfaction scale and Boston Carpal Tunnel Questionnaire (BCTQ) scores. The clinical data, cross-sectional area of the median nerve (CSA-MN) at the inlet of the carpal tunnel measured on US images, and the symptom relief for the patients receiving intra-epineurial and extra-epineurial injection were compared. Results The intra-epineurial injection rate was 38.6 % in the 101 US-guided injections. The clinical data, pre-injection CSA-MN at the inlet of the carpal tunnel, and pre-injection BCTQ scores showed no significant intergroup differences (p > 0.05). The group with intra-epineurial injections had significantly decreased CSA-MN (difference in means, 2.5 mm2; p Conclusion We characterized the US findings of intra-epineurial corticosteroid injection during US-guided hydrodissection. Intra-epineurial injection provided a more meaningfully reduction in edema of the MN, greater patient satisfaction, and greater symptom relief than extra-epineurial injection.

Endocardial Fibroelastosis of the Left Ventricle Affects Right Ventricular Performance in Fetuses with Hypoplastic Left Heart Syndrome: A Prospective Study Using M-Mode, PW- and Tissue Doppler Techniques.

Abstract: Purpose Myocardial function (MF) of the systemic right ventricle (RV) influences the postnatal course of neonates with hypoplastic left heart syndrome (HLHS) Our study examines whether the presence of endocardial fibroelastosis of the left ventricle (LV EFE) influences MF of the RV in HLHS fetuses Materials and Methods A prospective study was conducted including 10 controls (group 1), 10 HLHS fetuses with (group 2) and 10 without LV EFE (group 3) – all matched for gestational age M-mode was used to assess tricuspid plane systolic excursion (TAPSE) and the shortening fraction (SF) PW-Doppler-derived and PW-TDI-derived velocities were assessed E/A, E/e', e'/a' ratios and the myocardial performance index (mpi’) were calculated Results The examination of MF revealed significantly lower s’ velocities (p Conclusion These significant differences in MF between the groups might lend support to the notion of negative ventricular-ventricular interaction in the case of HLHS with LV EFE possibly influencing surgical outcomes

The Jellyfish Sign: A New Sonographic Cervical Marker to Predict Maternal Morbidity in Abnormally Invasive Placenta Previa.

Abstract: Purpose To investigate the value of a new cervical sonographic sign, called the jellyfish sign (JS), for predicting the risk of maternal morbidity in cases of abnormally invasive placenta (AIP) previa totalis. Materials and Methods Retrospective evaluation of transvaginal (TV) and transabdominal (TA) scans performed in all singleton pregnancies with placenta previa totalis. JS, i. e. the absence of the normal linear demarcation between the placenta previa and the cervix, was evaluated by TV scans. The presence/severity of AIP and outcomes of maternal morbidity were related to this sign. Results JS was noted in 8/39 (20.5 %) patients. The two analyzed groups, i. e. with and without JS, were similar. The specificity of JS in AIP diagnosis, histological findings of accreta/increta/percreta, need for caesarean hysterectomy or blood loss > 2000 ml ranges between 92 % and 96.2 %, with the PPV and NPV ranging between 71.4 % and 85.7 % and 61.3 % and 80.6 %, respectively. The JS group had a significant increase in blood loss (ml) (p = 0.003), transfusions (%) (p = 0.016), red blood cells (p = 0.002) and plasma (p = 0.002), admission to an postoperative intensive care unit (ICU) (%) (p = 0.002), hospitalization length (p 2000 ml (OR 16.6; 95 % CI 1.5:180.1, p = 0.021) also in a logistic regression model. Conclusion JS is useful in predicting the increase in maternal morbidity: massive transfusion, admission to the ICU and cesarean hysterectomy related to intraoperative bleeding in patients with a previa AIP.