Assessment of the Fetal Cerebral Artery: Importance of Doppler Preset Settings.

OBJECTIVES: The Doppler assessment of the middle cerebral artery (MCA) has a central role in the monitoring of high-risk pregnancies. The objective of this study was to investigate the importance of Doppler preset settings for measurement of the peak systolic velocity (PSV) and pulsatility index (PI) of the MCA. METHODS: The PI and PSV of the MCA were determined prospectively in 350 healthy fetuses between 19 and 42 weeks of pregnancy. The first measurement of the MCA (MCA.S) was performed with the conventional settings and the second (MCA.O) with an optimized setting of the maximum achievable frame rate. For the MCA.O measurement, the width of the B-mode image and the color Doppler window were adjusted as narrowly as possible. In addition, the MCA was shown in optimized high-definition zoom. Resulting values were compared with commonly used reference values. RESULTS: The PSV and PI values and frame rates of the MCA.O setting were noticeably greater than those of the MCA.S setting (P < .001 for all). For both settings, the PSV and PI values were increased compared to common reference values. CONCLUSIONS: The assessment of the MCA with the optimized Doppler default setting yielded increased PSV and PI values compared to the commonly used measurement technique. Moreover, the resulting median curves differed from the established median reference curves. Therefore, an updated standardization for measuring the MCA should be set out, and current reference values should be adjusted.

Does Lesion Size Affect the Value of Shear Wave Elastography for Differentiating Between Benign and Malignant Thyroid Nodules?

OBJECTIVES: We aimed to investigate the diagnostic performance of shear wave elastography (SWE) combined with conventional ultrasonography (US) for differentiating between benign and malignant thyroid nodules of different sizes. METHODS: A total of 445 thyroid nodules from 445 patients were divided into 3 groups based on diameter (group 1, ≤ 10 mm; group 2, 10-20 mm; and group 3, > 20 mm). The mean elasticity index of the whole lesion was automatically calculated, and the threshold for differentiation between benign and malignant nodules was constructed by a receiver operating characteristic curve analysis. Diagnostic performances of conventional US and SWE were compared by using pathologic results as reference standards. RESULTS: The mean elasticity was significantly higher in malignant versus benign nodules for all size groups. The differences in mean elasticity in the size groups were not statistically significant for malignant or benign nodules. The specificity of US combined with SWE for group 1 was significantly higher than that for groups 2 and 3 (77.8% versus 62.9% and 53.3%; P < .05), and compared with group 1, the sensitivity was significantly higher for groups 2 and 3 (92.4% and 94.3% versus 80.7%; P < .05). When SWE was added, the specificity increased and the sensitivity and diagnostic accuracy decreased for group 1, and the sensitivity increased and the specificity decreased for groups 2 and 3; however, the differences were not significant. CONCLUSIONS: Combined with SWE, US yielded higher specificity for nodules of 10 mm and smaller and higher sensitivity for nodules larger than 10 mm.

Influence of Ulipristal Acetate Therapy on Uterine Fibroid-Related Symptoms and on Uterine and Fibroid Volumes and Vascularity Indices Assessed by Ultrasound.

OBJECTIVES: To investigate the modifications of uterine and fibroid volume, to study Doppler changes in uterine arteries and fibroid-supplying vessels, and to assess possible symptomatic relief after 3 months of treatment with ulipristal acetate. METHODS: Forty-two premenopausal women with symptomatic fibroids were included in the study. They were evaluated clinically for the symptoms reported and underwent ultrasound examinations before starting treatment and after 3 months of therapy with ulipristal acetate. Transvaginal scanning was performed by the same sonographer, who measured the uterine volume and uterine artery pulsatility index and resistive index. Considering that some patients had more than 1 fibroid, the vascularization (supplying vessel pulsatility and resistive indices), locations, and sizes of a total of 73 fibroids were also recorded. RESULTS: After 3 months of ulipristal acetate, patients had a significant improvement of all symptoms (P < .05). The percentage of uterine volume reduction was 14% (P = .03), with fibroid volume reduction of 32.8% (P = .01). Uterine artery vascular indices decreased after treatment, but their reduction did not reach significant results, whereas all fibroid vascular indices decreased significantly after 3 months of ulipristal acetate (P < .05). When the fibroids were divided according to their localization, all had significant volume reduction after therapy, but type 5 had the highest decrease (42%) compared to other fibroid types (P = .03). CONCLUSIONS: Fibroid treatment with ulipristal acetate resulted in a significant improvement of fibroid-related symptoms; moreover, it proved to be effective in decreasing both uterine and fibroid volumes and fibroid vascularization. Type 5 fibroids seem to have the most major response to treatment.

Resident Accuracy of Musculoskeletal Palpation With Ultrasound Verification.

OBJECTIVES: The purpose of this observational study was to determine the accuracy of musculoskeletal palpation of the medial joint line of the knee, medial patellar tendon, and posterior tibialis tendon verified by ultrasound imaging among physical medicine and rehabilitation residents. METHODS: Eighteen physical medicine and rehabilitation resident physicians at a single specialized institution were asked to identify the medial joint line of the knee, medial patellar tendon, and posterior tibialis tendon on 2 separate standardized patient models during a single data collection. They were asked to place a paper clip flat on the surface of the skin parallel to the specified anatomic structure. A high-frequency linear array transducer was used to identify whether the paper clip was correctly placed over the structures and to measure the distance from the intended structure. RESULTS: The accuracy rates for palpation of the medial joint line, medial patellar tendon, and posterior tibialis tendon in both models were 14%, 36%, and 28%, respectively, for all levels of residents. Accuracy rates for all of the structures by level of education were 19%, 29%, and 31% for postgraduate years 2, 3, and 4. Median confidence scores were 3.75, 3.5, and 2 for the medial joint line, medial patellar tendon, and posterior tibialis tendon. CONCLUSIONS: This study highlights the level of inaccuracy of musculoskeletal palpation skills and draws further attention to an area of much-needed improvement in our musculoskeletal residency training programs. Ultrasound imaging is an effective noninvasive method for providing swift feedback to medical students and residents and thereby reduce the instances of inaccurate musculoskeletal palpation.

Ultrasonographic Evaluation of Zone II Partial Flexor Tendon Lacerations of the Fingers: A Cadaveric Study.

OBJECTIVES: Accurate assessment of zone II partial flexor tendon lacerations in the finger is clinically important. Surgical repair is recommended for lacerations of greater than 50% to 60%. Our goal was to evaluate ultrasonographic test characteristics and accuracy in identifying partial flexor tendon lacerations in a cadaveric model. METHODS: From fresh-frozen above-elbow human cadaveric specimens, 32 flexor digitorum profundus tendons were randomly selected to remain intact or receive low- or high-grade lacerations involving 10% to 40% and 60% to 90% of the radioulnar width within Verdan Zone II, respectively. Static and dynamic ultrasonography using a linear array 14-MHz transducer was performed by a blinded musculoskeletal radiologist. Sensitivities, specificities, and other standard test performance metrics were calculated. Actual and measured percentages of tendon laceration were compared by the paired t test. RESULTS: After randomization, 24 tendons were lacerated (12 low- and 12 high-grade), whereas 8 remained intact. The sensitivity and specificity in detecting the presence versus absence of a partial laceration were 0.54 and 0.75, respectively, with positive and negative likelihood ratio values of 2.17 and 0.61. For low-grade lacerations, the sensitivity and specificity were 0.25 and 0.85, compared to 0.83 and 0.85 for high-grade lacerations. Ultrasonography underestimated the percentage of tendon involvement by a mean of 18.1% for the study population as a whole (95% confidence interval, 9.0% to 27.2%; P < .001) but accurately determined the extent for correctly diagnosed high-grade lacerations (-6.7%; 95% confidence interval, -18.7% to 5.2%; P = .22). CONCLUSIONS: Ultrasonography was useful in identifying and characterizing clinically relevant high-grade zone II partial flexor digitorum profundus lacerations in a cadaveric model.

Accuracy of Ultrasound for Preoperative Assessment of Tumor Size in Patients With Newly Diagnosed Breast Cancer: Is It Affected by the Background Parenchymal Echotexture?

OBJECTIVES: To assess the impact of the background parenchymal echotexture on the accuracy of tumor size estimation using breast ultrasound (US). METHODS: A total of 140 women with newly diagnosed invasive breast cancer from January 2014 to December 2015 were enrolled in this study. Two radiologists retrospectively reviewed US images in consensus for background parenchymal echotexture interpretation. The maximum tumor diameter from static images was recorded. Tumor size measurements were considered as having agreement with histologic results if they were within ±5 mm compared to the pathologic size. The relationship between the accuracy of tumor size measurement by the background parenchymal echotexture and clinicopathologic characteristics was evaluated. RESULTS: Of these 140 patients, 77 (55.0%) showed a homogeneous background parenchymal echotexture, whereas 63 (45.0%) showed a heterogeneous echotexture. The mean tumor size was 1.9 cm (range, 0.5-4.9 cm). The overall accuracy of tumor size measurement was 76.4% (104 of 140). Tumors of women with a homogeneous background parenchymal echotexture were more accurately measured than those of women with a heterogeneous echotexture (87.0% versus 63.5%; P = .001). Tumors with a small size (<2 cm; P = .018) and ductal carcinoma in situ-negative (P = .031), human epidermal growth factor receptor 2 (HER2)-negative (P = .053), and triple-negative (P = .016) types were also more accurately measured. The independent factors associated with inaccurate tumor size measurement were a heterogeneous background parenchymal echotexture, a large tumor size, and the HER2-enriched type (P < .05). CONCLUSIONS: The background parenchymal echotexture affected the accuracy of tumor size estimation using breast US. Invasive breast cancers with large (≥2 cm) tumors and the HER2-enriched type showed significantly lower breast US accuracy compared to others.

Carotid Artery Stiffness Assessment by Ultrafast Ultrasound Imaging: Feasibility and Potential Influencing Factors.

OBJECTIVES: To evaluate the feasibility of the ultrafast ultrasound pulsed wave velocity (PWV) for carotid stiffness assessment and potential influencing factors. METHODS: Ultrafast PWV measurements of 442 carotid arteries in 162 consecutive patients (patient group) and 66 healthy volunteers (control group) were performed. High- and very high-frequency transducers were used in 110 carotid segments. The ultrafast PWVs at the beginning and end of systole were automatically measured. The correlations between the intima-media thickness (IMT) and ultrafast PWV and the equipment and carotid factors influencing the utility of ultrafast PWV were analyzed. RESULTS: Each ultrafast PWV acquisition was completed within 1 minute. The intraobserver variability showed mean differences ± SD of 0.12 ± 1.28 m/s for the PWV before systole and 0.06 ± 1.30 m/s for the PWV at the end of systole. Ultrafast PWV measurements were more likely obtained with the very high- frequency transducer when the IMT was less than 1.5 mm (P < .05). A generalized linear mixed-effects model analysis showed that the very high-frequency transducer had a greater ability to obtain a valid carotid ultrafast PWV measurement with an IMT of less than 1.5 mm (P < .05). The IMT was positively correlated with the PWV before systole and at the end of systole (r = 0.207-0.771; all P < .05) in the control group, patient group, and carotid subgroup with an IMT of less than 1.5 mm. A multiple regression analysis showed that the IMT and plaque were important independent factors in predicting failure of the ultrafast PWV (P < .001). CONCLUSIONS: The ultrafast PWV is an effective and user-friendly method for evaluating carotid stiffness. The IMT and transducer type are factors influencing the ability to obtain an ultrafast PWV measurement.

Quantitative Ultrasound Assessment of the Achilles Tendon Under Varied Loads.

This Institutional Review Board-approved pilot study attempted to detect the correlation between ultrasound shear wave elastographic measures and tendon loads. Five male fresh-frozen cadaveric Achilles tendons were loaded in 10-N increments from 0 to 60 N. Shear wave velocity measurements within each Achilles tendon were obtained at each load in longitudinal and transverse orientations. Shear wave velocity measurements were correlated with tendon tension on both longitudinal and transverse plane imaging and showed moderate and strong positive correlation coefficients, respectively. Of note, limitations of the clinically available shear wave elastographic technology for measuring high velocities exist.

Lung Ultrasonography in Patients With Idiopathic Pulmonary Fibrosis: Evaluation of a Simplified Protocol With High-Resolution Computed Tomographic Correlation.

OBJECTIVES: To compare a simplified ultrasonographic (US) protocol in 2 patient positions with the same-positioned comprehensive US assessments and high-resolution computed tomographic (CT) findings in patients with idiopathic pulmonary fibrosis. METHODS: Twenty-five consecutive patients with idiopathic pulmonary fibrosis were prospectively enrolled and examined in 2 sessions. During session 1, patients were examined with a US protocol including 56 lung intercostal spaces in supine/sitting (supine/sitting comprehensive protocol) and lateral decubitus (decubitus comprehensive protocol) positions. During session 2, patients were evaluated with a 16-intercostal space US protocol in sitting (sitting simplified protocol) and left/right decubitus (decubitus simplified protocol) positions. The 16 intercostal spaces were chosen according to the prevalence of idiopathic pulmonary fibrosis-related changes on high-resolution CT. The sum of B-lines counted in each intercostal space formed the US scores for all 4 US protocols: supine/sitting and decubitus comprehensive US scores and sitting and decubitus simplified US scores. High-resolution CT-related Warrick scores (J Rheumatol 1991; 18:1520-1528) were compared to US scores. The duration of each protocol was recorded. RESULTS: A significant correlation was found between all US scores and Warrick scores and between simplified and corresponding comprehensive scores (P < .0001). Decubitus simplified US scores showed a slightly higher correlation with Warrick scores compared to sitting simplified US scores. Mean durations of decubitus and sitting simplified protocols were 4.76 and 6.20 minutes, respectively (P < .005). CONCLUSIONS: Simplified 16-intercostal space protocols correlated with comprehensive protocols and high-resolution CT findings in patients with idiopathic pulmonary fibrosis. The 16-intercostal space simplified protocol in the lateral decubitus position correlated better with high-resolution CT findings and was less time-consuming compared to the sitting position.

An Interposed Pad in Open-Chest Echocardiographic Porcine Scans for Mimicking Ultrasound Signal Attenuation in a Human Chest.

Opening a chest in an experimental echocardiographic animal study eliminates ultrasound signal attenuation by the chest wall. We developed a scanning technique that involves the use of an attenuative pad created from a mixture of urethane and titanium dioxide. The pad was interposed within transmission gel between the transducer face and cardiac surface in open-chest scans in a porcine model. Comparative measurements of left ventricular echogenicity without and with the pad demonstrate that the pad reproducibly causes ultrasound signal attenuation that closely mimics chest attenuation in clinical transthoracic echocardiographic studies.

Power Doppler Ultrasonography and Shear Wave Elastography as Complementary Imaging Methods for Suspected Local Breast Cancer Recurrence.

OBJECTIVES: To prospectively investigate the diagnostic accuracy and clinical consequences of power Doppler morphologic criteria and shear wave elastography (SWE) as complementary imaging methods for evaluation of suspected local breast cancer recurrence in the ipsilateral breast or chest wall. METHODS: Thirty-two breast masses with a suspicion of local breast cancer recurrence on B-mode ultrasonography underwent complementary power Doppler and SWE evaluations. Power Doppler morphologic criteria were classified as avascular, hypovascular, or hypervascular. Shear wave elastography was classified according to a 5-point scale (SWE score) and SWE maximum elasticity. Diagnostic accuracy was assessed by the sensitivity, specificity, and area under the curve. A decision curve analysis assessed clinical consequences of each method. The reference standard for diagnosis was defined as core needle or excisional biopsy. RESULTS: Histopathologic examinations revealed 9 (28.2%) benign and 23 (71.8%) malignant cases. Power Doppler ultrasonography (US) had sensitivity of 34.8% (95% confidence interval [CI], 6.6%-62.9%) and specificity of 45.4% (95% CI, 19.3%-71.5%). The SWE score (≥3) had sensitivity of 87.0% (95% CI, 66.4%-97.2%) and specificity of 44.4% (95% CI, 13.7%-78.8%). The SWE maximum elasticity (velocity > 6.5cm/s) had sensitivity of 87% (95% CI, 66.4%-97.2%) and specificity of 77.8% (95% CI, 40.0% to 97.2%). The areas under the curves for the SWE score and SWE maximum elasticity were 0.71 (95% CI, 0.53-0.87) and 0.82 (95% CI, 0.64-0.93), respectively (P = .32). CONCLUSIONS: Power Doppler US is unsuitable for discrimination between local breast cancer recurrence and fibrosis. Although the SWE score and SWE maximum elasticity can make this discrimination, the use of these methods to determine biopsy may lead to poorer clinical outcomes than the current practice of performing biopsies of all suspicious masses.

Real-time Ultrasound Assessment of Astronaut Spinal Anatomy and Disorders on the International Space Station.

OBJECTIVES: Back pain is one of the most common conditions of astronauts during spaceflight and is hypothesized to be attributed to pathologic anatomic changes. Ultrasound (US) represents the only available imaging modality on the International Space Station, but a formal US protocol for imaging the structures of the spinal column does not exist. This investigation developed a method of acquiring diagnostic-quality images of the anterior lumbar and cervical regions of the spine during long-duration spaceflight. METHODS: Comprehensive spinal US examinations were conducted on 7 long-duration spaceflight astronauts before flight, in flight, and after flight and compared to preflight and postflight magnetic resonance imaging data. In-flight scans were conducted after just-in-time training assisted by remote expert tele-US guidance. RESULTS: Novice users were able to obtain diagnostic-quality spinal images with a 92.5% success rate. Thirty-three anomalous or pathologic findings were identified during the preflight US analysis, and at least 14 new findings or progressions were identified during the postflight US analysis. Common findings included disk desiccation, osteophytes, and qualitative changes in the intervertebral disk height and angle. CONCLUSIONS: Ultrasound has proven efficacy as a portable and versatile diagnostic imaging modality under austere conditions. We demonstrated a potential role for US to evaluate spinal integrity and alterations in the extreme environment of space on the International Space Station. Further investigations should be performed to corroborate this imaging technique and to create a larger database related to in-flight spinal conditions during long-duration spaceflight.

Repeatability and Reproducibility of the Ultrasonic Attenuation Coefficient and Backscatter Coefficient Measured in the Right Lobe of the Liver in Adults With Known or Suspected Nonalcoholic Fatty Liver Disease.

OBJECTIVES: To assess the repeatability and reproducibility of the ultrasonic attenuation coefficient (AC) and backscatter coefficient (BSC) measured in the livers of adults with known or suspected nonalcoholic fatty liver disease (NAFLD). METHODS: The Institutional Review Board approved this Health Insurance Portability and Accountability Act-compliant prospective study; informed consent was obtained. Forty-one research participants with known or suspected NAFLD were recruited and underwent same-day ultrasound examinations of the right liver lobe with a clinical scanner by a clinical sonographer. Each participant underwent 2 scanning trials, with participant repositioning between trials. Two transducers were used in each trial. For each transducer, machine settings were optimized by the sonographer but then kept constant while 3 data acquisitions were obtained from the liver without participant repositioning and then from an external calibrated phantom. Raw RF echo data were recorded. The AC and BSC were measured within 2.6 to 3.0 MHz from a user-defined hepatic field of interest from each acquisition. The repeatability and reproducibility were analyzed by random-effects models. RESULTS: The mean AC and log-transformed BSC (logBSC) were 0.94 dB/cm-MHz and -27.0 dB, respectively. Intraclass correlation coefficients were 0.88 to 0.94 for the AC and 0.87 to 0.95 for the logBSC acquired without participant repositioning. For between-trial repeated scans with participant repositioning, the intraclass correlation coefficients were 0.80 to 0.84 for the AC and 0.69 to 0.82 for the logBSC after averaging results from 3 within-trial images. The variability introduced by the transducer was less than the repeatability error. CONCLUSIONS: Hepatic AC and BSC measures using a reference phantom technique on a clinical scanner are repeatable and reproducible between transducers in adults with known or suspected NAFLD.

Ultrasound Features of Breast Cancer for Predicting Axillary Lymph Node Metastasis.

OBJECTIVES: The purpose of this study was to assess the clinical value of ultrasound (US) features of breast lesions for predicting the risk of axillary lymph node metastasis in patients with breast cancer. METHODS: In this retrospective study, 425 patients with breast cancer were recruited, and their preoperative US features and postoperative pathologic results were collected. The association of these US features of breast cancer with axillary lymph node metastasis was determined by univariate and multivariate analyses. RESULTS: Among the 425 patients, 200 (47.1%) had axillary lymph node metastasis, and 225 (52.9%) did not. The parameters of tumor shape, color Doppler flow imaging grades, histologic grade, and E-cadherin level were significantly and independently associated with axillary lymph node metastasis (P < .05 for all). CONCLUSIONS: Axillary lymph node metastasis was prone to happen in patients with US features of an irregular tumor shape and higher color Doppler flow imaging grades. Ultrasound imaging provides a promising tool for predicting axillary lymph node metastasis in patients with breast cancer.

Evaluation of a Novel Out-of-Plane Needle Guide.

OBJECTIVES: Most ultrasound-guided regional procedures use an in-plane approach. Out-of-plane approaches may be desirable in some situations but can be difficult because of an inability to visualize the needle until it intersects the plane of the ultrasonic beam. Here we present a novel out-of-plane needle guide, using a retreating depth stop, and compare its performance with unguided in-plane and out-of-plane techniques. METHODS: First- and third-year medical students with no or minimal ultrasound experience were recruited for the study. After a brief training session on in-plane and out-of-plane needling techniques, as well as use of the retreating-stop needle guide, they attempted to place a needle as close as possible to a target embedded in porcine tissue. The total time to complete the procedure was measured. Accuracy was measured by a skilled sonographer, who identified the needle tip and measured the distance to the target. The data were tested for significance using an analysis of variance. RESULTS: The mean total time spent differed significantly between groups (novel needle guide, 34 seconds; in-plane, 120 seconds; out-of-plane, 113 seconds; P = .021). Needle proximity was on average more accurate with the needle guide, although this difference was not statistically significant (novel needle guide, 8 mm; in-plane, 15 mm; out-of-plane, 14 mm; P = .289). CONCLUSIONS: In relatively inexperienced sonographers, the retreating-stop needle guide reduced the procedure time compared with in-plane and out-of-plane techniques. No significant changes in needling accuracy were observed.

Does Intravenous Infusion Influence Diagnostic Ultrasound-Induced Pulmonary Capillary Hemorrhage?

OBJECTIVES: Pulmonary diagnostic ultrasound (US) can induce pulmonary capillary hemorrhage (PCH) in mammals. This singular biological effect of diagnostic US imaging was discovered more than 25 years ago but remains poorly understood. Our objective here was to investigate rapid infusion of intravenous fluids as a possible stressor for capillaries, which might enhance pulmonary diagnostic US-induced PCH. METHODS: Rats were anesthetized with Telazol (Zoetis, Inc, Kalamazoo, MI), which yielded relatively low pulmonary diagnostic US-induced PCH, or Telazol and xylazine, which yielded relatively high pulmonary diagnostic US-induced PCH. Groups of rats were not infused or infused either with normal saline, 10% mannitol, or 5% albumin. Rats were scanned in a warmed water bath with B-mode US for 5 minutes with a 7.6-MHz linear array set to different mechanical index values to obtain exposure response information. Pulmonary capillary hemorrhage was observed as comet tail artifacts in the image and measured on the lung surface. RESULTS: For Telazol anesthesia, all of the PCH results were very low, with no significant differences at the maximum output with an in situ peak rarefactional pressure amplitude of 2.1 MPa (on-screen mechanical index, 0.9). The addition of xylazine to the Telazol anesthetic significantly enhanced the PCH (P < .001) without infusion and likewise for the mannitol and albumin infusion. Saline infusion eliminated this enhancement, with significantly reduced PCH for Telazol-plus-xylazine anesthesia (P < .001); however, both mannitol and albumin infusion resulted in significantly more PCH than saline infusion (P < .01). CONCLUSIONS: These results show PCH dependence on the specific intravenous infusion fluid and illustrate the complex importance of physiologic parameters for US-induced PCH.

Updated Retrospective Single-Center Comparative Analysis of Peripheral Nerve Block Complications Using Landmark Peripheral Nerve Stimulation Versus Ultrasound Guidance as a Primary Means of Nerve Localization.

OBJECTIVES: The purpose of this study was to perform an updated analysis of complications associated with upper and lower extremity peripheral nerve blocks (PNBs) performed with ultrasound (US) guidance versus the landmark approach. METHODS: We conducted a single-center retrospective cohort analysis to compare the incidence of PNB complications between the techniques. The primary outcome was local anesthetic systemic toxicity (LAST), whereas the secondary outcomes included short- and long-term nerve injuries. The current query included cases performed between 2012 and 2015. A combined analysis included data extending to 2006. The Statistical examination relied on the χ2 test. RESULTS: During this 4-year period, we performed 7789 US-guided and 498 landmark-guided blocks with no statistically significant difference in the incidence of nerve injury or LAST between the groups. Our 10-year analysis, however, revealed a significant increase (P < .01) in the rate of LAST with the landmark technique: 7 of 5932 versus 0 of 16,858 cases. The combined data also revealed a significant increase (P < .01) in short-term injuries associated with the landmark approach (30 of 5932 versus 33 of 16,858) but no significant difference in the incidence of long-term injuries. CONCLUSIONS: Our analysis supports a conclusion that the use of US guidance during PNBs leads to a significant reduction in the incidence of LAST, adding to growing evidence from similar investigations. The impact of US on the incidence of nerve injuries remains unclear, considering that the nature of transient deficits is thought to be multifactorial, and the frequency of lasting injuries did not differ significantly in this study.

Monitoring Morphologic Changes in Male Rowers Using Limited Portable Echocardiography Performed by a Frontline Physician.

Athletes' hearts have been studied for adaptive changes in response to exercise. Physiologic changes are normal responses to intense athletic training regimens, whereas pathologic changes predispose athletes to sudden cardiac death. The two alterations overlap in clinical presentation. Research continues to investigate the upper limits of cardiac remodeling to aid clinical decision making. Studying normal changes that occur in response to exercise will advance physicians' understanding of physiologic responses to exercise and potentially improve clinical distinction. To expand this body of knowledge, we present an observational case series that describes morphologic changes in athlete's hearts concurrent with performance measurements.

Use of a Simple, Inexpensive Dual-Modality Phantom as a Learning Tool for Magnetic Resonance Imaging-Ultrasound Fusion Techniques.

We describe an easily constructed, customizable phantom for magnetic resonance imaging-ultrasound fusion imaging and demonstrate its role as a learning tool to initiate clinical use of this emerging modality. Magnetic resonance imaging-ultrasound fusion can prove unwieldy to integrate into routine practice. We demonstrate real-time fusion with single-sequence magnetic resonance imaging uploaded to the ultrasound console. Phantom training sessions allow radiologists and sonographers to practice fiducial marker selection and improve efficiency with the fusion hardware and software interfaces. Such a tool is useful when the modality is first introduced to a practice and in settings of sporadic use, in which intermittent training may be useful.