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1. Asymptomatic Palpable Adnexal Masses 2. Acute Pelvic Pain 3. Family History of Ovarian Carcinoma 4. Abnormal Premonopausal Vaginal Bleeding: From Menarche to Menopause 5. Vaginal Bleeding - Postmenopausal 6. Tamoxifen 7. The Use of Ultrasound in the Evaluation and Treatment of the Infertile Woman 8. Sonographic Evaluation of First-Trimester Pain and/or Bleeding 9. Second- and Third-Trimester Bleeding 10. Cervical Sonography in Premature Labor 11. Estimating Gestational Age 12. The Sonographic Evaluation of a Pregnancy Whose Size is Greater than Dates 13. Uterine Size less than Dates: A Clinical Dilemma 14. Ruling Out Fetal Anomalies 15. Family History of Congenital Heart Disease 16. The Role of Sonography in the Evaluation of Pregnant Women with High Maternal Serum a-Fetoprotein 17. Triple Marker Screening Test Positive for Down Syndrome 18. Diabetes Mellitus and Pregnancy: The Role of Ultrasound 19. Sonographic Evaluation of Fetus Following Tertogen Exposure 20. Postpartum Hemorrhage 21.The Breat Nodule: Sonographic Characterization Index

These guidelines are an educationaltool designed to assist practitioners inproviding appropriate radiologic carefor patients. They are not inflexiblerules or requirements of practice andare not intended, nor should they beused, to establish a legal standard ofcare. For these reasons and those setforth below, the American College ofRadiology cautions against the use ofthese guidelines in litigation in whichthe clinical decisions of a practitionerare called into question.The ultimate judgment regardingtheproprietyofanyspecificprocedureor course of action must be made bythe physician or medical physicist inlight of all the circumstances pre-sented. Thus, an approach that differsfrom the guidelines, standing alone,does not necessarily imply that the ap-proach was below the standard ofcare. To the contrary, a conscientiouspractitioner may responsibly adopt acourse of action different from that setforth in the guidelines when, in thereasonable judgment of the practitio-ner, such course of action is indicatedby the condition of the patient, limita-tions on available resources, or ad-vances in knowledge or technologysubsequent to publication of theguidelines. However, a practitionerwho employs an approach substan-tially different from these guidelines isadvised to document in the patientrecord information sufficient to ex-plain the approach taken.The practice of medicine involvesnot only the science, but also the art ofdealing with the prevention, diagno-sis, alleviation, and treatment of dis-ease. The variety and complexity ofhuman conditions make it impossibleto always reach the most appropriatediagnosis or to predict with certainty aparticular response to treatment.Therefore, it should be recognizedthat adherence to these guidelines willnot assure an accurate diagnosis or asuccessful outcome. All that should beexpected is that the practitioner willfollow a reasonable course of actionbased on current knowledge, availableresources, and the needs of the patientto deliver effective and safe medicalcare. The sole purpose of these guide-linesistoassistpractitionersinachiev-ing this objective.

The American Registry of Radiologic Technologists (ARRT) is the largest national, voluntary certification organization for radiologic technologists, with 235,000 registered technologists and an annual examination volume of 20,000 to 25,000. The ARRT's board is appointed by the ACR (four members) and the American Society of Radiologic Technologists (five members). The ARRT is in the process of developing a certification for radiologist assistants. Standards of education, ethics, and examination will be adopted to identify individuals qualified to assume this new role. The program is scheduled to be available in the fall of 2005.

1All authors: Department of Radiology, Ochsner Clinic Foundation, Ochsner Medical Center, 1514 Jefferson Hwy., New Orleans, LA 70121. Address correspondence to E. I. Bluth. aving successfully managed the department of radiology at the Ochsner Clinic Foundation during the recent events of Hurricane Katrina, we thought it would be valuable to share and discuss key information regarding management during a catastrophe. Management during a catastrophe can be divided into three components: preplanning, managing the actual event, and modifying the emergency plan according to lessons learned from the previous event. The Ochsner Clinic Foundation is a 532-bed tertiary care academic medical center with 20 radiologists, 22 residents and fellows, and more than 300 other personnel within the radiology department on the main campus. Before Hurricane Katrina, we had had many previous hurricane alerts at Ochsner, and we updated our emergency plan regarding equipment, personnel, emergency power, and communications annually. The overall institutional plan called for key individuals to stay in the institution for 2 days after the hurricane struck and then evacuate by helicopter to safety. This plan had previously been communicated to and accepted by the whole institution, including the radiology department.

Our objective was to quantitatively assess the value of early posttransplantation hepatic artery resistive indexes in predicting vascular and nonvascular complications in adult orthotopic liver transplant (OLT) patients.Between 1999 and 2001, 110 consecutive adults received grafts. Doppler sonographic graft evaluations measured main, right, and left resistive indexes within 24 to 48 hr after surgery (normal resistive index cutoff, 0.6). Clinical, operative, procedural, and radiologic reports were reviewed for vascular and biliary complications. Frequency, Student's t test, logistic, and regression statistical analyses were performed.even patients (6.4%) had vascular complications, including two (1.8%) hepatic artery and two (1.8%) hepatic vein stenoses, one (0.9%) hepatic vein thrombosis, two (1.8%) portal vein thromboses, and one (0.9%) thrombosis and two (1.8%) stenoses of the inferior vena cava (IVC). In 19 patients (17.3%), biliary complications included anastomotic strictures and leaks 1 week to 18 months after transplantation. In 11 patients (10%), sonographically large hematomas required surgical evacuation. In grafts with vascular complications or large hematomas, the mean early posttransplant main, right, and left indexes were significantly lower (or = 0.6) than without these complications (p0.01). In grafts with and without biliary complications, mean early posttransplant main, right, and left indexes did not differ significantly.In adult OLT patients, low early posttransplant hepatic artery resistive indexes were sensitive (100%) and specific (80%) predictors for vascular complications (e.g., hepatic artery, portal vein, hepatic vein, and IVC) but not for biliary complications. All patients with indexes less than 0.6 within 24-48 hr after surgery should be monitored closely for vascular complications.

Purpose. To study the ability and accuracy of sonography to visualize carotid artery stents and assess criteria for carotid artery stent stenosis. Methods. Duplex Doppler sonographic examinations were performed on 143 patients in whom 158 carotid artery stents were placed. Follow-up sonography to evaluate 24 of these stents within 24 h of stent placement was compared with postprocedure angiography. Another 23 stents were evaluated with sonography and with follow-up angiography more than 24 h after the procedure. The remainder of the 111 stents were evaluated exclusively with sonography after stent placement. Sonography was used to evaluate stent visibility, stent-media separation, and degree of stent stenosis. Results. Wallstents were the best-visualized stents and Acculink the worst, but the differences were not statistically significant. Of 4 patients with stent-media separation >3 mm, 2 (50%) developed stenosis (40%–59%) at 6 and 12 months from stent placement. The other 2 stents with stent-media separation had not developed stenosis at 6 months' follow-up. A comparison of angiography and sonography performed on the date of stent placement revealed 19 true-negative sonography studies, 4 false-positive studies, 1 true-positive study, and no false-negative studies. A comparison of follow-up angiograms performed more than 24 h after the procedure with follow-up sonography revealed 17 true-negative studies, 1 false-positive study, 5 true-positive studies, and no false-negative studies. Conclusions. Sonography allows accurate evaluation of stent placement within the vessel and visualization of stent-media distance. Stent-media sep-aration may be an early detection sign for stent stenosis development. Velocity criteria developed for nonstented vessels, when applied to stented vessels, correlate well with angiographic findings. Doppler velocity measurements when compared with visible stent assessment may reduce false-positives. © 2005 Wiley Periodicals, Inc. J Clin Ultrasound33:321–328, 2005

Editor: I read with interest the article entitled “Carotid Angioplasty and Stent Placement: Comparison of Transcranial Doppler US Data and Clinical Outcome with and without Filtering Cerebral Protection Devices in 509 Patients” by Dr Vos and colleagues in the February 2005 issue of Radiology (1). In the study by these authors, there was a demonstration of an association between the volume of microemboli and macroemboli in association with protection devices for patients who underwent angioplasty and stent placement. The article is of great importance, but it did not include the considerable work that has been done regarding plaque characterization, plaque instability, and the presence of intraplaque hemorrhage within plaque. With ultrasonography (US), plaque has been successfully classified as heterogeneous or homogeneous, with heterogeneous plaque being associated with intraplaque hemorrhage and instability (2–10). It would have been interesting for the authors to have classified the plaque prior to angioplasty and stent placement to determine if there was a higher incidence of microor macroemboli in heterogeneous plaque when angioplasty and stent placement were performed. It would seem that in combining the work by these authors and the information in the literature on US there would be a safe subgroup of patients who have homogeneous plaque, who should undergo angioplasty and stent placement. This is the majority of patients.

As an investigation into the mechanical factors which contribute to aneurysm growth and rupture, flow field measurements for steady flow are presented for a range of Reynolds numbers. Steady flow through rigid aneurysm models with roughly elliptical geometry is studied. Data is reported for a model of length 4d and diameter 2.5d, where d is the inner diameter of the entrance tube. Flow rates were chosen such that model Reynolds numbers matched in vivo Reynolds numbers for a range of subject activity level from resting to highly active. Laser-Doppler velocimetry (LDV) was used to verify flow patterns visualized with CDFI, and to quantify the flow velocities during laminar, transition and turbulent flow regimes. A well defined core flow was observed for all Reynolds numbers studied. The observed flow as laminar at Re=450 and Re=1300, and a stable recirculation zone occurred outside the core flow. Turbulent flow was observed at Re=2800 and no recirculation was seen in this case. This investigation represents an initial step in a more extensive study of flow fields within abdominal aortic aneurysms, the results of which will have significant implications for clinical decisions concerning the treatment of aortic aneurysms. >

To evaluate the role and usefulness of diagnostic ultrasonography (US) in the assessment of hemodialysis access grafts with an intermediate probability of graft malfunction.One hundred forty-seven complete US examinations were performed in 91 patients. Average volume of flow, peak systolic velocity, and diameter of residual lumen were recorded. Patients were referred by the nephrology department when clinical findings were suggestive, but not obviously, of graft malfunction. Study results were deemed normal if flow volume exceeded 1,300 mL/min without significant visualized stenosis of 50% of the diameter or greater or if flow approached 1,300 mL/min without peak systolic velocity greater than 400 cm/sec.Of the 147 examinations, 49 (33%) had normal results, seven (5%) showed thrombosis at examination, and 91 (62%) had evidence of at least one significant visualized stenosis or diffuse notable degree of thrombus. Three patients with normal results required fistulography within 90 days, one for thrombosis. In the 91 studies with abnormal results, 69 patients underwent fistulography; results in 63 showed agreement, and three showed false-positive results. More central venous stenoses were found at fistulography than at US.US is a useful and reliable first step in managing clinically suspected hemodialysis graft stenosis. One-third of the studies showed no significant stenosis and did not require angiographic evaluation. US should be the initial study in patients suspected of having hemodialysis access dysfunction without exceptional evidence of stenosis.

Abdominal aortic aneurysms occur in as much as 2-3% of the population, and their rupture produces a mortality rate of 78-94% (1), causing 15,000 deaths per year in the U.S. alone. As an investigation into the mechanical factors that lead to aneurysm rupture, flow field measurements are presented for steady flow through a range of aneurysm sizes and Reynolds numbers. Seven rigid symmetric models of aneurysms were constructed with uniform lengths of 4d and diameters that ranged from 1.4 to 3.3d, where d is the inner diameter of the undilated entrance tube. Color Doppler flow imaging was used to visualize the flow fields, while laser Doppler velocimetry was used to quantify the flow field velocities and to determine critical Reynolds numbers for the onset of, and complete transition to, turbulent flow. Estimates of mean and peak wall shear stresses were derived from velocity measurements. Flow in these models varied from fully laminar to fully turbulent over the range of Reynolds numbers corresponding to in vivo flows. There was a large range over which the flow was intermittently turbulent. High wall shear occurred in the models when the flow was turbulent, suggesting that turbulence in in vivo aneurysms may contribute significantly to their risk of rupture.

Editor: At a recent RSNA refresher course, as the result of adverse circumstances one of five speakers was unable to attend at the last minute. These five speakers had made the same presentations the previous year, which were videotaped. Since two of the presentations were given with traditional slides, two were given with computer-generated slides, and the presentation by the speaker who was unable to attend was videotaped, we used this opportunity to poll course attendees regarding their preference for the type of scientific presentation. The attendees were asked to rate their preference for the presentation method separately from giving their opinions regarding scientific quality. The presentations were rated on a 1–5 scale, with 5 indicating the most preferred (excellent) method. The responses were compared by using a two-sample test of proportions. Approximately 180 course attendees responded. Overall, 82% (145/178) rated traditional slides as excellent or very good, compared with 87% (156/180) for computer-generated slides and 32% (56/174) for the videotaped presentation. By combining the excellent and very good ratings, differences were found to be significant for traditional slides versus videotapes and for computer-generated slides versus videotapes at the 5% level of significance (P , .05). The test failed to reject the null hypothesis, and there was no difference at the 5% level of significance in the percentage of respondents who rated computer-generated slides and traditional slides as excellent or very good. The audience members who responded to the survey preferred live presentation with the use of either traditional or computer-generated slides compared with videotapes. Most written responses criticized the videotaped presentation because audience members were unable to ask questions and request the presenter to further define points that they did not understand. Several attendees found the computergenerated slides distracting because of the motion activity related to adding words. In fact, some found it distracting to see information coming from the left or the right side of the slide. Others found this type of presentation more lively and said that it ‘‘kept them awake.’’ Attendees criticized the ‘‘fumbling around’’ that was required to hook up the computers for computer-generated slides when the presenters changed. In addition, several attendees preferred the doubleprojection format of traditional slides compared with the single-projection format of computer-generated slides. In summary, and perhaps most important, attendees at the RSNA scientific assembly who were polled preferred in-person presentations with either traditional or computer-generated slides.

To the Editor. —Dr Bundens and colleagues 1 report that the possibility of error in interpretation of venous duplex reports that use the term "superficial femoral vein" may result in improper treatment for patients. However, Bundens et al fail to discuss the responsibility that most radiologists who staff vascular laboratories feel regarding contacting referring physicians when significant abnormalities are detected on venous ultrasound. It is common practice to contact the referring physician and describe the significance of the acute venous thrombosis process when it is noted. As a result, it would be rather unusual for the referring physician to be unaware of the significance of an acute thrombosis involving the superficial femoral vein. While I have no objection to using a new name for this vein to avoid confusion, I do not think changing the name of the vein changes the responsibility of those physicians interpreting this examination to make

Background.— Continuous quality improvement is being advocated as the process that, if adopted, would improve the efficiency, productiveness, and quality of medical institutions, thereby helping to solve the health care crisis our country is facing. To determine if these techniques could be effective in a tertiary-care multispecialty group practice, a model project was undertaken. The model project chosen was to determine if we could improve the turnaround time for "stat" laboratory examinations performed in our large outpatient facility. Methods.— A 10-member team consisting of everyone involved in the process of laboratory testing was empowered to evaluate the present process and make appropriate changes. With traditional techniques of quality improvement, the process was assessed, data were collected and statistically analyzed, changes were introduced, and data were recollected and analyzed. Results.— After intervention, the preanalytic delays were reduced by 76% and the postanalytic delays by 88%. Waiting time for patients was reduced by an average of 62%. By instituting the changes suggested, the institution saved $225 000 on a one-time basis and $40 000 to $50 000 on a recurring basis. Conclusion.— Adoption of quality improvement techniques appears to be a desirable management paradigm that should be explored by all medical institutions interested in maximizing the quality of care offered while at the same time minimizing its cost. ( Arch Intern Med. 1992;152:837-840)

A retrospective study of 152 ileostomates with inflammatory bowel disease (IBD) revealed that 16 patients (10.5 per cent) had diagnoses of cholelithiasis before, at the time of, or after having ileostomies. Of the remaining patients, 69 were followed for possible cholelithiasis, most of those with sonographic examination. Sixteen of this latter group of patients (23.2 per cent) were found to have cholelithiasis, usually in an asymptomatic stage. Among women over 50 years old, seven of 11 (63.6 per cent) had gallstones. Due to this high prevalence of cholelithiasis, gallbladder imaging is recommended as a part of the preoperative workup and follow-up of ileostomates. Prophylactic cholecystectomy may be carefully considered in female patients with IBD at the time of proctocolectomy.

A retrospective study evaluated 50 patients who had pathologically proven intraplaque hemorrhage. The patients were pathologically divided into two groups by the presence or absence of intimal ulcerations. These two groups were then sonographically compared with regard to surface characteristics of the plaque, plaque size, size of the sonolucent area within the plaque, and location of the sonolucent area relative to the intimal surface. No defined sonographic characteristics could be used to separate these two groups of patients with heterogeneous plaques into those who had or did not have ulcerations. Most importantly, merely sonographically evaluating the surface of the plaque to determine if it was smooth or irregular could not be used as a successful means to identify which patients were at risk for ulceration.

Sixty-nine patients were evaluated prospectively by sonography and history to determine the presence of cholelithiasis. Sixteen patients (23%) had a positive diagnosis. A control group was also prospectively evaluated. We have determined that patients above age 50 with a permanent ileostomy are at statistically significant risk of having cholelithiasis, and their risk is greater than that of a control group matched for age and sex. Radiologists should recognize this association and carefully evaluate the gallbladder of any patient with a permanent ileostomy who has abdominal pain.

A criticism of duplex scanning of the carotid vessels is that the study is limited to evaluation of the carotid bifurcations, whereas with other vascular imaging studies the vertebral vessels can also be seen. We have prospectively collected data on our ability to evaluate the vertebral vessels on all patients who are sent for carotid evaluations. We have scanned 677 patients and have identified flow in one or both vertebral arteries in nearly 90% of these patients. Therefore, we urge that evaluation of vertebral vessels be made a routine part of the standard carotid duplex ultrasound examination.

By careful evaluation of the sonographic characteristics of carotid plaques, two patterns can be identified: (1) a homogeneous pattern containing uniform echoes corresponding to dense fibrous tissue and (2) a heterogeneous pattern containing mixed echoes and anechoic areas that represent intraplaque hemorrhage pathologically. A prospective study was conducted of 50 patients to determine the accuracy of identifying these different forms of plaque. The patients' carotid arteries were examined by a high-resolution duplex scanner before carotid endarterectomy. The plaques were evaluated carefully by vascular surgeons and pathologists for the presence of intraplaque hemorrhage. In this study, the accuracy of identifying the presence or absence of intraplaque hemorrhage with sonography was 90% (48 of 54); sensitivity, 94% (17 of 18); and specificity, 88% (27 of 31). High-resolution sonography appears to be an accurate means of identifying intraplaque hemorrhage and may ultimately be useful in identifying patients at risk for embolic disease.