Tissue Harmonic Imaging
Author:
Philip W. Ralls M.D.
Objectives: Upon completion of this CME article, the reader will be able to
1.
Explain what tissue harmonics are and how they are generated.
2.
Describe how tissue harmonic imaging has advantages over conventional pulse-echo
imaging.
3.
Describe how tissue harmonic imaging might be used in the clinical setting.
Introduction
Tissue harmonic imaging is a new grayscale imaging technique. It creates images that
are derived solely from the higher frequency, second harmonic sound produced when the
ultrasound pulse passes through tissue within the body. Tissue harmonics uses various
techniques to eliminate the echoes arising from the main transmitted ultrasound beam (“the
fundamental frequencies”), from which conventional images are made. Once the
fundamental frequencies are eliminated, only the harmonic frequencies are left for image
formation. Indeed, the quality of the harmonic image is primarily dependent on the
complete elimination of all echoes derived from the transmitted frequencies. Tissue
harmonic imaging offers several advantages over conventional pulse-echo imaging, including
improved contrast resolution, reduced noise and clutter, improved lateral resolution, reduced
slice thickness, reduced artifacts (side lobes, reverberations) and, in many instances,
improved signal-to-noise ratio.
What are Tissue Harmonics?
Harmonics are familiar to most of us because of their importance in music. Musical
tones can generally be described by their loudness, pitch (frequency) and quality. Quality is
the difference that can be heard between two notes that have the same loudness and pitch.
Thus, a guitar playing a C-note produces different quality sound than a piano playing the
same C-note. The difference between these two notes is a result of the presence of
harmonic frequencies. It is the varying amounts of harmonics that give an instrument its
characteristic sound. Harmonic frequencies are integral multiples of the fundamental
frequency. Thus, a string vibrating at a fundamental frequency of 440 Hz, (C-note) may also
have vibrational modes at 880, 1320, 1760 Hz corresponding to harmonics at 2X, 3X and 4X
the fundamental frequency.
Ultrasound pressure waves can be described in a very similar manner. A modern 2.0
MHz transducer transmits a band of frequencies centered on the 2.0 MHz frequency. For
this transducer, a typical transmitted frequency band might be from 1.2 MHz to 2.8 MHz,
covering a range of 1.6 MHz, or 80% bandwidth. In conventional fundamental imaging,
when tissue is evaluated with a band of frequencies centered at 2 MHz, most of the echoes
that come back to the transducer will be echoes related to the same 2 MHz frequency band.
Harmonics are multiples of the fundamental beam, therefore, transmitting a band of
frequencies centered at 2 MHz will result in the production of harmonic frequency bands
centered at 4 MHZ, 6 MHZ, 8 MHZ, etc..
Only a small part of the returning sound involves these higher frequency harmonics
(4, 6, 8 MHz) because they are much lower in amplitude than the reflected fundamental
beam. As a practical matter, only the lowest frequency harmonic (double the fundamental
frequency) is used to form images. This doubled frequency sound is called the second
harmonic. Higher order harmonics (three or more multiples of the fundamental) are not
used in image formation. There are a number of reasons why this is so, which are:

the range of frequencies that current transducers can detect is insufficiently large to
capture these higher frequency signals

these higher order harmonics are progressively lower in amplitude, and

the higher frequencies are more quickly lost as they pass through tissue
Generation of Tissue Harmonics
Harmonics are generated by the passage of the ultrasound beam as it passes through
tissue. The peaks and troughs of the transmit pulse cause the tissue to alternatively expand
and contract, distorting its shape. Because tissue is not linearly elastic, it contracts less than
it expands. During tissue contraction, tissue density increases, causing the peak of the sound
wave to travel slightly faster than the trough. The result of this process, called non-linear
propagation, is that the wave becomes progressively more asymmetrical. This asymmetrical
distortion results in harmonics.
Although the amount of harmonics that tissue generates at any given instant is small,
the harmonics build as the pulse propagates through tissue. A similar effect is seen as an
ocean wave approaches a beach. At sea, the wave is smooth and symmetrical. When the
wave reaches shallow water, friction causes the bottom of the wave to slow down, whereas
the top of the wave continues at its original velocity. As the wave gets progressively closer
to shore, it “sharpens”, or even breaks. Thus, as the ultrasound wave travels through more
tissue, more harmonics are generated.
Higher intensity transmit waves generate both higher intensity harmonics and more
harmonics. The production of harmonics is proportional to the square of the fundamental
intensity. Thus, a 3-dB increase in the fundamental beam will result in a 6-dB increase in
harmonic intensity. For this reason, harmonics are generated predominantly by the main
transmit beam. The region of maximal production of harmonics is at the focal zone,
because beam intensity is highest at that location. Little or no harmonics are produced by
weak waves, such as side lobes, grating lobes, scattered echoes, and at the edges of the main
ultrasound beam. As a result, beams formed from tissue harmonic signals have less side
lobes, less noise, and improved contrast resolution.
Artifact Reduction with Tissue Harmonics
The major benefit of tissue harmonic imaging is artifact reduction. Tissue harmonic
images often exhibit a reduction in image noise and clutter with a consequent improvement
in contrast resolution (improved signal-to-noise). Artifact reduction results in less noisy
images, making cysts appear clearer and improving visualization of pathologic conditions
and normal structures. Tissue harmonic imaging reduces artifact in several ways, which are:
1. Decreased scatter from the body wall
2. Reduced artifacts from weak echoes such as side lobes, scatter, and grating lobes
3. Less near field haze from body wall reverberations.
1. Decreased Effects of the Body Wall
Sound does not travel in straight lines or at a constant velocity through the body wall
because tissue has a complex composition – fat, skin, muscle, and subcutaneous tissue. This
causes significant distortion and scattering of the transmitted ultrasound beam. In
conventional fundamental imaging, beams have to pass through the body wall twice – once
with the initial transmission and second, when the echo returns. Unlike fundamental echoes,
tissue harmonic signals, which are produced in the tissue from within the body, only pass
through the body wall one time. Because tissue harmonics are mainly generated in the tissue
beyond the body wall, the distortion and scattering is greatly reduced.
2. Reduced Artifacts from Weak Echoes
One important consequence of nonlinear wave generation is that it depends on the
intensity (strength) of the incident wave. Roughly, the generation of harmonics may be
thought of as an inverse quadratic relationship or square law. That means that if a weaker
fundamental pulse (for example, a side lobe) is one third as strong as the echo from the main
beam, the side lobe will produce only one ninth of the harmonics. Therefore, a weak wave
(such as that from the edge of the ultrasound beam, or a scattered echo, or a side lobe)
produces little or no harmonics, while a strong wave (such as the center of the transmit
beam) produces disproportionately more harmonic energy. By detecting the harmonics only,
harmonic imaging preferentially rejects echoes that come from weak parts of the beam. In
this way, side lobe, reverberation, and other artifacts are reduced in harmonic images.
Harmonic-related artifacts, therefore, are less prominent than artifacts associated with the
fundamental frequency. This results in “cleaner” looking images, especially in cystic
structures, and improved detection of parenchymal lesions.
3. Decreased Body Wall Reverberations
Another major benefit of harmonic imaging is the virtual elimination of
reverberation artifacts from the body wall. Harmonics do not develop in the first few
centimeters, but many artifacts do. In particular, multiple reverberations between the
transducer and the body wall layers cast a ‘haze’ that overlies the image. Because in reality
these artifacts are mis-registered echoes from the near field, they do not contain harmonics
and disappear in the tissue harmonic image.
Image Formation in Tissue Harmonics
Tissue harmonic imaging operates by transmitting a fundamental beam that has a
lower frequency. This fundamental pulse, as it propagates through tissue inside the body,
generates the higher frequency harmonic sound. The key to understanding tissue harmonic
imaging is that the image is formed only from the higher frequency harmonic sound.
Echoes from the fundamental frequency are rejected and thus, are not used in making the
image. Indeed, if the higher amplitude fundamental echoes are not eliminated, they degrade
the image to the point that there is no benefit from tissue harmonic imaging. The stronger
fundamental echoes, if not eliminated, will mask the harmonics. Obviously, sophisticated
transmit beam formation and signal detection is required to produce good quality harmonic
images. It is possible that the ability to produce high quality harmonic images may be an
interesting test of an ultrasound system’s overall capabilities.
Several techniques are currently employed to detect harmonics and eliminate the
unwanted fundamental echoes. Filtration techniques remove the echoes from the
fundamental frequency and allow the harmonic frequencies to pass, so that the harmonic
image can be formed. Other techniques cancel the fundamental echoes. Some of these
include single line pulse inversion (PI), side-by-side phase cancellation, and transmit pulse
encoding. All of these techniques require excellent transmit beamformer performance.
Other pulse manipulation techniques will undoubtedly be developed in the future.
Filtration
Filtration to remove the fundamental frequency is the technique currently used most
commonly to produce tissue harmonic images. Filtration uses sophisticated transmit beam
formers to produce a narrower bandwidth and signal processing techniques to filter out the
spectrum of frequencies that are likely to arise from the fundamental beam. The
fundamental ultrasound pulse is not a single frequency, but is really a range of many
frequencies that are distributed around the mean transmitting frequency (for example, a band
of frequencies from 1.2 to 2.8 MHZ for a 2 MHZ transducer). Because of this, there are
frequencies at which the information from both the fundamental signal and the harmonic
signal overlaps.
If a system produces a broader bandwidth, then the overlap between the harmonic
echoes and the fundamental signals is greater. In this setting, filtration will then result in the
removal of significant harmonic information along with the unwanted fundamental echoes.
However, use of a narrower bandwidth will result in less overlap. With narrow bandwidth
beams, filtration can provide a much cleaner separation of the harmonic-related information
from the fundamental signal (figure 1).
Single Line Pulse Inversion (PI)
Pulse inversion is a technique that adds the echoes from two opposite polarity pulses
to cancel the fundamental echoes, leaving only the harmonic information. An initial pulse is
sent into the body and the returning echoes are recorded. This first pulse-echo cycle results
in both fundamental and harmonic frequencies returning from the tissue and the data
received are stored. A second inverted pulse (opposite in polarity, or phase) is then
transmitted. Fundamental and harmonic frequencies of the second cycle are received and
added to the data received from the first cycle. Assuming no patient motion, adding the data
will then cancel the linear, fundamental echoes. The non-linear harmonic information
remains, resulting in an unfiltered harmonic signal over the entire frequency bandwidth of
the transducer. This is advantageous because the images produced do not suffer degradation
of axial resolution. However, the potential problem is that this method can suffer image
degradation from tissue motion.
Side-by-side Phase Cancellation
Side-by-side phase cancellation is similar to pulse inversion. Instead of two firings of
opposite phase ultrasound beams along the same line, this method sends both signals
together at the same time with opposite phases. These adjacent lines are then added. The
resulting cancellation of the fundamental opposite phase lines leaves the harmonics, from
which images can be made. Like pulse inversion, this technique preserves the bandwidth of
the harmonic sound. This technique is a spatial cancellation technique, while pulse inversion
is a temporal cancellation technique.
Pulse Encoding
Pulse encoding of the transmitted ultrasound beam is another technique to cancel
the fundamental echoes and enhance harmonic detection. Transmit pulse encoding uses
relatively complex waveform sequences to give each a unique, recognizable signature or
code. This complex, coded pulse is sent into the body. The unique code is then recognized
in the return waveform by a special decoder that is part of the equipment. Because the
linear, fundamental echoes have a specific code, they can be identified and canceled. The
remaining nonlinear harmonic signal is then processed to form the image. This technique
has proved especially useful in the near field.
Tissue Harmonic – Image Characteristics
Decreased Image Dynamic Range
Images produced with harmonic imaging often appear different from those
generated with fundamental frequencies. The amplitude of the harmonic signals is generally
one to two orders lower in magnitude than the fundamental signal. Because of this, the
dynamic range of harmonic imaging is lower, as much as 18 dB lower than the fundamental
beam. This much weaker signal level of the harmonic results in images with more contrast.
This characteristic may, on occasion, actually improve visualization and conspicuity of subtle
parenchymal lesions.
Better Lateral Resolution – Reduced Slice Thickness
The beam profile (slice thickness) of the harmonic frequencies is always narrower
than the fundamental pulse that is used to produce it. This occurs because the acoustic
intensity of the transmitted ultrasound pulse is lowest along the edges and highest in the
center. Thus, the edges of any ultrasound beam produce fewer harmonics than the more
intense central beam. This peripheral dropout means that the harmonic beam has smaller
dimensions, both in lateral and slice thickness (elevation) directions.
Artifacts
Tissue harmonic imaging reduces some artifacts, and enhances others. Fortuitously,
it is often the detrimental artifacts that are reduced, while the useful artifacts, which often
reveal important information about the anatomy and pathology, are made more visible. For
example, echoes resulting from side lobes are often reduced (figure 2) or eliminated.
The square law in harmonic imaging, which states that harmonic production is
proportional to the square of the fundamental amplitude, results in minimizing certain
artifacts. Reverberations, side lobe artifacts, and partial volume artifacts due to slice
thickness are good examples of echoes that are small in amplitude and therefore produce
minimal harmonics.
Some artifacts may be more prominent on tissue harmonic images. Examples
include acoustic enhancement deep to a fluid collection (through transmission), acoustic
shadowing (figure 3), and comet tail artifacts.
Worse Images in “Glass Body” Patients
Because filtration decreases bandwidth, in some cases, the resolution in harmonic
images may be worse than fundamental imaging. Tissue harmonic images may be inferior to
conventional high frequency fundamental images in patients who are excellent ultrasound
subjects (“glass bodies”). This difference is related to the better contrast resolution of the
higher frequency fundamental image.
Clinical Effects of Tissue Harmonic Imaging
While the focus of this manuscript has been to improve the understanding of the
basic principles of tissue harmonic imaging, speculation regarding the clinical impact of this
modality is appropriate. Harmonic imaging is not a universal solution to ultrasound imaging
problems, although in certain patient populations it clearly provides more diagnostic
information. Preliminary studies suggest that tissue harmonic resolution improves clinical
imaging in several applications. The eventual impact of tissue harmonic imaging, however, is
not yet clear. Harmonic imaging relies on weak echoes that cannot be achieved uniformly
on a patient-to-patient basis. Only when tissue harmonic techniques are technologically
mature and more widely distributed will we know the ultimate clinical usefulness.
Tissue harmonic imaging may display pathology and normal structures with greater
clarity than fundamental imaging. Good images are often obtained with less effort. It may
be easier to scan technically difficult patients. Because of these features, tissue harmonic
imaging has the potential to decrease the time required to scan some patients.
The clearer images sometimes provided by harmonic imaging can lead to important
clinical information. Questionable lesions may be either confidently identified or excluded
on harmonic images. On occasion, harmonic images identify lesions that are invisible, or
nearly invisible, even in retrospect, on the fundamental images. Common duct stones (figure
4) and focal liver lesions are examples of this. Pathology suspected on fundamental images
may not be present when harmonics shows the anatomy more clearly.
Tissue harmonic imaging seems especially effective in renal imaging, probably
because of the considerable distortion related to the body wall in that area. In a number of
cases using tissue harmonics we have been able to confidently diagnose renal cell carcinoma
and kidney stones that were undetected with fundamental imaging. Often, simple renal cysts
can be definitively diagnosed on harmonic images when fundamental images are nondiagnostic (figure 5), reducing the need for follow-up CT exams.
By making it easier to obtain better quality images, tissue harmonic imaging may
improve the overall quality of ultrasound diagnosis. Tissue harmonic sonography is still in
its infancy. The eventual usefulness of harmonic imaging will be better understood, as it
becomes increasingly available and more technically mature on sonographic systems.
Figures
1
Tighter beam profile (narrower transmit bandwidth), makes it easier to remove the
fundamental echoes by filtration.
2
Echoes resulting from grating lobes are often reduced or eliminated.
3
The increased contrast of tissue harmonic images makes some artifacts more
prominent. Fortunately, these are usually “helpful” artifacts.
4
Tissue harmonics shows a common duct stone missed with fundamental imaging.
5
Simple renal cyst. Tissue harmonics often makes definitive diagnosis possible,
obviating further imaging.
References or Suggested Reading:
1.
Averkiou MA, Hamilton MF. Measurements of harmonic generation in a focused
finite-amplitude sound beam. J Acoust Soc Am 1995; 98:3439-42.
2.
Christopher T. Finite amplitude distortion-based inhomogeneous pulse echo
ultrasonic imaging. IEEE Trans. Ultrason. Ferroelec. Freq. Contr., 1997 Jan; 44:125139.
3.
Desser TS, Jeffrey RB Jr, Lane MJ, Ralls PW. Tissue harmonic imaging: utility in
abdominal and pelvic sonography. J Clin Ultrasound 1999 Mar-Apr;27(3):135-42.
4.
Hann LE, Bach AM, Cramer LD, Siegel D, Yoo HH, Garcia R. Hepatic sonography:
comparison of tissue harmonic and standard sonography techniques. AJR Am J
Roentgenol 1999 Jul;173(1):201-6.
5.
Hope Simpson D, Chin CT, Burns PN. Pulse Inversion Doppler: A new method for
detecting nonlinear echoes from microbubble contrast agents. IEEE Transactions
UFFC 1999; 46:372-382.
6.
Li PC. Pulse compression for finite amplitude distortion based harmonic imaging
using coded waveforms. Ultrason Imaging. 1999 Jan;21(1):1-16.
7.
Shapiro RS, Wagreich J, Parsons RB, Stancato-Pasik A, Yeh HC, Lao R. Tissue
harmonic imaging sonography: evaluation of image quality compared with
conventional sonography. AJR Am J Roentgenol 1998 Nov;171(5):1203-6.
Thanks for the indispensable assistance of Peter Burns, Anne Hall, Tom Jedrzejewicz, and
Jonathan Rubin
About the Author
Dr.Philip W. Ralls is a Professor of Radiology at Keck School of Medicine,
University of Southern California. He is an active Radiologist and is a Fellow of the
American College of Radiology and numerous other professional organizations.
Dr. Ralls has presented numerous lectures on ultrasound topics at many different
conferences around the country and is actively involved in research. In addition, he has
authored several publications in peer-review medical journals.
Examination:
1.
Tissue harmonic imaging offers several advantages over conventional pulse-echo
imaging, including all of the following except
A.
reduced noise and clutter
B.
reduced slice thickness
C.
increased artifacts (side lobes, reverberations)
D.
improved lateral resolution
E.
improved signal-to-noise ratio
2.
As a practical matter, only the
A.
first
B.
second
C.
third
D.
fourth
E.
fifth
harmonic is used to form images.
3.
Higher order harmonics (three or more multiples of the fundamental) are not used in
image formation, for which of the following reasons?
A.
the range of frequencies that current transducers can detect is insufficiently
large to capture these higher frequency signals
B.
these higher order harmonics are progressively higher in amplitude
C.
the higher frequencies are not lost as quickly as the lower frequencies as they
pass through tissue
D.
A & B above
E.
B & C above
4.
Regarding the generation of tissue harmonics, which of the following statements is
true?
A.
Because tissue is not linearly elastic, it contracts more than it expands.
B.
During tissue contraction, tissue density increases, causing the peak of the
sound wave to travel slightly faster than the trough.
C.
D.
E.
The result of the tissue’s contracting and expanding on the sound wave is
called linear propagation, in that the wave becomes progressively more
symmetrical.
Although the amount of harmonics that tissue generates at any given instant
is small, the harmonics decrease as the pulse propagates through tissue.
As the ultrasound wave travels through more tissue, less harmonics are
generated.
5.
The region of maximal production of harmonics is at the _____, because beam
intensity is highest at that location.
A.
focal zone
B.
side lobes
C.
grating lobes
D.
skin surface
E.
edges of the main ultrasound beam
6.
Tissue harmonic imaging reduces artifact in several ways by
A.
decreased scatter from the body wall
B.
reduced artifacts from weak echoes such as side lobes, scatter, and grating
lobes
C.
more near field haze from body wall reverberations
D.
A & B above
E.
B & C above
7.
Regarding the effects of the body wall, which of the following is a true statement?
A.
Sound does not travel in straight lines but does travel at a constant velocity
through the body wall.
B.
Even though tissue has a complex composition, this does not cause a
significant distortion of the transmitted ultrasound beam.
C.
In conventional fundamental imaging, beams have to pass through the body
wall twice.
D.
Tissue harmonic signals, which are produced in the tissue from within the
body, pass through the body wall twice.
E.
Because tissue harmonics are mainly generated in the tissue beyond the body
wall, the distortion and scattering is greatly increased.
8.
Regarding reduced artifacts from weak echoes, all of the following are true
statements except
A.
One important consequence of nonlinear wave generation is that it depends
on the intensity (strength) of the incident wave.
B.
Roughly, the generation of harmonics may be thought of as an inverse
quadratic relationship or square law.
C.
A weak wave (such as that from the edge of the ultrasound beam) produces
little or no harmonics, while a strong wave (such as the center of the transmit
beam) produces disproportionately more harmonic energy.
D.
By detecting the harmonics only, harmonic imaging preferentially rejects
echoes that come from weak parts of the beam.
E.
Harmonic-related artifacts, therefore, are more prominent than artifacts
associated with the fundamental frequency.
9.
Regarding decreased body wall reverberations, which of the following statements is
(are) true?
A.
Harmonics do develop in the first few centimeters, but many artifacts do not.
B.
Multiple reverberations between the transducer and the body wall layers cast
a ‘haze’ that overlies the image.
C.
Because in reality these artifacts are mis-registered echoes from the near field,
they do not contain harmonics and disappear in the tissue harmonic image.
D.
A & B above are true.
E.
B & C above are true.
10.
Regarding image formation in tissue harmonics, all of the following are true except
A.
Tissue harmonic imaging operates by transmitting a fundamental beam that
has a lower frequency.
B.
This lower frequency fundamental pulse, as it propagates through tissue
inside the body, generates the higher frequency harmonic sound.
C.
The key to understanding tissue harmonic imaging is that the image is
formed only from the higher frequency harmonic sound.
D.
Echoes from the fundamental frequency are included in order to make a
sharper image.
E.
Sophisticated transmit beam formation and signal detection is required to
produce good quality harmonic images.
11.
Several techniques are currently employed to detect harmonics and eliminate the
unwanted fundamental echoes including all of the following except
A.
Filtration techniques
B.
Single line pulse inversion
C.
Side-by-side phase cancellation
D.
Transmit pulse encoding
E.
Reduced signal-to-noise ratio
12.
Regarding filtration, which of the following statements is (are) true?
A.
Filtration uses sophisticated transmit beam formers to produce a narrower
bandwidth and signal processing techniques to filter out the spectrum of
frequencies that are likely to arise from the fundamental beam.
B.
If a system produces a broader bandwidth, then the overlap between the
harmonic echoes and the fundamental signals is less.
C.
With narrow bandwidth beams, filtration cannot provide a very clean
separation of the harmonic-related information from the fundamental signal.
D.
A & B above.
E.
B & C above.
13.
Regarding single line pulse inversion, the potential factor that can degrade the image
with this method is
A.
scar tissue
B.
a large amount of subcutaneous tissue
C.
D.
E.
obesity
hemorrhage within the tissue
tissue motion
14.
The technique that is a spatial cancellation technique is the
A.
Filtration technique
B.
Single line pulse inversion technique
C.
Side-by-side phase cancellation technique
D.
Transmit pulse encoding technique
E.
Reduced signal-to-noise ratio technique
15.
The technique that requires the equipment to have a special decoder is the
A.
Filtration technique
B.
Single line pulse inversion technique
C.
Side-by-side phase cancellation technique
D.
Transmit pulse encoding technique
E.
Reduced signal-to-noise ratio technique
16.
Regarding tissue harmonic image characteristics, the amplitude of the harmonic
signals is generally ______ orders lower in magnitude than the fundamental signal.
A.
one to two
B.
two to three
C.
three to four
D.
four to five
E.
five to six
17.
Regarding the slice thickness, which of the following statements is (are) true?
A.
The beam profile (slice thickness) of the harmonic frequencies is always
wider than the fundamental pulse that is used to produce it.
B.
The acoustic intensity of the transmitted ultrasound pulse is highest along the
edges and lowest in the center.
C.
The edges of any ultrasound beam produce fewer harmonics than the more
intense central beam.
D.
A & B above are true.
E.
B & C above are true
18.
An example of an artifact that may be more prominent on tissue harmonic imaging is
A.
a side lobe artifact
B.
a comet tail artifact
C.
a body wall reverberation artifact
D.
an artifact from the edge of the ultrasound beam
E.
a grating lobe artifact
19.
In some cases, the resolution in harmonic images may be worse than fundamental
imaging. Tissue harmonic images may be inferior to conventional high frequency
fundamental images in patients who
A.
are poor ultrasound subjects
B.
are ultrasound subjects with “glass bodies”
C.
D.
E.
20.
have a large amount of subcutaneous tissue
are obese
have scar tissue
According to the author, tissue harmonic imaging seems especially effective in _____
imaging
A.
musculoskeletal
B.
cardiac
C.
obstetrical
D.
renal
E.
gastrointestinal