Part III: Z6Ms 4D Acquisition and Display

Part III ♥ 4D Acquisition and Display   Select ► to continue Recognize the system parameters involved in 4D acquisition for optimal display Define and describe the benefit of RES™ enhanced resolution imaging format             Explain steps involved in creating a 4D valve rendering Describe Bi-Plane+ and its benefits in 4D imaging Identify post acquisition display options Select ◄ to go back Select ► to continue Upon successful completion of this course, you will be able to: Now that we understand balancing space and time as well as using the Bi-Plane+ feature, let’s take a look at mitral and aortic valve acquisition. Producing a quality volume rendering of any valve or structure, begins with optimizing our 2D image.  As we know, most live hearts do not look like the perfect images we see in the textbooks!   First, we find the best possible view, adjust our angulation specific to the orientation of the patient’s heart and optimize for any echocardiographic limitations such as lung artifact.   Since these are volume acquisitions, technically any view can produce a mitral or aortic volume; however, clinicians tend to prefer certain views over others.   Select ◄ to go back                                                                                     Select ► to continue   In the previous section, you learned about frame rate and how it affects the volume. Before we move on to acquiring a volume, we need to learn the Bi-Plane+ feature and how it benefits optimization of our 2D image.                Bi-Plane+ is more than a dual screen feature or opposing angles. This feature allows the operator to image on two planes with different rotation and tilt angles in a side-by-side format. Each plane can be manipulated individually.3                    Utilizing the separate rotate and tilt features gives flexibility for hearts outside of the standard imaging plane. This is beneficial for example, in ensuring the region of interest (ROI) incorporates the entire valve annulus before entering 4D imaging or if imaging is hindered by certain types of artifact.     Let's watch some clips of Bi-Plane+ in use before going more in depth. Click on the icon below to begin.     Select ◄ to go back                                                                                Select ► to continue                                                                                                           Bi-Plane+ Learn more about Bi-Plane+   Select the play arrow if page does not start automatically. Allow video to buffer if needed. When finished select the X in the upper right-hand corner to continue. Acquiring a 4D volume requires comprehension of the features and settings available to optimize the volume and obtain the needed information. The Z6Ms transducer has several features that allow volume acquisitions with high volume rates while still maintaining the detail required for clinical decision making.   The importance of frame rate in echocardiography becomes evident when imaging the dynamic motion of the heart. Accurate interpretation of wall motion, valve excursion, and regurgitant jets depends on visualizing movement of these structures as a continuous action.   4D volume imaging is no different when it comes to achieving high frame rates, or in this case volume rates. Acquiring a volume of any cardiac structure starts with carefully balancing the optimization settings.   Let’s begin by discussing frame rate and the factors that affect it. Select ◄ to go back                                                                                    Select ► to continue   In 4D acquisition, it is important to be aware of all optimization features to achieve the desired resolution. Previously we discussed adjusting scan depth and sector size to maintain high volume rates while utilizing the larger 90 x 90 format.   Now we address the format of zoomed imaging. In ultrasound imaging there are two types of zoom, read zoom which is a post-processing function and write zoom which a pre-processing function.1   Pre-processing means the image processes and then stores to memory while in post-processing the image stores to memory, is then retrieved from memory and reprocesses.1   The ACUSON SC2000™ ultrasound system write zoom feature is called RES enhanced resolution imaging.  You’ll find the 'RES' button just above the trackball on the left side as we saw in Lecture 2.   There is also a read zoom feature, which is the Zoom control on the bottom left side of the control panel. Press to activate and rotate to adjust amount of magnification.   What is the real difference between the 'RES' and Zoom features and how do they affect 4D volumes and volume rates? Click on the icons below to learn more about Zoom and RES enhanced resolution format. Zoom vs RES See how Zoom and RES affect imaging Element HTMLZoom Magnification The zoom feature selects the region from memory and reprocesses it by making the individual pixels larger. To make room for the larger pixels, some of the original pixels are lost.   In the box of heart candies, if the selected region hypothetically consists of 300,000 pixels, when zoom activates on that region, the individual pixels enlarge so the pixel quantity decreases to 7,000.   While the selected area enlarges, pixels are lost leading to poorer resolution. You can see how the enlarged selection is much more pixelated.  Heart image courtesy of Adobe Stock Photos.RES enhanced resolution formatThe write zoom feature, or RES enhanced resolution imaging, is a pre-processing function that enlarges a region of interest by adding pixels before storing to memory, maintaining resolution.   In this image of the heart candies, the selection enlarges, at the same time adding pixel density to increase resolution. The result is an enlarged image with good detail. You can see how the enlarged region maintains crisper detail compared to the very pixelated image from the previous screen.When finished click the X in the upper right-hand corner to exit, then click ► to continue. Sound File Audio ScriptThe zoom feature selects the region from memory and reprocesses it by making the individual pixels larger. To make room for the larger pixels, some of the original pixels are lost.   In the box of heart candies, if the selected region hypothetically consists of 300,000 pixels, when zoom activates on that region, the individual pixels enlarge so the pixel quantity decreases to 7000.   While the selected area enlarges, pixels are lost leading to poorer resolution. You can see how the enlarged selection is much more pixelated.   The write zoom feature, or RES enhanced resolution imaging, is a pre-processing function that enlarges a region of interest by adding pixels before storing to memory, maintaining resolution.   In this image of the heart candies, the selection enlarges, at the same time adding pixel density to increase resolution.   The result is an enlarged image with good detail. You can see how the enlarged region maintains crisper detail compared to the very pixelated image from the previous screen.   When finished, click the X in the upper right corner to exit. Then click the next arrow to continue.   Review RES and Zoom Review the location of RES and Zoom on the control panel Base ImageHotspotsText BlocksImage FileRES enhanced resolution imaging format enlarges the image by modifying it before storing to memory, maintaining resolution. Zoom magnification enlarges the image by modifying a previously stored image, decreasing resolution. Frame rate refers to how many images per second enter into image memory and are retrieved from memory to display on screen. Higher frame rates display smoother, continuous motion. Two factors that influence frame rate are scan depth and sector size. Both have an inverse relationship to frame rate. Decreasing the depth and narrowing the sector size shortens the travel time for return echoes, increasing frame rate and producing a smoother image.1   Spatial and temporal resolution also affect frame rate. Temporal resolution is the capability of accurately displaying a moving structure at a specific time point while spatial resolution refers to detecting and accurately displaying separate anatomic structures.  When opting for greater spatial detail, we sacrifice frame rate and inversely we lose spatial detail when opting for smoother image playback by optimizing for temporal resolution.   Relationships Affecting Frame Rate ↑ Spatial Resolution = ↓ Temporal Resolution  ↓ Frame Rate  ↑ Temporal Resolution    = ↓ Spatial Resolution ↑ Frame Rate ↓ Depth = ↑ Frame Rate ↓ Sector Size = ↑ Frame Rate                                                                                                            Select ◄ to go back                                                                                    Select ► to continue AXIAL LATERAL Axial and lateral resolution are the components of spatial resolution. Axial resolution refers to the distance between two reflectors along the scan line or parallel to the beam, and is equal to one half the spatial pulse length.1 Lateral resolution is the ability to distinguish reflectors across scan lines or perpendicular to the beam, which is a function of the transducer’s beam width.    An image with good axial and lateral resolution displays two close structures as separate objects. Temporal resolution refers to the ultrasound system’s ability to distinguish events that are close together in time rather than individual reflectors. If an ultrasound system has good temporal resolution, then the image displays continuous, smooth motion.1 We measure temporal resolution in milliseconds. It is the time from the beginning of one frame to the beginning of the next frame.  This time is also how long it takes to complete one frame.  Cardiac imaging requires less time between frames, or higher frame rates, in order to correctly display the movement of heart structures.   In the diagram to the right, imagine watching an arrow make 180 degree turn. The first line of arrows depicts the frames you would see at a high frame rate. In such a clip, you would visualize several of the movements the arrow makes in completing the turn.   The second line depicts a lower frame rate where you would visualize fewer movements of the arrow turning. The last line depicts a very low frame rate where you would only visualize the beginning and end of the turn.     Select ◄ to go back Select ► to continue Imagine if that was imaging a heart! You would only see the mitral valve open and then closed in a clip. You would miss all the motion in between the open position and the closed position. In Lecture 2, you were introduced to the SpaceTimeTM control on the left side of the LCD panel, next to Tilt/Edge. Pressing this control toggles between Quick Rotate and SpaceTime. Rotating SpaceTime allows the user to switch between spatial and temporal optimization. Setting S1, S2 and S3 optimize for spatial detail with S3 being the greatest detail. The T1 setting optimizes for temporal resolution. In B-mode volume imaging on the Z6Ms transducer, SpaceTime sets a target volume rate and as the volume size changes, the system adjusts the spatial resolution to maintain volume rate. This means that reducing the volume size will increase the spatial resolution and increasing volume size will decrease spatial resolution. When reducing the volume size, you may notice the volumes per second may decrease and then suddenly increase to a value that is larger than the initial volume rate. This occurs because the SpaceTime control has a finite number of resolution settings and the system selects the settings closest to the target volume rate. There is also a limit to spatial resolution at which point making the volume very small may increase the volume rate while spatial resolution remains the same. Obtaining a very large volume may not decrease the spatial resolution any further as the image would then become non-diagnostic.                                   The S3 setting is only functional in 4D imaging with the Z6Ms transducer.    Click on the icons below to view examples of how different settings affect imaging. In the 18 vps clip we use a depth of 100mm, narrowed sector size and the S1 setting. Motion is well visualized as well as detail in the valve. In the 20 vps clip, we decrease the depth to 90 mm, maintain the narrowed sector and S1 setting. Motion is well visualized with a slight increase in volume rate to 20 vps. In both cases, we balance spatial and temporal resolution. If we were to increase the spatial settings to S2 or S3, we would see more detail in the valve, but we may sacrifice temporal resolution. Depending on the anatomy being evaluated, it may be desirable to enhance spatial detail and not as important losing temporal resolution. In both examples, we use a standard 90 x 90 imaging plane, which allows the user to visualize the entire valve and its surrounding area.   Select ◄ to go back                                                                                                                      Select ► to continue   18 vps Watch an example of an 18 vps clip   Select the play arrow to begin. Click the X in the upper right corner when finished. 20 vps Watch an example of a 20 vps clip   Select the play arrow to begin. Click the X in the upper right corner when finished. There are two main relationships the planes can have to each other, lateral or parallel. After pressing the Bi-Plane+ control on the control panel, the system automatically enters the Lateral Tilt mode with the planes defaulting to an orthogonal, or perpendicular relationship. Lateral Tilt enables the operator to angle the beam back and forth in the green plane, demonstrated in the diagram to the right. To operate the Lateral Tilt function, ensure the green plane is active and use either the trackball or the Tilt/Edge control on the upper left of the control panel. If both the green and red planes are active, you can rotate the planes together using either the 0/60° control or the Quick Rotate control, then use the trackball or Tilt/Edge control to operate the Lateral Tilt function from the new rotation angle. With Lateral Tilt active, a cursor displays identifying the location of the tilt. In this image, the view on the left demonstrates a slightly off-center short axis with a lateral tilt, notice the cursor on the left, identifying the angle of tilt. The view on the right now displays the left ventricular outflow tract (LVOT). The icon displays the green and red planes in an orthogonal relationship and the green plane tilted off the center axis.   In Parallel Tilt, the red and green planes are no longer orthogonal but rather become parallel to each other. Use the trackball or Tilt/Edge control to pan back and forth off the initial plane without moving the transducer tip. This is a useful feature when the transducer tip loses contact or other types of artifact occur.      To switch from Lateral Tilt to Parallel Tilt, click the soft key above the trackball to highlight Parallel. The icon will change so the red and green lines overlap each other at 0 degrees.       Select ◄ to go back                                                                                    Select ► to continue   Click on the icons below to watch an animation of Bi-Plane+ and then watch how it's used in practice.   Bi-Plane+ Animation Watch an animation of the Bi-Plane+ feature   Select the play arrow if page does not start automatically. Allow video to buffer if needed. When finished select the X in the upper right-hand corner to continue. Lateral Tilt Watch how to use the Lateral Tilt feature   Select the play arrow if page does not start automatically. Allow video to buffer if needed. When finished select the X in the upper right-hand corner to continue. Free Tilt Watch how to use the Free Tilt feature   Select the play arrow if page does not start automatically. Allow video to buffer if needed. When finished select the X in the upper right-hand corner to continue. Parallel Tilt Watch how to use the Parallel Tilt feature   Select the play arrow if page does not start automatically. Allow video to buffer if needed. When finished select the X in the upper right-hand corner to continue. Mitral valve volume acquisition generally begins by finding a good long axis view. Activating the Bi-Plane+ function ensures we visualize the entire mitral annulus.   Press the 4D control to activate 4D volume imaging.                     Programming eSieScan™ workflow protocols saves time by eliminating button pushes and ensures exam consistency and completeness.   Entering volume imaging, the initial image on the screen is the same view as we saw in 2D, but we want to orient the valve to the surgical view.  We could manipulate the volume manually by adding and removing volume, but pressing either the U2 button or the Mitral Valve button on the Image Menu automates the process.   Initial LAX View Mitral Valve Button Surgical View After orienting the valve, we can use the trackball to further situate the volume in the manner best suited to the exam. Placing the cursor on the volume displays a curved double arrow icon indicating we can rotate the on screen volume utilizing the trackball and mouse keys. Another method to ensure our volume displays correctly is to manipulate the MPR's or multiPlanar reference planes, to the left of the on screen image. Using the trackball and mouse keys, we can move and rotate any of the reference planes.   Placing the cursor at the intersection of two planes displays a four-way arrow indicating we can move both planes at the same time using the trackball and mouse keys. Moving the cursor to the edge of the MPR, displays a two-way circular arrow, indicating we can rotate the plane on its axis. Placing the cursor anywhere else in the MPR, an arrow and box icon display. Clicking while this icon displays synchronizes the volume to that MPR view. Another feature to help us visualize structures is the Dual V tool. With the volume on the screen, clicking on the Dual V icon on the Image Menu splits the volume into two from opposite viewing angles. On screen, we see two orthogonal reference planes and two opposing volume views.   While in Dual V, we can manipulate the view by clicking on the box in the red plane and altering the size and position of the view.     Notice the change in the opposing volumes as the box is modified.     Click on the icons below to learn how to acquire and manipulate a volume acquisition.     Select ◄ to go back                                                                                     Select ► to continue Mitral Valve Volume Learn how to acquire a mitral valve volume   Select the play arrow if page does not start automatically. Allow video to buffer if needed. When finished select the X in the upper right-hand corner to continue. Volume Manipulation Learn tricks and tips to volume manipulation MItral Valve Repair Watch a mitral valve repair acquisition   Select the play arrow if page does not start automatically. Allow video to buffer if needed. When finished select the X in the upper right-hand corner to continue. We just learned how to acquire and work with a 4D volume rendering of the mitral valve. The steps to acquiring an aortic valve volume are similar. A main difference is there is no need to re-orient the volume to an alternate view after acquisition.    Beginning in 2D, we obtain a short axis (SAX) view of the aortic valve, ensuring visualization of all three cusps.   After obtaining a good SAX view, activate Bi-Plane+ to ensure a good long axis (LAX) as well.  Using the tilt and rotate functions, the left ventricular outflow tract (LVOT) opens up setting a good foundation for a 4D volume rendering of the aortic valve.   After optimizing the 2D image, press the 4D button to activate volume imaging.   To increase detail, you can use RES enhanced resolution format while in the Bi-Plane+ mode, then press the 4D button.                     There is a workflow difference from 2D imaging utilizing the RES enhanced resolution format. After adjusting the region of interest (ROI) do not press the RES button again, press the 4D button. Click on the icon below to learn how to acquire an aortic valve volume. Select ◄ to go back                                                                               Select ► to continue Aortic Valve Volume Learn how to acquire an aortic valve volume   Select the play arrow if page does not start automatically. Allow video to buffer if needed. When finished select the X in the upper right-hand corner to continue. In the last section, you learned the finer techniques of acquiring mitral and aortic volumes. In this section, you will learn the various review display options available once that volume is on the screen.   With the volume active, the image menu on the left side of the screen displays the options available for volume review. We have already mentioned the mitral valve button, but what about the other options?  Let's take a look. Click on the icon below to view the different display options and how they affect the image on the screen. Select ◄ to go back                                                               Select ► to continue Volume Display Review volume display options Slide NumberText BlocksCalloutsAudio ScriptImage File1Displays the volume on the right and three reference planes on the left. DISPLAY This display option displays the volume on the right and three reference planes on the left. 2DISPLAY Displays the volume and three reference planes in four equal quadrants. The next option displays the volume and three reference planes in four equal quadrants.3DISPLAY Displays nine slices of the anatomy that are orthogonal to the reference plane on the bottom right side. The last option displays nine slices of the anatomy that are orthogonal to the reference plane on the bottom right side. 4AXIS MARKERS Displays or hides all axis markers on the reference planes. Axis markers displays or hides all axis markers on the reference planes.5CUT PLANE Enables or disables the cut plane function for viewing the anatomy of interest in a volume. Cut plane enables or disables the cut plane function for viewing the anatomy of interest in a volume. 6Box Edit Reset  Unsynchronized Cut PlaneCancels any changes made to the volume using the box editing tool. Disables synchronization of the cut plane with any of the reference planes.Box edit reset cancels any changes made to the volume using the editing tool and the unsynchronized cut plane tool disables synchronization of the cut plane with any of the reference planes. 7CUT PLANE WIREFRAME Displays or hides the wireframe on the cut plane, which indicates the boundaries of the volume. Cut plane wireframe displays or hides the wireframe on the cut plane, which indicates the boundaries of the volume. 8Wireframe Displays or hides the wireframe, which indicates the boundaries of the wireframe. Wireframe displays or hides the wireframe which indicates the boundaries of the wireframe. 9LOCK PLANES UNLOCK: Unlocks all axes to enable the individual manipulation of all reference planes.LOCK ALL: Locks all axes on all reference planes to enable the manipulation of one reference plane to affect the other two reference planes.LOCK BIPLANE: Locks the axes on two planes and unlocks the axis on the third plane. Lock planes has three options, ‘unlock’ unlocks all axes to enable the individual manipulation of all reference planes, ‘lock all’ locks all axes on all reference planes to enable the manipulation of one reference plane to affect the other two reference planes, and ‘lock biplane’ locks the axes on two planes and unlocks the axis on the third plane. 10REFERENCE PLANE Displays all reference planes in one view. Reference plane displays all reference planes in one view. 11SieShell Animates the volume to display the volume as the two halves to view all the walls of the heart. sieShell animates the volume to display the volume as the two halves to view all the walls of the heart. 12IMAGING PARAMETERS Hides or displays the active imaging parameter setting active at the time of the exam. Imaging parameters hides or displays the active imaging parameter setting active at the time of the exam. 13DUAL V Simultaneously displays two views of the same volume from opposite viewing angles. Dual V simultaneously displays two views of the same volume from opposite viewing angles. 14Mitral Valve Button Orients the valve to the surgical view. Click the X in the upper right corner when finished, then click ► to continueThe mitral valve button orients the valve to the surgical view. Axial Resolution: The distance between two reflectors along the scan line or parallel to the beam, equal to one-half the spatial pulse length.   Bi-Plane+: 2D imaging feature that scans two imaging planes with different rotation and tilt angles while viewing the planes in a side-by-side format.   Free Tilt: In Bi-Plane+, the ability to tilt off the zero angle and rotate planes independently of each other.   Lateral Resolution: The ability to distinguish reflectors across scan lines or perpendicular to the beam, which is a function of the transducer's beam width.   Lateral Tilt: In Bi-Plane+, with planes in an orthogonal relationship, the ability to angle the beam back and forth in the green plane off the zero axis.   Orthogonal: Having a relationship of right angles, or perpendicular. Parallel Tilt: In Bi-Plane+, with planes in a parallel relationship, the ability to angle the beam off the zero axis. Pre-processing: The images processes and then stores to memory.   Post-Processing: Retrieves the image already stored to memory and allows for modification.   RES enhanced resolution imaging: A pre-processing function that enlarges a region of interest by increasing pixel density before storying to memory.   Read Zoom: A post-processing function.   Spatial Resolution: The ability to detect and accurately display separate anatomic structures.   Temporal Resolution: The ability to accurately display a moving structure at a specific time point.   Write Zoom: A pre-processing function.   Zoom Magnification: A post-processing or read zoom function that selects the region from memory to reprocess it by making the individual pixels larger.   Select ◄ to go back                                                                                             Select ► to continue 1.  Kremkau, F.W., (2016). Sonography Principles and Instruments. St. Louis, Missouri, Elsevier. 2.  Vettukkatil, J., (2009). 3Dechocardiography: the art of defining cardiac morphology.  Accessed at http://www.3dechocardiography.com/index.html        3.  Siemens. (2014).  ACUSON SC2000™ Diagnostic Ultrasound Instructions for Use. Siemens Medical Solutions USA, Inc: Mountain View, CA. 4. orthogonal. (n.d.). Dictionary.com Unabridged. Retrieved September 28, 2016 from Dictionary.com website http://www.dictionary.com/browse/orthogonal   Congratulations! You have completed the 4D acquisition and display online training course. Listed below are the key points that have been presented. Take time to review the material before you proceed to the final quiz. When you’ve finished reviewing, click the next arrow to continue. Download and print a copy of the Course Review.   Recognize the system parameters involved in 4D acquisition for optimal display Cardiology needs high frame rates to ensure the detail required for clinical decision making. Scan depth, sector size, spatial, and temporal resolution affect frame rate. Spatial and temporal resolution have an inverse relationship. Axial and lateral resolution are the components of spatial resolution. Axial resolution is the ability to distinguish reflectors that are parallel to the beam. Lateral resolution refers to reflectors perpendicular to the beam. Define and describe the benefit of RES enhanced resolution format Pre-processing means the image processes and stores to memory. Post-processing means the image stores to memory is retrieved from memory and then reprocesses. Zoom magnification is a post-processing function because it retrieves the image from memory and enlarges the pixels, losing resolution. Describe Bi-Plane+ features and benefits in 4D imaging Bi-Plane+ allows the operator to view opposing images in a side-by-side format. Lateral, Free, and Parallel Tilt are functions of Bi-Plane+. Free Tilt is the ability to tilt off the zero angle and rotate planes independently of each other. Use the Tilt/Edge control or the trackball to operate the Lateral Tilt feature. Parallel Tilt places both planes parallel to each other. Using the Bi-Plane+ feature ensures a good volume rendering. Explain steps involved in creating a 4D valve rendering When acquiring a mitral valve volume, use the U2 button or the Mitral Valve button to orient the volume to the surgeon's view. eSieScan workflow protocols allow for pre-defined workflow sequence. Identify post acquisition display options After volume acquisition, use the MPR reference planes to further optimize the view. The Image Menu contains various options to display the volume. ACUSON SC2000, eSie valves, eSie PISA,  and RES are trademarks of Siemens Medical Solutions, USA, Inc.   Select ◄ to go back                                                                                SElect ► to continue Due to varying regulatory requirements, product availability varies from country to country. Some/all of the products and/or features referred to in this module may be available in your country. This course addresses an international audience of healthcare customers and cannot consider all country-specific statistics, guidelines and regulations. It is your responsibility to understand the regulations for your country or regions. Images and graphics used in this tutorial are for educational purposes only. They may have been modified or compressed, and may not reflect the actual image quality of the system. Selecting the ► continues this course and you confirm that you have read and understood this disclaimer.  Let’s take a closer look at Bi-Plane+ and how it functions. After pressing the Bi-Plane+ button on the control panel, two images display side-by-side, at 90 degree opposing angles (orthogonal). The relationship of the two planes displays in the icon on the upper left corner of the screen. The red line corresponds to the view on the left and the green line corresponds to the view on the right. Corresponding red and green lines border each view.   Each plane can be manipulated independently of the other or in conjunction with the other. The icons below demonstrate the active plane. The icon on the left indicates both planes are active and can be manipulated. The center icon depicts only the green plane is active (default) and the icon on the right indicates only the red plane is active.     To switch between these three options, press the 0/60° control on the control panel.  Rotate the control to adjust the angle of the active plane.     Select ◄ to go back                                                                                                                                                         Select ► to continue   Select the play arrow to watch changes in volume rate as we adjust the SpaceTime control. Select ◄ to go back                                                                                                                                              Select ►  to continue   Select the play arrow if page does not start automatically. Allow video to buffer if needed. Select ◄ to go back                                                                                                                                              Select ►  to continue   Select the play arrow if page does not start automatically. Allow video to buffer if needed. Select ◄ to go back                                                                                                                               Select ► to continue Special thanks to Lissa Sugeng, MD, MPH, Rachel Hylen, RDCS and the staff of Yale New Haven Hospital for their guidance and expertise in creating this content. Video protocols courtesy of: Yale New Haven Hospital Echocardiography Lab New Haven, Connecticut.