Objective: To evaluate two different dual-energy computed tomography (DECT) post-processing protocols for the detection of MSU deposits in foot tendons of cadavers with verification by polarizing light microscopy as the gold standard. Material and Methods: A total of 40 embalmed cadavers (15 male; 25 female; median age, 82 years; mean, 80 years; range, 52–99; SD ± 10.9) underwent DECT to assess MSU deposits in foot tendons. Two postprocessing DECT protocols with different Hounsfield unit (HU) thresholds, 150/500 (=established) versus 120/500 (=modified). HU were applied to dual source acquisition with 80 kV for tube A and 140 kV for tube B. Six fresh cadavers (4 male; 2 female; median age, 78; mean, 78.5; range 61–95) were examined by DECT. Tendon dissection of 2/6 fresh cadavers with positive DECT 120 and negative DECT 150 studies were used to verify MSU deposits by polarizing light microscopy. Results: The tibialis anterior tendon was found positive in 57.5%/100% (DECT 150/120), the peroneus tendon in 35%/100%, the achilles tendon in 25%/90%, the flexor halluces longus tendon in 10%/100%, and the tibialis posterior tendon in 12.5%/97.5%. DECT 120 resulted in increased tendon MSU deposit detection, when DECT 150 was negative, with an overall agreement between DECT 150 and DECT 120 of 80% (p = 0.013). Polarizing light microscope confirmed MSU deposits detected only by DECT 120 in the tibialis anterior, the achilles, the flexor halluces longus, and the peroneal tendons. Conclusion: The DECT 120 protocol showed a higher sensitivity when compared to DECT 150.

American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations.The AIUM Practice Parameter for the Performance of Duplex Sonography of Native Renal Vessels was revised by the American Institute of Ultrasound in Medicine (AIUM) in collaboration with other organizations whose members use ultrasound for performing this examination(s) (see "Acknowledgments").Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately.This Practice Parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations.The parameters reflect what the AIUM considers the appropriate criteria for this type of ultrasound examination but is not intended to establish a legal standard of care.Examinations performed in this specialty area are expected to follow the Parameter with recognition that deviations may occur depending on the clinical situation. IndicationsIndications for renal duplex sonography include, but are not limited to:

Journal of Ultrasound in MedicineEarly View Practice ParameterFree Access The AIUM Practice Parameter for the Performance of the Extended Focused Assessment With Sonography for Trauma (EFAST) First published: 10 June 2022 https://doi.org/10.1002/jum.16027AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Introduction The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. The AIUM practice parameter for the performance of the extended focused assessment with sonography for trauma (EFAST) was developed and revised by the AIUM in collaboration with other organizations whose members use ultrasound for performing this diagnostic test (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately. This practice parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations. The parameters reflect what the AIUM considers the appropriate criteria for this type of ultrasound examination but are not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the parameter with recognition that deviations may occur depending on the clinical situation. This practice parameter has been developed to provide assistance to practitioners performing EFAST. During the last 3 decades, particularly with its widespread growth in the early 1990s, the FAST included assessments of the peritoneal cavity, and analysis of the pericardial and pleural spaces for hemorrhage. In the early 2000s, the extended FAST (EFAST) added rapid evaluation of the chest for detection of pneumothorax, and this more thorough trauma examination is taught and used in standard practice today. The EFAST is a diagnostic test of information not otherwise obtained by physical examination. The EFAST is a proven and useful diagnostic test for the evaluation of the torso and abdomen after traumatic injury, particularly in the setting of hemodynamic instability. The examination has been shown to be highly specific, with varying sensitivity, in the identification of free intraperitoneal and intrathoracic fluid. Evidence indicates that ultrasound imaging is more sensitive for pneumothorax than supine plain-film chest radiography. It is important to note that the EFAST examination is a screening test, and false-negative examinations may occur, particularly early in the course of management. False-positive examinations for free fluid may also be encountered in patients with a history of ascites, those receiving peritoneal dialysis, and patients with concurrent pleural effusions. Before its development, more invasive procedures were required to evaluate these patients, including diagnostic peritoneal lavage and, at times, laparotomy. In the management of the trauma patient, adherence to the following parameter will maximize the probability of detecting free fluid in the acutely injured patient. The EFAST allows the analysis for possible hemopericardium, hemothorax, pneumothorax, and hemoperitoneum. The portability of ultrasound equipment allows the EFAST to be performed at the patient's bedside or in the rapid triaging of multiple individuals in mass casualty situations, including assessments in the field. Emergency medical services personnel have begun to use EFAST in several areas worldwide for these purposes. The use of ultrasound in a particular institution or setting must be based on access to equipment and appropriately trained or supervised personnel, and should be subject to an organized quality assurance program. Indications Indications for the EFAST primarily evaluate the torso and abdomen for evidence of traumatic injury in the peritoneal, pericardial, and pleural cavities (American College of Emergency Physicians [ACEP] guideline/ACEP Imaging Compendium). There are no absolute contraindications, although if it is clear that the patient requires emergent surgical intervention, then a relative contraindication to performing the test may exist. For example, it still may be necessary to exclude pericardial tamponade or pneumothorax before transferring a patient to the operating room for emergent surgery. Qualifications and Responsibilities of Personnel Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines in accordance with AIUM accreditation policies. Sonographers performing the ultrasound examination should be appropriately credentialed in the specialty area in accordance with AIUM accreditation policies. Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32. The EFAST examination provides information to aid in decision-making regarding further evaluation or testing, clinical management, and therapeutic interventions. Rapid provision and interpretation of such examinations are critical for appropriate patient care. The clinical care of patients in life-threatening situations should always take precedence over these guidelines. Physicians from a variety of medical specialties may perform the EFAST examination. If appropriately trained, advanced practice providers, emergency medical personnel, and sonographers can obtain the ultrasound images. Image interpretation should be performed by a supervising physician. Training of physicians in the diagnostic interpretation of EFAST examinations should be in accordance with specialty-specific guidelines. Physicians who supervise nonphysician sonographers should render a diagnostic interpretation in a time frame consistent with the management of acute trauma. Specification of the Examination The objective of the abdominal portion of the diagnostic study is to analyze the peritoneal cavity for free fluid. This requires examination of the abdomen (right upper and left upper quadrants as well as the pelvis), the pericardium, and if performing an EFAST, the bilateral pleura in the thorax. The ability to denote free fluid in the pelvis is aided by the presence of a fluid-filled bladder. As with all ultrasound examinations, orthogonal images (transverse, longitudinal, and coronal planes) help elucidate areas of concern seen in any single plane, and all areas of interest should be scanned through completely using a fanning motion in each plane. Changes in transducer angle and position can help improve analysis of a given area. Images may be obtained through anterior, lateral, or other approaches to denote free fluid in the evaluated areas. As with most imaging and ultrasound examinations, techniques evolve over time and with increased clinical and imaging experience. More specifically, primary ultrasound windows for the EFAST include the following: The Right Upper Quadrant View (also known as the Perihepatic, Morison Pouch, or Right Flank View)—This uses the liver as an ultrasound window to interrogate the hepatorenal space (Morison Pouch) for free fluid. The transducer is placed in a coronal orientation on the patient's right side with the probe marker pointed toward the patient's head. Slight cephalad movement of the transducer allows imaging of the right pleural space for free fluid. Care should be taken to carefully insonate the area between the dome of the liver and diaphragm to identify subdiaphragmatic free fluid. Caudal probe movement allows visualization of the inferior pole of the right kidney, the caudal liver tip, and right pericolic gutter for free fluid assessment. The transducer should be fanned throughout the anterior and posterior directions to interrogate the entire field. The Left Upper Quadrant View (also known as the Perisplenic or Left Flank View)—This uses the spleen as a window to interrogate the spleen and the perisplenic space above the spleen, below the diaphragm, and the splenorenal recess. The transducer is placed in a coronal orientation on the patient's posterior left side, with the probe marker pointed toward the patient's head. Scanning cephalad allows visualization of the left pleural space. Scanning caudad allows visualization of the inferior pole of the left kidney, the caudal spleen tip, and the left pericolic gutter. Again, the transducer should be fanned throughout the anterior–posterior space to interrogate the entire field. The Pleural Space Views—Each pleural space may be investigated via angulation and cephalad movement of the transducer along the ipsilateral flank. This can be performed in conjunction with the right and left upper quadrant views. Abnormal fluid collections in the pleural space are visualized as anechoic collections above the echogenic diaphragm. Visualization of the thoracic spine (a “spine sign”) also indicates fluid or consolidation in the pleural space. At times, fluid that may be hemorrhagic, proteinaceous, or infectious will appear more echogenic or complex in nature. An upright or slight reverse Trendelenburg position of the patient may assist in the detection of pleural fluid. The Pelvic View (also known as the Retrovesical, and for female patients: Retrouterine, or Pouch of Douglas View)—This allows assessment of the most dependent space in the peritoneum for free fluid. Analysis through a fluid-filled bladder (which can be filled, if necessary, by fluid placed through a Foley catheter or clamping the Foley catheter) may help analysis for pelvic fluid. When free fluid is present, it is noted most often posterior or superior to the bladder and uterus in adults. The bladder should be scanned in its entirety in both the sagittal and transverse planes. The Pericardial View (also known as the Subcostal or Subxiphoid View)—Subxiphoid images can be obtained by placing the transducer on the upper abdomen and pointing superiorly midline or toward the left shoulder using the liver as an acoustic window. Alternative cardiac windows can be additive or may be necessary if an adequate subxiphoid view cannot be obtained in a particular patient. The parasternal long-axis view of the heart is typically the next most common view used; however, other views, including the apical 4-chamber, may be used, as long as the pericardium can be assessed circumferentially. The potential space of the pericardium is analyzed for the presence of any free fluid in anterior or posterior locations. The presence of free fluid prompts assessment for tamponade. The Anterior Thoracic View (Pleural Sliding Views)—The pleura normally oppose each other and slide against each other easily. The separation of the pleura by a pneumothorax and subsequent absence of this sliding may be imaged typically in a supine patient in the second or third intercostal space with a high-frequency transducer, although lower-frequency transducers may also be used. Other intercostal spaces may also be used for lung evaluation. Pleural sliding with reverberation artifacts (A-lines) is present in the normal lung. M-mode imaging may aid in the evaluation of the lung for pneumothorax. The identification of a lung point is highly specific for the diagnosis of pneumothorax and should be sought when time allows. A lung point represents the site where the lung adheres to the parietal pleura immediately adjacent to the pneumothorax. A lung pulse (subtle cardiac pulsation of the parietal pleura at the lung periphery) can differentiate the lack of ventilation, such as in apnea or main stem intubation, from pneumothorax. Additional dedicated views may include the following: The Right and Left Pericolic Gutter Views—Longitudinal and transverse views through peritoneal windows inferior to the level of the ipsilateral kidney and next to the ipsilateral iliac crest may reveal free fluid surrounding the bowel. These windows may be of limited use because of the absence of an acoustic window, such as a fluid-filled bladder or a solid organ. Air-filled bowel may also limit these views. The presence of larger amounts of fluid may aid in visualization. The images may be obtained laterally or from an anterior approach. The Parasternal View—The parasternal window allows visualization of the heart in the long or short axis. This view may be used when a patient's subcostal view is suboptimal. The Apical View—The apical view may allow visualization of pericardial fluid by placing the transducer around the nipple line at the left fifth intercostal space. This view may also be used when the subcostal view is not optimal. Supplemental views: Inferior Vena Cava (IVC) Views—Multiple views of the IVC are accessible by using either a subxiphoid or lateral approach. The lateral approach makes use of the liver as an acoustic window. The primary aim of IVC evaluation is to aid in the assessment of the intravascular volume status. IVC evaluation is particularly useful in those patients at the extreme ends of the spectrum: either hypovolemic (eg, secondary to massive hemorrhage) or severely fluid overloaded. Dynamic IVC evaluation has also been shown to be useful in assessing patients' response to volume resuscitation or transfusion of blood products. Other Considerations for the EFAST Examination Include the Following Points Trendelenburg positioning may increase the sensitivity of the ultrasound examination for visualizing free fluid in the right upper quadrant or left upper quadrant. Semi-Fowler positioning may increase the sensitivity of detection of a pneumothorax in the apical lung zones and detection of hemothorax at the lung bases. An EFAST examination is not designed to be performed only once, and it may be repeated during the patient's stay for reassessment of the patient's condition either routinely or as a consequence of clinical decompensation. As a caveat, one must remember that trauma ultrasound provides a picture of a patient's condition at one moment in time. It does not eliminate the possibility of injury or fluid collections that are below detectable thresholds. Acute hemorrhage appears as anechoic fluid collections described previously in this document. However, as the blood clots, fluid collections may appear complex, hypoechoic, or even isoechoic to surrounding structures. In some cases, areas within dense structures that are actively bleeding may appear hyperechoic to surrounding tissues. Contrast-enhanced ultrasound (CEUS) can be utilized in combination with the EFAST exam in the evaluation for solid organ injury in patients with abdominal trauma. There are currently 3 FDA-approved ultrasound contrast agents, but CEUS in EFAST exams is not widespread and the use of contrast media may be off-label for certain views. It is only mentioned here to bring awareness of this application. Providing recommendations for the use of CEUS is not within the scope of these practice parameters. For more information, please refer to the AIUM Practice Parameter for the Performance of Contrast-Enhanced Ultrasound Examinations.1, 2 Limitations There are limitations to EFAST assessments, including reduced ability to detect free fluid in children or exact locations of injury to mesenteric structures, diaphragm, bowel, or solid organs. The EFAST is also limited in identifying retroperitoneal hemorrhage, although injuries can at times be seen. The potential false-positive diagnosis of free traumatic fluid in the peritoneum may be due to fluid present in patients for physiologic reasons, including ruptured ovarian cyst, as well as pathologic reasons, such as patients with ascites or inflammatory processes in the abdomen or pelvis. One must also be aware that free fluid is typically present intraperitoneally in patients with ventriculoperitoneal shunts, in those who undergo peritoneal dialysis, and in those after recent peritoneal lavage and surgery. It can be difficult to identify free fluid in patients with severe polycystic kidney or ovarian disease. Additionally, perinephric fat may also be mistaken for free fluid. Ultrasound may also be technically limited in the trauma patient due to bowel gas, obesity, subcutaneous or peritoneal emphysema, patient positioning, the degree of injury and rate of bleeding, adhesions from prior surgery, and often in patients who are either in pain or combative secondary to traumatic injury. Like many diagnostic ultrasound examinations, the main limitation of the EFAST is that the operator must be knowledgeable in its clinical use and limitations, and be aware that a negative EFAST does not exclude all injuries. Limitations to the pericardial assessment for hemopericardium include pericardial fat pads, cysts, and preexisting pericardial fluid. Limitations to pleural assessment for hemothorax include pleural fluid from preexisting pleural disease as well as extension of fluid into the pleural space from the pericardium or peritoneum. Finally, the limitations in the evaluation for pneumothorax include mistaking the absence of pleural sliding after a mainstem bronchus intubation for a pneumothorax as well as failure to recognize the associated presence of a lung pulse, and false-positive examinations after pleurodesis or in patients with severe chronic obstructive pulmonary disease. Other lung or chest wall pathologies may inhibit adequate visualization of pleural sliding. Although the sensitivity in the detection of pneumothorax is very high, it is important to note that small apical, mediastinal, non-pleural-based, or localized pneumothoraces may not be visualized in a focused thoracic ultrasound examination. Further information may be obtained by referring to the ACEP Emergency Ultrasound Imaging Criteria Compendium—Trauma.3 Documentation Accurate and complete documentation is essential for high-quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow-up studies if clinically applicable, in accordance with the AIUM Practice Parameter for Documentation of an Ultrasound Examination. The diagnostic interpretation of findings in an EFAST examination is limited to those areas assessed and imaged. In particular, an EFAST analysis does not allow the diagnostic evaluation of all abnormalities in the chest, abdomen, or pelvis. A guide for documentation may also be found in the ACEP standard reporting guidelines.4 Equipment Specification The EFAST examination may be conducted with any device that provides diagnostic quality. The equipment should be adjusted to operate at the highest clinically appropriate frequency, realizing that there is a trade-off between resolution and beam penetration. For most preadolescent pediatric patients, transducers with a smaller footprint (including phased array transducers) are preferred. In neonates and small infants, a higher-frequency transducer may be necessary. For adults, mean frequencies of 3.5 and 5 MHz are most commonly used. Occasionally, very large patients may require a lower frequency such as 2 MHz for analysis. Quality and Safety Policies and procedures related to quality assurance and improvement, safety, infection control, and equipment performance monitoring should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices. ALARA (As Low as Reasonably Achievable) Principle The potential benefits and risks of each examination should be considered. The ALARA principle should be observed for factors that affect the acoustical output and by considering transducer dwell time and total scanning time. Further details on ALARA may be found in the current AIUM publication Medical Ultrasound Safety. Infection Control Transducer preparation, cleaning, and disinfection should follow manufacturer recommendations and be consistent with the AIUM Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers Between Patients, Safe Handling, and Use of Ultrasound Coupling Gel. Equipment Performance Monitoring Monitoring protocols for equipment performance should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practice. Policies and procedures related to image quality, equipment performance monitoring, infection control, and patient safety as well as patient education with regard to the EFAST should be developed and implemented in accordance with either the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices or the guidelines developed by specialty specific organizations such as the ACEP. Acknowledgments This parameter was developed by the AIUM in collaboration with the American College of Emergency Physicians (ACEP). We are indebted to the many volunteers who contributed their time, knowledge, and energy to developing this document. Collaborative Subcommittees AIUM Rachel Liu, MD Vivek Tayal, MD, FACEP, FAIUM Nova Panebianco, MD MPH Daniel Theodoro, MD MSCI Penelope Lema, MD ACEP Elaine Situ-LaCasse, MD Michael Gottlieb, MD AIUM Expert Advisory Group Alyssa Abo, MD AIUM Clinical Standards Committee James M. Shwayder, MD, JD, chair Rachel Bo-ming Liu, MD, vice chair Creagh T. Boulger, MD Bryann Bromley, MD Nirvikar Dahiya, MD John R. Eisenbrey, PhD Rob Goodman, MBBCh, MBA, BMSc Ethan J. Halpern, MD Oliver Daniel Kripfgans, PhD Jean Spitz, MPH, CAE, RDMS John Stephen Pellerito, MD Margarita Revzin, MD Original copyright 2007; Revised 2014, 2022 References 1AIUM practice parameter for the performance of contrast-enhanced ultrasound examinations. J Ultrasound Med 2020; 39: 421– 429. Wiley Online LibraryPubMedWeb of Science®Google Scholar 2Zhang Z, Hong Y, Liu N, Chen Y. 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Background: Management of complex renal cysts is guided by the Bosniak classification system, which may be inadequate for risk stratification of patients for intervention. Fractional tumor vascularity (FV) calculated from volumetric contrast-enhanced ultra-sound (CEUS) images may provide additional useful information. Objective: To evaluate CEUS and FV calculation for risk stratification of patients with complex renal cysts. Design, setting, and participants: This was a pilot prospective study with institutional review board approval involving patients undergoing surgery for Bosniak IIF-IV complex renal cysts. CEUS was performed preoperatively on the day of surgery with two-dimensional (2D) and three-dimensional (3D) imaging and sulfur hexafluoride lipid -type A microspheres as the ultrasound contrast agent. Outcome measurements and statistical analysis: A custom MATLAB program was used to select regions of interest on CEUS scans. FV was calculated according to FV = 1 -(total nonenhancing area/total lesion area). We assessed the ability of 2D-and 3D-derived per-centage FV (2DFV%, and 3DFV%) and Bosniak classification schemes (pre-2019 [P2019B] and post-2019 [B2019]) to predict malignancy, aggressive histology, and upstaging on surgical pathology. Performance was assessed as area under the receiver operating char-acteristic curve (AUC). Results and limitations: Twenty eligible patients were included in final analysis, of whom 85% (n = 17) had Bosniak IV cysts and 85% (n = 17) had malignant disease on final pathology. Four (24%) of the malignant lesions were International Society of Urological Pathology grade 3-4. The AUC for predicting malignancy was 0.980, 0.824, 0.863, and 0.824 with P2019B, B2019, 2DFV%, and 3DFV%, respectively. When the Bosniak classifi-cation was combined with FV%, three models had an AUC of 1, while the combined 2DFV % + B2019 model had AUC of 0.980. Conclusions: FV is a novel metric for evaluating complex cystic renal masses and enhances the ability of the Bosniak classification system to predict malignancy. This metric may serve as an adjunct in risk stratification for surgical intervention. Further prospective evaluation is warranted. Patient summary: Cysts in the kidney are currently classified using a scheme called the Bosniak system. We assessed measurement of the percentage of vascular tissue (called fractional vascularity) in cysts on a special type of ultrasound scan. This promising test adds information when combined with the Bosniak system and can help in guiding appropriate treatment. (c) 2022 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons. org/licenses/by/4.0/).

An anomalous origin of the right coronary artery from the opposite sinus of Valsalva with an intramural course (R-ACAOS-IM) may cause sudden cardiac death in children and adolescents. However, the natural history and management of patients in whom this anomaly is detected later during adulthood remains uncertain. The goals of this study were to assess the impact of an R-ACAOS-IM on the clinical outcomes in an adult population and to determine if adult patients with this anomaly who do not have significant coronary artery disease (CAD) can be managed safely without surgical intervention. A database review identified patients aged >35 years with anomalous coronary arteries diagnosed by cardiac catheterization or coronary computed tomography angiography. The outcomes of patients with R-ACAOS-IM were compared with patients with anomalous left circumflex coronary arteries with retroaortic course (LCx-RA) (an anomaly not associated with ischemic events). The primary outcome was all-cause mortality. The study population consisted of 185 patients aged 59 ± 12 years. Clinical characteristics were similar in the R-ACAOS-IM (n = 88) and LCx-RA (n = 97) groups. At a follow-up of 6.6 ± 4.5 years, there was no difference in mortality (hazard ratio 0.64, 95% confidence interval 0.32 to 1.28, p = 0.20) when adjusted for gender, age, and CAD. A subgroup analysis of 88 patients with no obstructive CAD managed nonoperatively found no difference between the LCx and R-ACAOS-IM groups in mortality (hazard ratio 2.45, 95% confidence interval 0.45 to 13.40, p = 0.30). There was no significant difference between the 2 groups in the composite outcome of death, nonfatal myocardial infarction, or survived cardiac arrest. The outcome of adult patients who have anomalous R-ACAOS-IM are similar to patients who have anomalous LCx-RA with a known benign course. In conclusion, these results suggest that most patients who survive this anomaly into adulthood may be managed conservatively without intervention.

INTRODUCTION:To report the impact of our 25-year multidisciplinary care delivery model experience on patients with muscle invasive bladder cancer treated at our National Cancer Institute (NCI)-designated Sidney Kimmel Cancer Center at Jefferson University. To our knowledge, our multidisciplinary genitourinary cancer clinic (MDC) is the longest continuously operating center of its kind at an NCI Cancer Center in the United States.MATERIALS AND METHODS:We selected a recent group of patients with cT2-4 N0-1 M0 bladder cancer seen in the Sidney Kimmel Cancer Center Genitourinary Oncology MDC from January 2016 to September 2019. These patients were identified retrospectively. SEER-18 (Surveillance, Epidemiology, and End Results) database, November 2019 submission was queried to obtain patients with similarly staged disease diagnosed between 2015 and 2017. Completion rates of radical cystectomy, use of neoadjuvant therapies, and survival outcomes were compared between the two cohorts.RESULTS:Ninety-one patients from the MDC form this time period were identified; 65.9% underwent radical cystectomy and 71.8% received neoadjuvant therapy in the form of chemotherapy, immune checkpoint inhibition or a combination of the two - higher than reported national trends for neoadjuvant therapies. Progression of disease was seen in 24.2% of patients. A total of 8675 patients met inclusion criteria in the SEER database. Rates of radical cystectomy were significantly higher in MCD patients when compared to SEER derived data (65.9% vs. 37.7%, p =< 0.001). MCD patients had significantly better cancer-specific survival (mean 20.4 vs. 18.3 months p = 0.028, median survival not reached).CONCLUSION:Our long term experience caring for patients with genitourinary malignancies such as bladder cancer in a uniform multidisciplinary team results in a high utilization of neoadjuvant therapies. When compared to a contemporary SEER-derived cohort, multidisciplinary patients were more likely to undergo radical cystectomy and had longer cancer-specific survival.

PURPOSE:Novel CT reconstruction techniques strive to maintain image quality and processing efficiency. The purpose of this study is to investigate the impact of a newer hybrid iterative reconstruction technique, Adaptive Statistical Iterative Reconstruction-V (ASIR-V), in combination with various CT scan parameters on the semi-automated quantification using various lung nodules. METHODS:A chest phantom embedded with eight spherical objects was scanned using varying CT parameters such as tube current and ASIR-V levels. We calculated absolute percentage error (APE) and mean APE (MAPE) using differences between the semi-automated measured diameters and known dimensions. Predictive variables were assessed using a multivariable general linear model. The linear regression slope coefficients (β) were reported to demonstrate effect size and directionality. RESULTS:The APE of the semi-automated measured diameters was higher in ground-glass than solid nodules (β = 9.000, p < 0.001). APE had an inverse relationship with nodule diameter (mm; β = -3.499, p < 0.001) and tube current (mA; β = -0.006, p < 0.001). MAPE did not vary based on the ASIR-V level (range: 5.7%-13.1%). CONCLUSION:Error is dominated by nodule characteristics with a small effect of tube current. Regardless of phantom size, nodule size accuracy is not affected by tube voltage or ASIR-V level, maintaining accuracy while maximizing radiation dose reduction.

Purpose Ultrasound’s versatility and ease of use has expanded its application in many clinical settings. Technological advancements with contrast-enhanced ultrasound (CEUS) have allowed high quality imaging similar to CT or MRI with lower risk of contrast toxicity and radiation exposure. In this review article we examine the development of CEUS and its vast applications in the field of urology. Methods A PubMed literature search was performed using keywords: contrast enhanced ultrasound, prostate cancer, renal cancer, and multiparametric ultrasound. Results The development of CEUS has improved transrectal ultrasound imaging with increased detection of prostate cancer (PCa). Further enhancements of CEUS such as subharmonic imaging (SHI), flash replenishment imaging (FRI) and contrast ultrasound dispersion imaging (CUDI) allow improved PCa diagnosis. CEUS has also emerged as an important tool in characterizing suspicious renal mass without compromising renal function with contrast imaging. Conclusion CEUS has modernized imaging and diagnosis of prostate and renal cancer. Future advancements and utilization of CEUS will allow its expansion into other urological subspecialties.

Introduction: Anomalous right coronary arteries (RCA) arising from the left sinus of Valsalva with an interarterial course (lAC) may cause sudden cardiac death in children and adolescents. However, the natural history and management of patients in whom this anomaly is first detected during adulthood remains uncertain. Methods: Database review identified patients ≥35 years old with anomalous coronary arteries diagnosed by cardiac catheterization or coronary computed tomographic angiography. The outcomes of patients with anomalous RCA with IAC treated conservatively were compared to patients with anomalous left circumflex (LCX) coronary arteries with retroaortic course (an anomaly not associated with ischemic events). The primary outcome was all-cause mortality. Secondary outcomes included survived cardiac arrest and myocardial infarction. Results: The study population consisted of 185 patients (115 men, 70 women) aged 59 ± 12. Clinical characteristics were similar in the RCA (n=88) and LCX (n=97) groups. At follow-up of 6.6 ± 4.4 years there were no statistically significant differences between the 2 groups in mortality (p=0.11) or in secondary outcomes (P=0.89). Conclusions: The outcome of adult patients who had an anomalous RCA with lAC were similar to patients who had anomalous LCX with a known benign course. These results suggest that most patients who survive this anomaly into adulthood may be managed conservatively without intervention.

You have accessJournal of UrologyCME1 May 2022MP33-04 CONTRAST-ENHANCED ULTRASONOGRAPHY FOR THE EVALUATION OF COMPLEX RENAL CYSTS Cassra Clark, Corinne Wessner, Shuo Wang, Andrew Denisenko, Andrew Shumaker, Joonyau Leong, Andrea Quinn, Erica Mann, Lydia Glick, Timothy Han, Kibo Nam, Katherine Smentkowski, John Eisenbrey, Leonard Gomella, Edouard Trabulsi, Costas Lallas, Mark Mann, James Mark, Flemming Forsberg, Andrej Lyshchik, Ethan Halpern, and Thenappan Chandrasekar Cassra ClarkCassra Clark More articles by this author , Corinne WessnerCorinne Wessner More articles by this author , Shuo WangShuo Wang More articles by this author , Andrew DenisenkoAndrew Denisenko More articles by this author , Andrew ShumakerAndrew Shumaker More articles by this author , Joonyau LeongJoonyau Leong More articles by this author , Andrea QuinnAndrea Quinn More articles by this author , Erica MannErica Mann More articles by this author , Lydia GlickLydia Glick More articles by this author , Timothy HanTimothy Han More articles by this author , Kibo NamKibo Nam More articles by this author , Katherine SmentkowskiKatherine Smentkowski More articles by this author , John EisenbreyJohn Eisenbrey More articles by this author , Leonard GomellaLeonard Gomella More articles by this author , Edouard TrabulsiEdouard Trabulsi More articles by this author , Costas LallasCostas Lallas More articles by this author , Mark MannMark Mann More articles by this author , James MarkJames Mark More articles by this author , Flemming ForsbergFlemming Forsberg More articles by this author , Andrej LyshchikAndrej Lyshchik More articles by this author , Ethan HalpernEthan Halpern More articles by this author , and Thenappan ChandrasekarThenappan Chandrasekar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002587.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Complex renal cysts are evaluated using the Bosniak classification system. However, they remain difficult to manage because inter-reader variability and subjective interpretation of the Bosniak system. This pilot study intends to evaluate the use of contrast-enhanced ultrasonography (CEUS) to differentiate the solid and cystic components of complex renal cysts and compare these results to the final surgical pathology report. METHODS: 23 patients undergoing surgery for Bosniak 2F-4 lesions participated in this IRB-approved pilot study. Patients were scanned prior to surgery with both 2D and 3D ultrasound exams. Each injection consisted of a 2.0 mL bolus injection of Lumason contrast (Bracco Imaging, Monroe Township, NJ) followed by a 10 mL saline flush. A custom MATLAB program was used for selection of regions of interest (ROIs) (Figure 1). Fractional tumor vascularity (FTV in %) was then calculated and compared to estimated solid component on the final pathology report.Fractional Tumor Vascularity = 1 − (Total Non-enhancing area/Total lesion area) The primary endpoint of this study was the correlation of 2D/3D-derived fractional vascularity with pathological estimation and tumor staging on explant. RESULTS: No adverse events were observed during any contrast agent administration. Data was analyzed on 22 of 23 patients (Patient 22 excluded due to poor image quality). Mean age was 60.9±15.0 years (range 30 to 85) and mean preoperative lesion size was 4.0±1.6 cm (range 1.2 to 8.3 cm). Nine patients had radical nephrectomies and 14 had a partial nephrectomy. On final pathology, 4 lesions were benign and 19 were malignant. The results of 2D and 3D analysis as well as final pathology are included in Table 1. In general, malignant lesions and more aggressive histology had higher FTV. CONCLUSIONS: Quantitative 2D and 3D CEUS can evaluate FTV of potentially malignant complex cystic renal masses, which may be able to augment current radiographic classification systems. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e570 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassra Clark More articles by this author Corinne Wessner More articles by this author Shuo Wang More articles by this author Andrew Denisenko More articles by this author Andrew Shumaker More articles by this author Joonyau Leong More articles by this author Andrea Quinn More articles by this author Erica Mann More articles by this author Lydia Glick More articles by this author Timothy Han More articles by this author Kibo Nam More articles by this author Katherine Smentkowski More articles by this author John Eisenbrey More articles by this author Leonard Gomella More articles by this author Edouard Trabulsi More articles by this author Costas Lallas More articles by this author Mark Mann More articles by this author James Mark More articles by this author Flemming Forsberg More articles by this author Andrej Lyshchik More articles by this author Ethan Halpern More articles by this author Thenappan Chandrasekar More articles by this author Expand All Advertisement PDF DownloadLoading ...

You have accessJournal of UrologyImaging/Radiology: Uroradiology I (PD10)1 Sep 2021PD10-12 CONTRAST-ENHANCED ULTRASOUND AS A NOVEL TECHNOLOGY FOR THE PRE- AND POST-OPERATIVE EVALUATION OF URETHRAL STRICTURES Joon Yau Leong, Priscilla Machado, Corinne E. Wessner, Edouard J. Trabulsi, Ethan J. Halpern, Flemming Forsberg, John R. Eisenbrey, and Paul H. Chung Joon Yau LeongJoon Yau Leong More articles by this author , Priscilla MachadoPriscilla Machado More articles by this author , Corinne E. WessnerCorinne E. Wessner More articles by this author , Edouard J. TrabulsiEdouard J. Trabulsi More articles by this author , Ethan J. HalpernEthan J. Halpern More articles by this author , Flemming ForsbergFlemming Forsberg More articles by this author , John R. EisenbreyJohn R. Eisenbrey More articles by this author , and Paul H. ChungPaul H. Chung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001978.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethral strictures may cause obstructive urinary symptoms and is traditionally diagnosed with cystoscopy or retrograde urethrogram (RUG). We conducted a prospective, pilot study evaluating the utility of contrast-enhanced ultrasound (CEUS) for the evaluation of urethral strictures pre- and post-surgery. METHODS: Patients with bulbar urethral strictures electing to undergo surgical repair provided informed consent to participate in this IRB-approved study. CEUS urethrography was performed under anesthesia prior to surgical repair and again at 3-month outpatient follow up using the ultrasound contrast agent Lumason (Bracco Imaging) injected transurethrally. CEUS imaging was performed using an Aplio i800 scanner (Canon Medical Systems) with an i8CX1 transducer. Stricture length based on RUG, 2D grayscale ultrasound, and CEUS were measured by a blinded observer and correlated with intra-operative measurements (as the reference). RESULTS: A total of 28 men (mean age 50.8±18.2 years and BMI 29.7±6.4 kg/m2) were enrolled. Nineteen subjects (67.9%) had previously undergone a median of 2 transurethral dilation procedures. Mean urethral stricture length when measured on RUG, 2D ultrasound, CEUS and direct intra-operative measurement were 1.78±1.35 cm, 2.00±1.09 cm, 2.03±0.99 cm and 2.02±1.08 cm, respectively. CEUS showed the best correlation (R2=0.709, p <0.001) with measured intra-operative stricture length (Figure 1). Seventeen patients (61%) returned for post-operative CEUS evaluation. CEUS urethrography was able to detect large-caliber stricture recurrence (can accommodate flexible cystoscope) in 5 patients and failed to detect small-caliber recurrence (cannot accommodate cystoscope) in 1 patient for an overall 88% sensitivity and 100% specificity. CONCLUSIONS: Our pilot study demonstrates the ability of CEUS to be an accurate and potentially efficacious modality for assessing urethral stricture pre- and post-operatively. CEUS may provide easier visibility of the urethra compared to grayscale imaging and an opportunity for urologists to increase use in the clinic avoiding the need for fluoroscopy and radiation exposure to patients. Further studies assessing the utility of CEUS should be performed in larger cohorts. Source of Funding: Material Support from Bracco Diagnostics © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e131-e132 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joon Yau Leong More articles by this author Priscilla Machado More articles by this author Corinne E. Wessner More articles by this author Edouard J. Trabulsi More articles by this author Ethan J. Halpern More articles by this author Flemming Forsberg More articles by this author John R. Eisenbrey More articles by this author Paul H. Chung More articles by this author Expand All Advertisement PDF downloadLoading ...

BACKGROUND. Ultrasound guidance allows performance of carpal tunnel release with smaller incisions and quicker recovery than traditional open or endoscopic surgery. OBJECTIVE. The purpose of this study was to evaluate the long-term effectiveness of ultrasound-guided carpal tunnel release in improving function and discomfort in patients with carpal tunnel syndrome. METHODS. Retrospective review was conducted of 61 ultrasound-guided carpal tunnel release procedures performed on 46 patients (15 bilateral procedures) with clinically diagnosed carpal tunnel syndrome. The procedures were performed with a single-use transection device and local anesthesia at an outpatient radiology office. Patients answered three questionnaires (Quick Disabilities of the Arm, Shoulder, and Hand [QDASH] and two parts of the Boston Carpal Tunnel Syndrome Questionnaire-the symptom severity [BCTSQ-SS] and functional status [BCTSQ-FS] scales) to assess the function of and discomfort in the affected wrist immediately before and 2 weeks and at least 1 year after the procedure. Higher scores indicated increasing disability. Patients also answered a global satisfaction question at follow-up. Preprocedure and postprocedure scores were compared by paired Wilcoxon signed rank tests. RESULTS. The 46 patients (25 women, 21 men; mean age, 60.6 years; range, 21-80 years) had median preprocedure scores of 45.4 for QDASH, 3.2 for BCTSQ-SS, and 2.5 for BCTSQ-FS. The median scores 2 weeks after the procedure were 22.5 for QDASH, 1.7 for BCTSQ-SS, and 1.9 for BCTSQ-FS. All scores decreased (p < .001) from preprocedure scores and surpassed reference standards for clinically important difference in scores. Follow-up questionnaires obtained for 90% (55/61) of wrists a median of 1.7 years (range, 1.0-2.8 years) after the procedure showed further declines (p < .001) in median scores: 2.3 for QDASH, 1.2 for BCTSQ-SS, and 1.1 for BCTSQ-FS. At long-term follow-up evaluation, 96% (52/54) of wrists had lower QDASH and 98% (53/54) had lower BCTSQ (average of BCTSQ-SS and BCTSQ-FS) scores compared with the preprocedure scores. Among the patients who participated in the survey, 93% (37/40) were satisfied or very satisfied with the long-term outcomes. No immediately postoperative complications occurred. Two patients needed surgical intervention 8 and 10 days after surgery, one for infection after injury and one for posttraumatic compartment syndrome. CONCLUSION. Ultrasound-guided carpal tunnel release quickly improves hand function and reduces hand discomfort; improvement persists beyond 1 year. CLINICAL IMPACT. Ultrasound-guided carpal tunnel release may be a safe, effective, and less invasive alternative to traditional surgery.

Background and Presentation: In this study, we present the case of a 64-year-old female with a chief complaint of abdominal pain and bloating, which had been persistent over a period of 4 months. Imaging revealed a 6.1-cm left-sided pancreatic mass as well as a 19.1-cm multiloculated cystic lesion in the pelvis, later revealed to be replacing the left ovary. The pancreatic mass was biopsied through endoscopic ultrasound-guided fine needle aspiration, and diagnosed as adenocarcinoma by cytology. The patient was treated with neoadjuvant chemotherapy and radiation before laparotomy for resection of the pancreas and left adnexal mass. Her response to treatment was followed radiologically and biochemically with cancer antigen (CA) 19-9 (114-35 U/mL), carcinoembryonic antigen (12-4.8 ng/mL), and CA-125 (119-15.3 U/mL) levels. She subsequently underwent an Appleby procedure, and resection of left pelvic mass and bilateral oophorectomy. Permanent sections revealed residual pancreatic ductal carcinoma with treatment effect, and a multicystic epithelial neoplasia of the left ovary for which the differential was primary ovarian carcinoma versus metastatic disease. Conclusions: Molecular mutational analysis was performed on sections of both the ovarian tumor and the pancreatic tumor to aid in diagnosis. The ovarian tumor in this case showed exactly the same mutations, KRAS G12R and TP53 G245S, as in the treated pancreatic cancer. This raised the high probability that these tumors originated from the same clonal event. The findings suggested that the ovarian tumor was an isolated metastasis of the pancreatic primary, despite the morphologic ambiguity between the two sites of neoplasia.

PURPOSE:To evaluate changes in utilization of cardiac imaging-transthoracic, transesophageal, and stress echocardiography (TTE, TEE, and SE), coronary CT angiography (cCTA), cardiac MRI (cMRI), myocardial perfusion imaging (MPI), and cardiac positron emission tomography (cPET).MATERIALS AND METHODS:The 2010-2019 Physician/Supplier Procedure Summary files were used to find imaging utilization per 100 000 Medicare beneficiaries. Global and professional claims were aggregated, representing total interpretive services. Specialty codes identified provider specialty. Results were stratified by physician offices, hospital outpatient departments (HOPDs), inpatient setting, and the emergency department.RESULTS:From 2010 to 2019, there was a partial shift from cardiologist offices to the HOPD for TTE (office: -23%; HOPD: +107%) and SE (office: -44%; HOPD: +11%). Cardiologist cCTA also shifted from the office (-57%) to the HOPD (+211%). Radiologist-performed cCTA grew in all locations but most in the HOPD (+355%), with radiologists performing more cCTA than cardiologists in all settings. cMRI rates remain low but rose in the HOPD for both cardiologists (+209%) and radiologists (+207%). Cardiologist MPI rates dropped dramatically in the office (-52%), with a smaller absolute rate increase in the HOPD (+71%). cPET nearly tripled in the cardiology office (+193%), but rates remained steady for radiologists.CONCLUSION:While most cardiologist in-office imaging has shifted to the HOPD, there has been an increase in in-office cPET, likely due to a combination of technological advances, interpretation familiarity, and financial incentives. Radiologist cCTA rates continue to increase, representing a growing opportunity for radiologists to collaborate in cardiac imaging.Keywords: CT Angiography, Echocardiography, MR Imaging, PET, Radionuclide Studies, SPECT, Cardiac, Work Force Issues Supplemental material is available for this article. © RSNA, 2021.

Purpose To determine if Medicaid expansion is associated with increased volumes of lung cancer screenings. Methods A quasi-experimental study was performed to compare the annual growth rates in lung cancer screenings between states that expanded Medicaid (n = 31) versus those that did not (n = 17). Using the American College of Radiology Lung Cancer Screening Registry, we calculated the average annual growth rate between 2016 and 2019 for both groups. Secondary analyses between these two groups also included calculations of the percentages of studies considered appropriate by USPSTF criteria. Results No significant difference was identified in the average annual growth in lung cancer screenings between Medicaid expanding and non-expanding states (57.6%, 50.3%, P = 0.51). No difference was observed in the percentage of studies considered appropriate (Medicaid expanding = 89.6%, non-expanding = 90.2%, P = 0.72). At baseline, there were socioeconomic differences between both groups of states. Medicaid expanding states had a more urban population (76.5% versus 67.9%, P = 0.05) and higher average incomes ($56,947, $49,876, P < 0.05). Conclusion No association is found between Medicaid expansion and increasing volumes of lung cancer screening exams. Although no data is available in the registry for screening exams before the implementation of Medicaid expansion (2014), most nationwide estimates of lung screening rates report a low baseline (<5%). Furthermore, despite being advantaged in other ways, such as with a more urban population or with higher incomes, the Medicaid expansion cohort does not demonstrate a higher growth rate. These findings suggest Medicaid expansion alone will not increase lung cancer screenings.