Reassessing the role of the human chorionic gonadotropin (hCG) discriminatory zone in the evaluation of patients with a pregnancy of unknown location

Abstracts would be similar to the pattern of lung empyema. By adjusting the amount of agar powder, different pattern would be demonstrated: with the amount of powder increased, the particles seen wound increased, which made it looks like collapsed lung under sonographic study. For creating the model of consolidation, we added Gelatine into the agar powder to make the jelly harder. Conclusion: The phantom for lung pathologies created in our study could be made easily with inexpensive cost and the images of sonographic study are similar to the real ones. This model could be used to teach common lung pathologies seen in clinical scenes. References: 1. Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R. “Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Metaanalysis. J Emerg Med.2019 Jan;56(1):53-69. 2. Zanobetti M1, Scorpiniti M2, Gigli C et.al. “Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED”. 2017 Jun;151(6):1295-1301. 3. James V, Kee CY, Ong GY. “A Homemade, High-fidelity Ultrasound Model for Simulating Pneumonia with Parapneumonic Effusion and Empyema. J Emerg Med. 2019 Jan 9. pii: S0736-4679(18)31206-X. 4. Rippey J, Gawthrope I. “Creating thoracic phantoms for diagnostic and procedural ultrasound training”. Australas J Ultrasound Med. 2012 May;15(2):43-54. Single practice audit of indications and findings in fetal growth ultrasound Debra Paoletti,1,2 Catherine Jackson,3 Wu Syong Tan4 1 Canberra Hospital, Garran, ACT, Australia, 2 School of Medicine, Australian National University, Canberra, ACT, Australia, 3 Capital Women’s Health, Canberra, ACT, Australia, 4 Canberra Fetal Assessment Centre, Canberra, ACT, Australia Introduction: In Australia, ultrasound assessment of pregnancy is not routine after 22 weeks gestation, however ultrasound for fetal growth forms a substantial part of the case load in a typical obstetric ultrasound practice. Aim: To determine how many ultrasound assessments beyond 22 weeks gestation are performed in a typical obstetric ultrasound practice, the gestations they were performed, and the most common indications for referral. Methods: A retrospective study was undertaken to evaluate occasions of service for fetal growth ultrasound beyond 22 weeks in 2016 in a private ultrasound practice dedicated to obstetrics and gynaecology in Canberra, ACT. Results: Over one quarter of patients seen in 2016 were referred for ultrasound examinations beyond 22 weeks. Most ultrasounds (58%) were performed between 32 and 36 weeks, and for most (53%), this was the only growth scan performed. Common indications were for unspecified fetal growth concerns, maternal diabetes, and suspected placental abnormalities. Conclusion: Many providers of obstetric care consider an ultrasound between 32 and 36 weeks part of clinical care, despite recommendations against routine third trimester.

Increased pancreatic echogenicity and severity on US: Association with glycemic progression and incident diabetes Hyun Jeong Park, Ji Yun Oh, Hye Shin Ahn, Eun Sun Lee, Sung Bin Park, Byung Ihn Choi Chung-Ang university hospital, Seoul, South Korea Purpose: To investigate the relationship of increased pancreatic echogenicity (IPE) on US with the risk of glycemic progression and incident diabetes.

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Methods: This retrospective study was approved by the institutional review board, with waiver of informed consent. Consecutive individuals who had undergone abdominal ultrasonography as part of a health examination at a tertiary hospital between January 2010 and June 2010 were included. IPE was defined as increased echogenicity of the pancreas compared with that of the left lobe of liver or renal cortex. IPE subdivided into mild, moderate, and severe degree comparing to the retroperitoneal fat echogenicity. Glycemic progression was defined as the development of new prediabetes or diabetes in normoglycemic subjects or as new diabetes in prediabetic subjects during the follow up period (median, 86.8 months; interquartile range, 84.1 90.6 months). The occurrence of incident diabetes, defined as a new diagnosis of diabetes during follow-up, was also analyzed. Results: A total of 596 subjects were included in the follow-up analysis. Mean age of the 596 subjects was 48.6 years § 11.5, and 55.4 % (n = 330) were female. The prevalence of IPE was 63.8 % (380/596). Mild, moderate, and severe IPE groups were 32.4%, 22.7%, and 8.7%, respectively. During the follow-up, 79 (13.3%) of the 596 subjects developed glycemic progression and new diabetes. Only presence of IPE was not associated with glycemic progression (P = 0.401). However, IPE more than moderate degree revealed significant associated with glycemic progression (hazard ratio, 1.38; 95% confidence interval: 1.920 8.300; P = 0.002). Conclusion: Only presence of increased pancreatic echogenicity is not a risk factor of glycemic progression. IPE more than moderate degree is associated with impaired glycemic parameters and higher risk of glycemic progression and incident diabetes. References: 1. Jun Seok Lee et al. Clinical implications of fatty pancreas: Correlations between fatty pancreas and metabolic syndrome, World J Gastroenterol 2009;15(15): 1869-1875. 2. Horng-Yih Ou et al. The Association between Nonalcoholic Fatty Pancreas Disease and Diabetes, Plos one 2013;8:e62561. 3. Chi-Sheng Hung et al. Increased Pancreatic Echogenicity with US: Relationship to Glycemic Progression and Incident Diabetes. Radiology 2018;287:853-863. 4. Hajime Yamazaki et al. Lack of Independent Association Between Fatty Pancreas and Incidence of Type 2 Diabetes: 5-Year Japanese Cohort Study. Diabetes Care 2016;39:1677 1683. 5. Cosmas Rinaldi A et al. Non-alcoholic fatty pancreas disease, pancreatic cancer, and impact of endoscopic ultrasound examination on screening and surveillance, EMJ Gastroenterol. 2017;6(1):69-74.

Reassessing the role of the human chorionic gonadotropin (hCG) discriminatory zone in the evaluation of patients with a pregnancy of unknown location Sophie Peryman,1,2 Jenny Sim,1 Karen Wallis,1 Miriam Scadeng1 1 Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand, 2 Department of Radiology, Waitemata District Health Board, Auckland, New Zealand Objective: This study aimed to determine the usefulness of the Human Chorionic Gonadotropin (hCG) Discriminatory Zone (DZ) (defined as the serum hCG value above which an intrauterine gestational sac is consistently seen on ultrasound in normal pregnancies1) as a diagnostic tool in the evaluation of patients presenting symptomatically (lower abdominal pain and/or vaginal bleeding) with a pregnancy of unknown location (PUL). A PUL is defined as a clinical scenario where a woman has a positive pregnancy test and no evidence of either intrauterine pregnancy or ectopic pregnancy on transvaginal ultrasound2. This objective will be achieved in this study by asking three questions: Firstly, how useful is the DZ in identifying an ectopic pregnancy? Secondly, how useful is the DZ in identifying a failed intrauterine

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pregnancy? And third, can a patient with an hCG level above DZ levels and a PUL following the initial scan can progress to a live, intra uterine pregnancy? Methods: A retrospective chart review of ultrasound records at one, large urban hospital in Auckland, New Zealand identified 97 patients with lower abdominal pain and/or vaginal bleeding, who had serum hCG testing and transvaginal ultrasound performed within 12 hours of initial hospital presentation. The following information was recorded: hCG level, initial ultrasound findings, follow up outcomes, age, gravida and parity. Statistical analysis using Kruskal-Wallis and Wilcoxon were then performed. Results: In total, 97 women met the criteria and were included in the study. Twenty-seven women had an hCG level of 1000 IU/L or higher, with true PUL on ultrasound. Of these, three went on to develop a normal intrauterine pregnancy, three were ectopic and 20 were miscarriages. The highest hCG value with a true PUL that progressed to a live intrauterine pregnancy was 2767 IU/L. The hCG discriminatory zone showed wide variability in hCG values and no statistically significant difference between median hCG values in the initial transvaginal ultrasound groups. The difference in median hCG values were found to be statistically significant between the final outcome groups of IUP, miscarriage and ectopic. However, the large overlap in values across the groups shows that hCG has low specificity. Conclusion: This study recommends limited reliance on the hCG DZ and raises awareness of the high variability of hCG values. The hCG DZ was not shown to be useful in this study in the evaluation of women with a pregnancy of unknown location.

Noinvasive fibrosis assessment in fatty liver disease in diabetes patients Alina-Simona Popescu,1 Ioan Sporea,1 Camelia Gianina Foncea,1 Silviu Nistorescu,1 Diana Gherhardt,1 Raluca Lupusoru,1 Radu Cotrau,1 Alexandra Sima,1 Roxana Sirli,1 Mirela Danila,1 Tudor Moga,1 Romulus Timar2 1 Gastroenterology and Hepatology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania, 2 Diabetes and Nutrition Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania Background and Aim: Noninvasive tools are well accepted by patients for fibrosis assessment in chronic liver diseases, including nonalcoholic fatty liver disease (NAFLD). Transient elastography (TE) is an accepted alternative to liver biopsy for fibrosis evaluation. NAFLD is quite frequent in clinical practice and it is difficult to identify those patients who have nonalcoholic steatohepatitis (NASH). The aim of this study was to assess the value of simple biological tests (APRI, FIB 4 Index and BARD score) for ruling out the presence of significant and severe fibrosis and their correlation with TE in diabetic patients with NAFLD. Material and Method: We conducted a prospective study which included 469 diabetic patients (p) out of which 454 had steatosis (average age 61 § 9.3 years, 55.1% female), evaluated both by serum markers (TGO, TGP, platelets) and by TE-Fibroscan (Echosens,Paris, France), with incorporated CAP function. Based on specific formulas we calculated APRI, FIB4 index and BARD score. Liver stiffness measurements (LSM) were considered reliable if 10 valid values with an IQR/median < 30% were obtained. For differentiation between stages of liver fibrosis, the following cut-off values were used [1]: significant fibrosis > 8.5 kPa, severe fibrosis > 10.1kPa, and for steatosis we considered: S1(mild)230-275 db/m, S2 (moderate)-275-300 db/m, S3 (severe) > 300 db/m. Results: We tried to rule out significant fibrosis by using APRI < 0.5 (77%p) - 63% of them with LSM < 8.5 kPa, resulting in NPV of 85.7%; and severe fibrosis by using APRI < 2 (98.5%p) - 80.6% of them with LSM < 10.1 kPa, resulting in NPV of 86%. We found a

Volume 45, Number S1, 2019 moderate, but significant correlation between liver fibrosis assessed by TE and liver fibrosis predicted by APRI (Pearson r = 0.5, p = 0.001). Regarding FIB4 score, we found that 94%p had FIB4 < 2.6, thus ruling out severe fibrosis, among which 99% had LSM < 10.1kPa, resulting in NPV of 85%. The correlation between FIB4 and TE was weak, but statistically significant (r = 0.23, p = 0.0001). 18.3% of patients had a BARD score < 2, 95.2% of them with LSM < 10.1 kPa, resulting in a strong NPV of 86.1%. Conclusion: simple tests such as APRI score < 2, FIB4 score < 2.6 and BARD score < 2 can quite accurately rule out advanced fibrosis. These simple scores could be used as first line tests to rule out patients with advanced fibrosis.

Performance of a THED system for ruling in/ruling out Liver Cirrhosis as compared with Transient Elastography Tudor Moga, Alina-Simona Popescu, Popa Alexandru, Raluca Lupusoru, Camelia Gianina Foncea, Andrea Zsch€ atzsch, Meghana Enumula, Roxana Sirli, Mirela Danila, Ioan Sporea Gastroenterology and Hepatology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania Introduction: While most ultrasound elastography methods employ transient stimulation methods, the new time harmonic elastography (THED) relies on time-harmonic vibrations in the same manner as magnetic resonance elastography. The aim of our study was to assess the performance of the THED system for ruling in/out liver cirrhosis (LC) considering transient elastography (TE) as the reference method, as well as and the correlation of THED values with TE. Material & Method: We evaluated by THED a group of 70 patients. Each subject has been fasting for more than 6 hours before evaluation. 10 valid LS measurements were performed in the same day, both by THED and by TE. We used the TE cut-off values published by Tsochatzis (1): significant fibrosis (F  2)- 7.0kPa and for LC (F = 4)12kPa as reference values. Quality criteria recommended by the manufacturer: SR  60%, IQR < 30% have been used for each subject. For a better work flow we transformed the measurement units also in KPa. Results: From the 70 patients, 34 were women and 36 men. Mean age 55.2 § 11.7, mean BMI 27.8 § 6.2 kg/m2. Of the 70 patients, 15.8% (11/70) were F4, 25.7% (18/70) were F2-3, 58.5 % (41/70) were F0-1. We had 100% feasibility for all the patients that were previously evaluated by TE. The cut-off for ruling out LC by THED measurements on our study group was < 1.5 m/s (7.2 KPa), AUROC = 0.83, 95%CI (0.73-0.91), P < 0.0001, Se = 100%, Sp = 35.1%, PPV = 31.4%, NPV = 100%. The cut-off for ruling in LC by THED measurements was > 2 m/s (11.9 kPa). AUROC = 0.83, 95%CI (0.73-0.91), P < 0.0001, Se = 18%, Sp = 100%, PPV = 100, NPV = 80.6%. There was a direct, positive and strong correlation between LS measurements by THED and TE evaluated with Pearson correlation coefficient, r = 0.73, p < 0.001. Conclusions: In our study, the cut-of values to rule-out and rule-in LC by LS measurements with THED system were < 7.2 KPa and > 11.9 kPa, respectively. There was a strong correlation between the LS values obtained by the two elastographic methods.

Ultrasound-based elastography methods for predicting the presence of esophageal varices in patients with alcoholic liver cirrhosis Camelia Gianina Foncea, Alina-Simona Popescu, Raluca Lupusoru, Tudor Moga, Radu Cotrau, Patricia Belintan, Alexandru Popa, Roxana Sirli, Mirela Danila, Ioan Sporea Gastroenterology and Hepatology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania