Volume 8 Issue 3 - Australasian Society for Ultrasound in Medicine

ISSN 1441-6891Volume 8 Number 3 August 2005Australasian Society for Ultrasound in MedicineULTRASOUNDB U L L E T I NASUM Annual Scientific MeetingNuchal Translucency Course 29 SeptemberSkills Development Day 29 SeptemberMain Scientific Program 30 September – 2 OctoberASUM Annual General Meeting Adelaide10:00 am Saturday 1 OctoberAsia Link Meeting Bangkok Thailand10–11 NovemberASUM Multidisciplinary Workshop 2006Gold Coast 24–25 March 2006DMU Preparation Course Gold Coast22–26 March 2006ASUM Annual Scientific Meeting 2006 Melbourne14–17 September 2006●●●●●●●Abnormal fetal feetUpper abdominal massesDiagnosis of pleural effusionAntenatal diagnosis of vasa previaLeft ventricular failureFirst trimester guidelinesNon-medical entertainment ultrasound

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PresidentDr David RogersImmediate Past PresidentDr Glenn McNallyHonorary SecretaryMrs Roslyn SavageHonorary TreasurerDr Dave CarpenterChief Executive OfficerDr Caroline HongULTRASOUND BULLETINOfficial publication ofthe Australasian Societyfor Ultrasound in MedicinePublished quarterlyISSN 1441-6891Indexed by the Sociedad Iberoamericanade Informacion Cientifien (SIIC) DatabasesEditorDr Roger DaviesWomen’s and Children’s Hospital, SACo-EditorMr Keith HendersonASUM Education ManagerEditorial CoordinatorMr James HamiltonASUM Education Officer, DMU CoordinatorAssistant EditorsMs Kaye Griffiths AMANZAC Research CRGH Institute NSWMs Janine HortonSt John of God Imaging VicMs Louise LeeGold Coast Hospital QldEditorial contributionsOriginal research, case reports, quiz cases,short articles, meeting reports and calendarinformation are invited and should beaddressed to The Editor (address below)Membership and general enquiriesshould be directed to ASUM (addressbelow)Published on behalf of ASUMby Minnis CommunicationsBill Minnis Director4/16 Maple GroveToorak Melbourne Victoria 3142 Australiatel +61 3 9824 5241 fax +61 3 9824 5247email minnis@minniscomms.com.auDisclaimerUnless specifically indicated, opinionsexpressed should not be taken as those ofthe Australasian Society for Ultrasound inMedicine or of Minnis CommunicationsAUSTRALASIAN SOCIETY FORULTRASOUND IN MEDICINEABN 64 001 679 1612/181 High StreetWilloughby Sydney NSW 2068 Australiatel +61 2 9958 7655 fax +61 2 9958 8002email asum@asum.com.auwebsite:http //www.asum.com.auISO 9001: 2000Certified QualityManagementSystemsU L T R A S O U N DB U L L E T I NASUM Ultrasound Bulletin August: 8: 3Notes from the EditorSafety in ultrasound is always an important issue and the right of the fetus ‘notto be exposed to a source of potential harm where no health benefit exists’ hasbeen firmly placed on the ‘safety in ultrasound’ agenda. In July the Council tooka stand regarding social scanning and readers are encouraged to read the ASUMStatement and letters on pages 35 to 38 and to contribute to the discussion.Reader attention is also drawn to the Letters section on page 14 where Schluteret al. challenge the current mid trimester growth charts used in Australia and NewZealand.This issue also contains an eclectic collection of articles of excellent scientificvalue. In their case report, Fauchon et al. examine the grey areas of antenatalultrasound diagnosis of anomalies specifically in regard to abnormal fetal feet. Intheir article, Watson and Benzie examine fetal upper abdominal masses and casestudy how ultrasound can alert referring clinicians to the presence or absenceof pathology so as assist effective clinical management decisions. Davies et al.discuss the diagnosis of pleural effusion in their article and suggest that the treatmenttechnique described overcomes or avoids many of the limitations of existingoptions. Wong et al., in their case study, report on antenatal diagnosis of vasaprevia and O’Leary provides a pictorial essay of left ventricular failure.Preparation for the Annual Scientific Meeting in Adelaide is nearly completeand the outstanding scientific program is detailed on pages 2 to 5. Readers areencouraged to register for ASUM 2005 ASM and spend a stimulating few daysin Adelaide.Roger DaviesEditorASM 2005ASM 2005 Program 2THE EXECUTIVEPresident’s message 7CEO’s message 10RESEARCH AND TECHNICALAbnormal fetal feet – thedifferential diagnoses 15Fetal upper abdominal masses:a prenatal diagnostic dilemma 19Ultrasound guided chemicalpleurodesis with doxycycline 23A 3D approach to antenatal diagnosisof vasa previa with 2D ultrasoundimaging 28A pictorial essay of left ventricularfailure 31POLICIES AND STATEMENTSGuidelines for the Performance ofFirst Trimester Ultrasound 33Interim Statement on the AppropriateUse of Diagnostic UltrasoundEquipment for Non-medical Use 35SOCIAL SCREENINGLetters and editor’s notes 36EDUCATIONDMU and DDU Part 1 and Part 2pass candidates 32Diploma of Medical UltrasonographyReport 42Examination dates and venues 44THE SOCIETYBook and CD reviews 39The 2004 Beresford ButteryOverseas Traineeship Experience 46NZ Branch Annual Conference 47Obituary James Robert Syme 48Corporate members & New members 50ASUM Calendar 51ASUM Ultrasound Bulletin 2005 August; 8 (3)1

ASM 2005Program 35th Annual ScThursday 29th September – Sunday 2nd OctobThursday 29th September 2005Nuchal Translucency CourseSkillls Development Day9.30 am10.40 am11.50 amRhodri Evans Head andNeck Node Chains withBiopsy DemonstrationDebbie HardyOvercoming DifficultMorphology ScansRhodri Evans SalivaryGland Assessment withBiopsy DemonstrationJeff SiegmannMorphology Scans. WhatDo I Really Need toKnow?Robert ZiegenbeinExercise InducedLeg Pain/EntrapmentChristopher SykesWrist/Hand UltrasoundRos Savage & PeterEsselbach SafeScanning and OH&SHeather WebberBreast – CombinedMammographic andUltrasound AssessmentRoger Gent &Lino Piotto InterestingPaediatric Case StudiesSue Farnan AnkleUltrasoundBarry Chatterton &Peter Spyropoulos EyeUltrasoundMartin Necas LowerExtremity ArterialAssessmentChristopher SykesCarotids and Discussionon Surgical FollowupRoger Gent PaediatricHipsJane Fonda TV ScanningLunch2.00 pm3.10 pmMartin Necas VenousRefluxSean McPeake GroinUltrasoundLino Piotto PaediatricAbdomen – ThinkingOutside the SquareRichard Allen AbdomenDopplerBeth Gaskin & EwaJanicki Dealing withPatient GriefMartin Necas DopplerObservations of ArterialAbnormalities: FreshLook at HemodynamicsNick Gelekis The FetalHeartPiotr Niznik The FetalHeartSean McPeakeSonography of the Buttockand HamstringJenifer Kidd EndoluminalGraft Assessment4.15 pm DrinksFriday 30th September 20059:00 amOpening AddressChris Sheedy An update from the Department of Health and AgeingPeter Burns Understanding New Technology in UltrasoundAnna Parsons Sonographic Evaluation of Abnormal Bleeding: Uterine Physiology and Sonographic Technique, Including SonohysterographyRhodri Evans Staging Head and Neck Cancer with Ultrasound Using FNA and Core Biopsy TechniquesMorning Tea11.30 amO&GPeter Muller Uterine Artery Dopplerand Biochemical Marker Assessment ofPlacental FunctionMartin Necas Sonographic Evaluation ofBand Like Structures in ObstetricsChris Wilkinson Fetal DopplerAssessment of IUGRVASCULARJoseph Polak Ultrasound and EarlyAtheroscelerosis PreventionLeandro Fernandez Doppler Ultrasound inRenovascular HypertensionRobert Ziegenbein The Dynamics of Veins,Popular MisconceptionsPROFFERRED PAPERSSee list on page 5Lunch2.00 pmGENERALVASCULARMIXEDWes Cormick Benign Breast DiseaseLeandro Fernandez Advanced Sonographyof Near Field Skin and SubcutaneousStructuresRob Gibson Gall Stones and Bile Ducts– Making the Most of UltrasoundByung Ihn Choi Elastography: Work inProgressJoseph Polak Carotid Plaque, isCharacterisation Useful?Jenifer Kidd The Role of Duplex UltrasoundFollowing Lower Extremity EndovascularInterventionAnne Padbury Foam Echosclerotherapy ofthe Small Saphenous VeinJoseph Polak Multimodality Imaging ofCerebrovascular Disease, the Role ofUltrasoundSue Westerway Growth Patterns,Macrosomia, Intervention and Birth WeightDifferences in Chinese vs CaucasianPopulationsRob Cocciolone Serum Screening Markersand Pregnancy OutcomePROFFERRED PAPERSSee list on page 52 ASUM Ultrasound Bulletin 2005 August; 8 (3)

ientific Meeting of ASUMe r 2005 Adelaide Convention Centre, AustraliaFriday 30th September 2005Afternoon Tea4.00 pm O&GMartin Necas Fetal Vascular AnomaliesPeter Muller The Genetic Sonogram – CanWe Adjust Risk?Anna Parsons Sonographic Evaluationof Abnormal Bleeding at Any Age: ClinicalPractice and CasesGENERALRob Gibson Chronic Liver Disease andPortal HypertensionRhodri Evans Potential Pitfalls in Evaluationof Neck Cysts and Abscesses.Wes Cormick US in Breast Cancer– Actually Making a Difference3D ULTRASOUNDPeter Burns Real Time 3D UltrasoundByung Inh Choi Three DimensionalUltrasound of Hepatobiliary DiseasesLeandro Fernandez Doppler and 3DUltrasound of Carotid Artery6.00 pm Welcome Reception in the Trade AreaSaturday 1st October 20057.30 am Breakfast with the Professors08.30 amO&GVASCULARSTANDARDSMANUFACTURER’SSHOWCASE 1PROFFERRED PAPERSSee list on page 5Pippa Kyle Medical Disordersin Pregnancy – Who May NeedUltrasound Investigations?Gary Pritchard 3D Ultrasound Hypeor Hope?Jane Fonda Sonographic Detectionand Assessment of EctopicPregnancyVanessa Pincham New Strategiesfor Trisomy 21 Risk Assessment in theFirst TrimesterJoseph Polak Epidemiology ofCardiovascular Disease, the Role ofUltrasoundPeter Burns Diagnosing Focal LiverLesions with Contrrast US, a NewRelationship Between Ultrasound,MRI and CTJenifer Kidd Optimising the DuplexEvaluation of Aortic EndograftsKathryn Busch ArterialNeovascularisation in RecalasisingVenous Thrombosis: a ProgressReportKaren Pollard Everyday Challengesin Being a Safe Practitioner ofObstetric Ultrasound ExaminationsTania Griffiths Diagnostic Ultrasound– Biological EffectsJenny Parkes Equity andReproducibility Issues in PracticalAssessment of Student SonographersMargo Gill University BasedEducation for Sonographers – Issuesand Challenges for the Profession10.00–10.30 am ASUM ANNUAL GENERAL MEETING / MORNING TEA10.30 amO&GMSKGENERALMANUFACTURER’SSHOWCASE 2Byung Ihn Choi Malignant LiverTumours: UltrasoundJuliet Kaye MRI as an Adjunct toUltrasound in Fetal AbnormalitiesPeter Muller The Screening FetalEchocardiogram, How and for Whom?Pippa Kyle Screening/Diagnosisof Congenital Heart Disease in TheFetusTerry Robertson The Abnormal FetalHeart – The Cardiologist ProspectivePeter Burns Nonlinear ImagingMethodsRethy Chhem UltrasoundAssessment of the AnkleAnita Lee Relationship of HighResolution of MusculoskeletalSonography to Clinical Findings inEarly Rheumatoid ArthritisBarry Chatterton & Grant RaymondSound and Light, OphthalmologicalViews of the EyePROFFERRED PAPERSSee list on page 5Kerry Thoirs Ultrasound of the UlnarNerve. What are the Normal Values?Lunch1.00 pmO&GMSKMIXEDMANUFACTURER’SSHOWCASE 3Byung Ihn Choi Benign Liver Mass:UltrasoundMaria Necas Ultrasound Assessmentof Ovarian VeinsAnna Parsons Evaluation of PelvicPain: The Ultrasound Assisted PelvicExaminationChris Wilkinson Management ofIsoimmunisation with Middle CerebralArtery DopplerPippa Kyle Multiple PregnancyWes Cormick Ultrasound in NonrheumatoidArthropathyRethy Chhem US of MusculoskeletalInfectionPeter Burns Imaging Angiogenesiswith UltrasoundRoger Gent The Role of Sonographyin Paediatric Abdominal TraumaLino Piotto Investigation ofAbdominal Pain in ChildrenPROFFERRED PAPERSSee list on page 5ASUM Ultrasound Bulletin 2005 August; 8 (3)3

ASM 2005Saturday 1st October 2005Afternoon Tea3.00 pmPROFFERRED PAPERSSee list on page 5O&GCharles Lott Male InfertilityEvaluationChristine Kirby Ultrasound andFemale InfertilityMSKSteve Zadow Ultrasound of thePainful Adult Hip Emphasising theLateral HipRethy Cchem US of the KneeGENERAL ENDOCRINEBill McLeay Surgery andPreoperative Imaging in PrimaryHyperparathyroidismRodhi Evans Thyroid NodulesAnna Parsons SonographicEvaluation of the Tubes andExtraovarian Adnexal PhenomenaSean McPeake SonographicAssessment of Hamstring Pain inAthletesLeandro Fernandez 3D Ultrasoundin Small Parts, Testicle, Thyroid andParathyroid5.00 pm Poster Defence (with South Australian wine and cheese)7.00 pm Gala Dinner All that GlittersSunday 2nd October 20057.30 am Recovery Breakfast with the Professors08.30 am MIXED SESSIONPippa Kyle Hydrops FetalisRob Gibson Pancreatic Ultrasound – Is it StillUseful in 2005?Wes McCormick Fetal Hearts – SortingOutflows Out and How to See That VSDJoseph Polak Venous Ultrasound, Value inUpper Extremity DVTMSKNeill Simmons Sonography of the Foot andAnkleJulie Gregg Diagnosis and Treatment ofMetatarsophalyngeal Joint InstabilityRethy Cchem Ultrasound of ArthritisAndrew Garnham Clinital Assessmentin MSK Ultrasound. A Sports Physician’sPerspectiveSunday Brunch11.15 amRoger Gent Ultrasound of Appendicitis inChildrenDenise Roach The Use of UltrasoundImaging in the Diagnosis of Thoracic OutletSyndromeAnna Parsons The Secret Life of theOvaries: the Difference Between Neoplasia,Metaplasia and Physiologic CystsRobert Ziegenbein & Andrew GarnhamExercise Induced Leg Pain and EntrapmentWayne Gibbon Ultrasound GuidedIntervention in Skeletal DiseaseFred Joshua Validity and Reliability of PowerDoppler Sonography of the MCP Joints inRheumatoid ArthritisTea Break1.00 pmRobert Gibson Work-up of the JaundicedPatientPeter Burns New Developments in BreastImaging Including Contrast and MRI/USCoRegistrationRodhi Evans Salivary Glands and the LarynxWes Cormick Breast Prosthesis andComplicationsWes Cormick Gas as a Contrast Agent inMSK UltrasoundWayne Gibbon Ultrasound Detection ofMechanisms Underlying Overuse Injuries.The ‘Cause of the Cause’ for PainChris Sykes Ultrasound Assessment of theTriangular Fibro CartilageRethy Cchem US of Non-Rotator-cuff Lesionsof the Shoulder2.45 Closing AddressARE YOU REGISTERED?CONTACT ICMS: www.icms.com.au/asum2005Meeting SecretariatICMS Pty Ltd84 Queensbridge StreetMelbourne Victoria 3006 Australiatel +61 3 9682 0244 fax +61 2 9682 0288ASUM Ultrasound Bulletin 2005 August; 8 (3)

ASM 2005 PROFFERED PAPERSFriday 30th September200 Fetal Tele-Ultrasound Consultations: Clinical Value andCost-EffectivenessDavid L Watson,-Mater Mothers Hospital, QueenslandWhat is the Best Videocompression Algorithm for Digital FetalUltrasound Video clips?David L Watson, Mater Mothers Hospital, QueenslandEnsure the Essure: Combining New Technology in 3D ultrasoundwith New Technology in Fertility ControlGary R Pritchard, Brisbane Ultrasound for Women,QueenslandSpectral Doppler should be performed at a Fixed Angle: TheEvidencePeter R Coombs, Monash Medical Centra,-Victoria-QRS Duration Alone Misses Cardiac Dyssynchrony inSubstantial Proportion of PatientsRebecca Perry, Flinders Medical Centre, South Australia-Coronary Artery Wall Thickness of the Left Anterior descendingArtery using High Resolution Transthoracic Echocardiography– Intra- and Inter-Operator VariabilityRebecca Perry, Flinders Medical Centre, South AustraliaAcute Fetal Cardiac and other Haemodynamic Redistributionafter Intrauterine Transfusion for Treatment of Severe RedBlood Cell AlloimmunisationNayana A Parange, Women's and Children's Hospital,University of Adelaide, South AustraliaUltrasound Assessment of the Brachial Artery to DetermineEndothelial Function in Pregnancy-Ann E Quinton, University of Sydney at Nepean Hospital,-NewSouth WalesDevelopment of Australian Customized Fetal Growth ChartsMax Mongelli, Nepean Hospital, New South WalesDevelopment of Australian Customised Fetal Growth ChartsMax Mongelli,-Nepean Hospital, New South WalesSaturday 1st OctoberThe Importance of the Mastoid Fontanelle View for RoutineCranial Ultrasounds of Preterm InfantsSheryle R Rogerson, Royal Women’s Hospital, VictoriaExtension of Ultrasound Use to Determine Soft Palate ShapesTania L Griffiths, Monash University, VictoriaDuration of Examination for the 18–20 Week Fetal MorphologyUltrasound Examination can be Shortened using Digital VideoClips Capture rather than Conventional Still Image CaptureDavid L Watson, Mater Mothers Hospital, Queensland--Can the Use of Ultrasound Improve the Management ofWomen who Present to an Acute Gynaecology Unit?George Condous, St Georges Hospital, United KingdomWhat is the Optimal Approach to Classifying Failing Pregnanciesof Unknown Location (PULs)?George Condous, St Georges Hospital, United KingdomCan We Improve the Performance of Diagnostic Tests toPredict the Outcome of Pregnancies of Unknown Location(PULs)?George Condous, St Georges Hospital, United KingdomCan we Reduce the Number of Follow up Visits for Pregnanciesof Unknown Location (PULs)?George Condous,-St Georges Hospital, United KingdomFetal Facial Bones in the Mid Trimester Assessment. Can TheyHelp Screen for Trisomy 21?Gary R Pritchard, Brisbane Ultrasound for Women,QueenslandLearning Curve for Fetoscopic Laser Surgery for Severe Twin-Twin Transfusion Syndrome Can be ShortenedFung Yee Chan, University of Queensland,-QueenslandPerinatal Outcomes with Laser Therapy for Severe Twin-TwinTransfusion SyndromeFung Yee Chan, University of Queensland, QueenslandHaving Diagnosed Ectopic Pregnancy using TransvaginalUltrasound, Can the Trend in hCG Levels Help Decide Whento Give Methotrexate?George Condous, St Georges Hospital, United KingdomChanging Pattern of Tertiary Referrals for Prenatal Diagnosisin a Major Centre, Australia 1993–2002Fung Yee Chan, University of Queensland, QueenslandIs It safe to Perform Dilatation and Curettage in Womenwith No Signs of an Intra- or Extra-Uterine Pregnancy onTransvaginal Ultrasound?George Condous, St Georges Hospital, United KingdomChanging Pattern of Advanced Maternal Age and PrenatalDiagnostic Procedures in a Tertiary Referral Centre, AustraliaFung Yee Chan, University of Queensland, QueenslandCan we Use the Ultrasonographic Appearance of an EctopicPregnancy to Predict the Likelihood of Success for Expectantand Medical Management?George Condous, St Georges Hospital, United KingdomCan we predict the outcome of Medical Management ofEctopic Pregnancies Earlier than One Week?George Condous, St Georges Hospital, United KingdomADELAIDE ASM 2005 IS A MEETING NOT TO MISSASUM Ultrasound Bulletin 2005 August; 8 (3)

ASM 2005Adelaide ASM 2005 is a meeting not tomissStephen Bird and Roger Davies Co-convenors ASUM 2005 ASMReaders are urged to register for theAnnual Scientific Meeting of theAustralasian Society for Ultrasoundin Medicine, to be held this yearat the Adelaide Convention Centre,Adelaide and preceded by the SkillsDay Workshop and Course on 29thSeptember 2005The strength of the scientific programmakes this the ‘must attend’ultrasound meeting of 2005. Ten internationalkey note speakers will comprehensivelycover all aspects of diagnosticultrasound and will be supportedby a national faculty representingthe 2005 ‘Who’s Who of Ultrasound’.The widely known and respectedPeter Burns is presenting a marathonsix brand new plenary papers on thevery latest developments in ultrasoundimaging combined with other imagingmodalities, including MRI andCT. These papers are highly relevantand will be of special interest to thoseperforming and reporting breast, hepatobiliaryand obstetrics/gynaecologyimaging.Rethy Chemm and our local fac-ulty – including Neil Simmons, WesCormick and Sean McPeake, willoffer a superb MSK component to themeeting, culminating in a Super MSKSunday where one of the plenaryrooms will feature MSK exclusively.Prof Choi and Prof Rob Gibsonwill provide a very important abdominalimaging component to the programwith recent developments inhepatobiliary and other abdominalultrasound imaging.Rhodri Evans is a world leader inhead and neck imaging, with a specialinterest in the use of ultrasoundfor staging head and neck cancer.Papers will be presented on a range ofhead and neck topics including FNA/core biopsy staging, thyroid, salivaryglands and the larynx. As a skilledpractical scanner, Rhodri is presentinga live scanning workshop as part ofthe Skills Development Day.The vascular program is headlinedby the fabulous Joseph Polak and supportedby the local faculty includingJeni Kidd, Denise Roach and RobertZiegenbein. The vascular componentof the meeting is very strong as aresult of the excellent speakers includedin the program.The first class obstetrics and gynaecologyprogram is headlined by AnnaParsons who is presenting a fascinatingrange of plenary session gynaecologypapers. Pippa Kyle will provideobstetric presentations, supported byPeter Muller, Gary Pritchard, GeorgeCondous, Wes Cormick and others.The ASUM 2005 Annual ScientificMeeting has been designed to providemaximum value to the registrants witha strong scientific program complimentedby fabulous social functions.On Saturday and Sunday morning,Breakfast with the Professors willallow you to speak with the invitedfaculty in a relaxed, informal setting.We look forward to your participationat ASUM 2005 in Adelaide.For further information, pleaseview the meeting website atwww.icms.com.au/asum2005ASUM Beresford ButteryOverseas TraineeshipASUM and GE are proud to announce the awardof the 2005 ASUM Beresford Buttery Traineeshipto Naguesh Naik Gaunekar.The ASUM Beresford Buttery Traineeship hasbeen awarded annually since its inception in1996 as a traineeship in the field of obstetricand gynaecological ultrasound, in memory ofBeresford Buttery FRANZCOG, DDU, COGUSwho made an inestimable contribution to hisprofession.The award provides for attendance at an appropriateeducational program at the ThomasJefferson Research and Education Institute inPhiladelphia.2005 Teaching FellowshipsIn 2005 ASUM is providing three teaching fellowships. sponsoredby GE and Toshiba. The goal of the fellowships is to augment theeducational activity available to our dispersed membership.Giulia Franco Teaching Fellowship NSW(sponsored by Toshiba) NovemberMartin Necas will conduct meetings and teaching clinics in PortMacquarie, Tamworth, Dubbo/Orange, and possibly Newcastle.The local organiser is Peter Murphy, Education Officer of the NorthCoast Sub-branch.Chris Kohlenberg Teaching Fellowship #1 Tasmania(sponsored by GE) NovemberNeil Simmons will conduct a Saturday meeting in Hobart, a teachingclinic at Burnie and an evening meeting in Launceston. Thelocal organiser is Fiona Thompson.Chris Kohlenberg Teaching Fellowship #2 NorthernTerritory and Queensland (sponsored by GE)Peter Coombs will conduct meetings and workshops in AliceSprings, Darwin, Cairns and Townsville. The local organisers areVirginia Loy (Alice Springs), Sharyn Bush (Darwin) and RoslynSavage (Queensland). For details see the online calendar@www.asum.com.au6 ASUM Ultrasound Bulletin 2005 August; 8 (3)

THE EXECUTIVEPresident’s messageDr David RogersWelcome to this August edition of theASUM Ultrasound Bulletin. It onlyseems like last week that the NewYear was being celebrated and alreadywe are in the second half of the year.2005 continues to be a very busy yearfor the Society, with many landmarksbeing achieved along the way.Indemnity insuranceThe most outstanding progress madein recent times has been in the area ofprofessional indemnity insurance (PI).Previously, ASUM could only offermembers a policy that was quite overpriced by comparison with other PIpolicies. After a tremendous amountof work, especially by Stephen Bird,a new policy has been negotiated thatprovides cover for sonographer membersfor only $100.00 per year. This isthe cheapest and most effective indemnitypolicy available in Australasiaand I offer my congratulations to theteam that negotiated it. This policyshould be of benefit to all, reducingoverheads for every sonographermember. It has been offered alongwith the ASUM annual subscriptionsbut, unfortunately, it was announcedafter the initial subscription noticeswent out. However, if you had alreadypaid your subscription before the newPI policy was announced, the ASUMSecretariat will be happy to arrangecover for you.Social scanningRecently, ASUM has been involved inconsiderable activity regarding 3D and4D fetal scanning for what can bestdescribed as entertainment purposes.Several new scanning companies havebeen set up for commercial 3D and4D fetal scanning, without any medicalinput. This is completely againstthe policies of ASUM; the Societyrecommends that ultrasound be usedin a judicious manner and not for mereentertainment. Undoubtedly, there isa consumer demand for pictures suchas these and public demand must beaccommodated. However, the majorconcern with this type of scanning isthat patients will become confusedas to whether they have had a medicalultrasound scan, or a non medicalpicture taking session. Further concernis raised regarding discovery offetal abnormalities. It is unlikely thatnon medical people will have skillsin dealing with patients where abnormalitiesare detected.Glenn McNally, on behalf ofASUM, has produced a statementabout social fetal scanning and isseeking agreement and support fromother professional colleges such asRANZCR, RANZCOG and ASA.David Rogers, Caroline Hong and Glenn McNally with GE China staffIn addition, ASUM is discussing theissue with the Medical Councils ofAustralia and New Zealand and theMinistries of Health on both sides ofthe Tasman. Hopefully, this type ofuncontrolled scanning can be limitedat an early stage.Elections, Annual Report andthe AGMAt this time of year, there are manyofficial processes that must be completed.The Annual Report is circulatedwith this issue and details ASUMevents and progress over the last 12months. This report is published priorto the AGM, which will be held duringthe Adelaide meeting in September.Also prior to this, elections will beheld for sonographer and medical/scientific positions on Council. Formany years, there has only been sufficientinterest to fill the exact numberof places that have become available.However, I am very pleased to see thatASUM is now in the healthy positionwhere there are many nominees forvacant positions. It can only be a goodthing for the Society to have suchinterest and I wish all nominees wellASUM Ultrasound Bulletin 2005 August; 8 (3)7

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THE EXECUTIVEAdelaide ASMLooking ahead, the Annual ScientificMeeting will be held in Adelaide atthe end of September. The line-up ofspeakers is outstanding and I am lookinthe upcoming elections.DMU AsiaThe DMU (Asia) began its first teachingcourse recently, with an intake of11 students in Kuala Lumpur. Thislong term project between ASUM andthe Vision College has finally cometo fruition. The organisation of thetwo-year course has been very wellput together by Wee Loong Lee andAlan Williams, a senior sonographerfrom Tasmania. We wish them successwith their venture. ASUM will besupporting this course with oversightof examination and teaching in somespecific modules.Meetings in Shanghai, Beijingto open China linkIn the middle of May, a delegationfrom ASUM was invited to meet withand speak to the Chinese UltrasoundSociety, a branch of the ChineseMedical Association. Glenn McNally,Caroline Hong and myself attendedmeetings in Shanghai and Beijing,culminating in a dinner presentation toa group of prominent ultrasound specialists.This has been the end productof considerable effort on ASUM’s partto establish contact with the ChineseUltrasound Society. From what I cansee, this is likely to be a very fruitfulexchange.Ultrasound in China is a singleimaging discipline, not included withinradiology or obstetrics. The majorityof patients have to pay for theirown medical care, hence, ultrasoundis used extensively in place of othermore expensive forms of imaging.As such, the Chinese can teach us agreat deal about: contrast enhancedultrasound; ultrasound guided therapy,such as radio frequency and microwaveablation of tumours; and highintensity focused ultrasound treatmentof tumours and fibroids.We have been invited back to speakat the Annual Scientific Meeting ofthe Chinese Ultrasound Society inChengdu in the middle of September.We look forward to this meeting andhave invited Ron Benzie to speak onobstetric scanning.In the future, I am sure we willinvite Chinese speakers to our conferencesand we will learn a great dealfrom them. I must convey my sincerethanks to the members of the ChineseThe ASUM executive meets with the Chinese Ultrasound SocietyNZ Ministry of Health Medical Adviser, Dr David Galler met with Dr David Rogers, Dr CarolineHong and ASUM representatives in WellingtonUltrasound Society and, in particularDr Jiang, for their hospitality duringthis trip and wish to thank GeneralElectric for generously assisting withour travel arrangements.NZ Joint meetingThe New Zealand Branch Meeting,held in Wellington in conjunction withthe Annual Scientific Meeting of theCollege of Radiologists in July, had aparticular focus on abdominal and vascularimaging. The programme alsocontained some additional variety,with several top level speakers.The July Council Meeting was heldin conjunction with the joint meetingand further progress was made ondeveloping the policies discussed at thestrategic planning meeting held duringthe last Council Meeting.ing forward to attending. I am sure theeducational content will be top level.The meeting will be held at the newlyrevamped Adelaide Convention Centre.Thailand joint meetingIn November, ASUM is holding a jointmeeting with the Medical UltrasonicSociety of Thailand, in Bangkok.This meeting is looking very good,with an excellent line-up of speakers.Holidaying in Thailand is currentlyvery cost effective and, if you are consideringgoing, it may be worthwhileto plan on a few days on the beaches.I understand the effects of the tsunamihave been dealt with.Thank you, everyoneI would like to take this opportunityto thank Caroline Hong, KeithHenderson, James Hamilton and theSecretariat for their continued effortsat this busy time of year, which isdominated by official processes.David RogersPresident ASUMASUM Ultrasound Bulletin 2005 August; 8 (3)9

THE EXECUTIVECOUNCIL 2004–2005CEO’s messageEXECUTIVEPresidentDavid Rogers NZMedical CouncillorImmediate Past PresidentGlenn McNally NSWMedical CouncillorHonorary SecretaryRoslyn Savage QldSonographer CouncillorHonorary TreasurerDave Carpenter NSWScientific CouncillorMEMBERSMedical CouncillorsMatthew Andrews VicRon Benzie NSWRoger Davies SADavid Davies-Payne NSWSonographer CouncillorsStephen Bird SAMargaret Condon VicKaye Griffiths NSWJanine Horton VicASUM Head OfficeChief Executive OfficerCaroline HongEducation ManagerKeith HendersonAll correspondence should bedirected to:The Chief Executive OfficerASUM2/181 High StWilloughbyNSW 2068Australiaasum@asum.com.auhttp//www.asum.com.auDr Caroline HongThis message is written at another busytime at the ASUM secretariat. In Juneeach year, the office prepares for allthe necessary paperwork and processesthat are required for compliance. Itis also a time for accepting nominationsfor Council and for expressionsof interest as volunteers on committeesand boards of examiners.ASUM is a not-for-profit organisationwith its financial year ending on30th June. It is audited annually inaccordance with the Corporations Act,complying with the requirements as aregistered company limited by guarantee.ASUM is also audited annuallyfor ISO 9000:2001 for quality managementsystems and is accredited forthe international standards.All full members will be issuedwith a copy of the Annual Reportoutlining the achievements for the last12 months together with the auditedfinancial accounts.ASUM NZ joint meeting withRANZCR NZThis year the ASUM NZ Branchheld its annual scientific meetingjointly with the RANZCR NZ at theWellington Convention Centre from28–31st July 2005.It was well attended by membersfrom both organisations from NewZealand and Australia.The keynote international speakersfrom USA, Canada and Australia,supported by the local speakers, presentedan interesting program whichwas enjoyed by all. Once again, weacknowledge the valuable contributionof all our sponsors and volunteerson the Organising Committee,especially the co-convenors, CraigMcQuillan and Paul Kendrick. At theGala Dinner, awards were presented tothe worthy recipients by the presidentsof both organisations.At the ASUM NZ Branch AGM,Yvonne Taylor stepped down fromher role as Chair after two years ofdedicated service. Rex de Ryke waselected as the new Branch Chair andwill continue to serve the Societywell.Meeting with NZ Health MinistryThe President and CEO met formallywith the NZ Ministry of Health’sPrincipal Medical Advisor, Dr DavidGaller, in Wellington and discussedmany topical ultrasound issues.The ASUM Council held a fullday business meeting on Saturday30th July 2005 at the Duxton Hotel inWellington.ASUM Online Clinical HandbookMembers are reminded that this valuableeducational resource is availableonline. The ASUM Online ClinicalHandbook is presented as an educationalaid for experienced practitioners.The information has been contributedby many individual practitionersand we are grateful for this. A lotof work has been done by Dr DavidDavies-Payne, Chair of the Educationand ASM Committee. The Handbookwas a major project initiated by DrDavid Rogers when he was Chair ofthe Education Committee.DDU ExaminationThe DDU Part I and II examinationsare now all over and the results havebeen notified to the candidates. Onceagain, we are grateful to the Chairof the DDU Board of Examiners,Dr Chris Wreidt, all members on theDDU Board of Examiners, the individualDDU examiners and all the volunteersof ASUM who were involved in the10 ASUM Ultrasound Bulletin 2005 August; 8 (3)

The DMU (Asia) will deliver high teaching standardsPromoting the DMU (Asia) at Vision Collegeexamination process.This qualification is of a veryhigh standard and continues to attractincreasing interest from the medicalprofession. Please contact MarieCawood at ASUM head office, emailregistrar@asum.com.au if you haveany questions or require informationabout the DDU. The information andhandbooks are also available on thewebsite and updated regularly forfuture candidates who are planning tosit for these examinations next year.DMU ExaminationThe DMU Part I and DMU Part IIWritten Examinations were heldthroughout Australia and New Zealandon Saturday 30th July 2005. The DMUPart II OSCE/Oral Examinationswill be held on Saturday 8th Octoberfor Cardiac and Vascular candidatesand on Saturday 15th October forthe General and Obstetric candidates.DMU Practical Examinations are conductedat individual practices fromApril through October.DMU (Asia) off to a good startASUM is pleased to announce thatthe DMU (Asia) course commencedon 6th June 2005 at Vision Collegein Kuala Lumpur, Malaysia. The firstintake of students is being taught bysonographer lecturer of DMU (Asia) MrAlan Williams and a team of competentmedical and sonographer volunteer lecturersfrom ASUM and Asia, along withthe support from at least five affiliatedteaching institutions.Alan Williams, previously a seniorsonographer working in Tasmania andan ASUM member, qualified withthe ASUM DMU, was recruited viaASUM by Vision College as theirfirst sonographer lecturer. He hasbeen working very hard with the localmedical specialists on developing thecoursework based on the ASUM DMUand in accordance with the agreementbetween ASUM and Vision College.The course is designed to ensurethat the same high standards of DMUwill be offered in the DMU (Asia).This course has gone through thelocal regulatory assessment and haspassed the necessary local authorities’requirement for recognition as a postgraduate diploma. The DMU (Asia)course is offered to graduates withthe relevant tertiary background. It isalso attracting interest from generalpractitioners who have an interest inultrasonography. The training of ultrasonographythrough the DMU (Asia)will, over time, create a high standardof practice in Asia.ASUM has appointed representativesto the DMU (Asia) advisorypanel. Dr Andrew Andrew Ngu, DrGlenn McNally and two councillorsonographers have been nominated tothis panel. There will also be representativesfrom ASUM on the DMU(Asia) Board of Examiners, whoseexpertise and services will be requiredat a later stage. Dr Andrew Ngu andMrs Roslyn Savage will be traveling toKuala Lumpur to offer some teachingto the students in August this year. DrDavid Rogers and Dr Roger Gent willalso deliver some lectures at VisionCollege in March 2006.ASUM will be assisting VisionCollege to recruit the second sonographerlecturer (position advertised in thisissue) and updates will be posted on thewebsite.ASUM Asia Link ProgramScholarshipISUM (Indonesia) scholar awardedDr Daniel Makes, President of theIndonesian Society for Ultrasoundin Medicine (ISUM) has been themost active in responding to ASUM’srecent announcement of several AsiaLink Program scholarships. ThroughISUM, a young specialist obstetriciangynaecologist, Dr Taufik Jamaan,who graduated in 2000 from theDepartment of Ob/Gyn, Faculty ofMedicine, University of Indonesia,Jakarta, has been chosen to be therecipient of the scholarship. He hasbeen placed to spend some time inSydney with Prof Ron Benzie andwith Dr Glenn McNally and theirrespective ultrasound teams.ASUM BookshopThis is an online ASUM bookshop wheremembers can easily access the latesttitles in their specialty in ultrasound.The bookshop is run by Mi-tec MedicalPublishing. Members who are busy, withlittle time to keep abreast of the latesttitles in medical ultrasound, will find thisservice to be of value. The complete listof the latest ultrasound textbooks andpublications can be obtained at www.mitec.com.au and the ASUM Bookshopsection. Orders can be placed by email toorders@mitec.com.auMembers are also reminded thatbooks can also be obtained from ourcorporate member, Elservier Australiaby emailing e.pappas@elservier.comor calling +61 2 9517 8953.ASUM Ultrasound Bulletin 2005 August; 8 (3)11

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THE EXECUTIVEMember ServicesSonographer professionalindemnity insuranceWe are pleased to advise that theASUM Council has negotiated a greatnew deal on professional indemnityinsurance. This provides cover forsonographers undertaking sonographicand radiographic procedures.Details and application forms havebeen sent out to all members. Thisoffer is available to both existing andnew sonographer and associate members.It is still not too late to take upthis fantastic offer; please let yourcolleagues know about it. Contact theASUM Secretariat or go to our websiteat www.asum.com.au for moreinformation.AMP Affinity Home LoanPackageMembers are reminded that the AMPAffinity Home Loan Package is nowavailable to current members ofASUM. This special package wasnegotiated a few months ago as aservice to members. Go to the ASUMwebsite www.asum.com.au for details.It could save you thousands of dollarson your home loan; several membershave already responded to this specialpackage.Hertz preferential carrental rates available to ASUMmembersIf you have not already applied for theHertz Gold Card, you are well advisedto spend a few minutes to completethe application form and sent it toHertz.The application fee has beenwaived for ASUM members. ASUMhas appointed Hertz Australia as thepreferred car rental partner for theSociety’s member benefit program.As ASUM's official car rental partner,Hertz will offer you exclusive specialmember rates and value-added benefitsall year round. All you have todo is quote the Customer DiscountProgram (CDP) number 1594587when you make a reservation. See theASUM website at www.asum.com.aufor details.Register now for these meetingsASUM 2005 Adelaide, 28th Sept– 2nd OctGood food, fine wine and a sense ofhistory are found in Adelaide, whichboasts more restaurants per capita thanany other city in Australia.We look forward to seeing manymembers and new faces at the ASUM2005 ASM, to be held in the state-ofthe-artAdelaide Convention Centre.Stephen Bird, Roger Davies andthe local Organising Committee havecreated an excellent program of learning,networking opportunities andsocial events.For the first time, a child mindingservice will also be made available.Tours around the beautiful AdelaideCity highlights, Barossa Valley wineregion, Cleland Wildlife Reserve,Kangaroo Island, Flinders Ranges andWilpena Pound are also available.You can register online and theprogram is regularly updated on thewebsite at www.asum.com.au or www.icms.com.au/asum2005.ASUM – MUST MeetingBangkok 10–11th NovThailand, also known as the Landof Smiles, will be the venue for thenext ASUM Asia Link Excellence inUltrasound Meeting. The joint meetingconvenors from both societies havedesigned an interesting program whichwill appeal to everyone with an interestin Ob/Gyn and General ultrasound.All ASUM members are welcometo attend this meeting, which can becombined with your holidays overseasin Asia. November in Thailand coincideswith the Loy Krathong Festivaland will enchant you with the Thais’rich and colourful culture.This is the second joint meetingwith the Medical Ultrasonic Society ofThailand (MUST). ASUM delegateswho attended previous meetings inAsia have reported excellent value formoney and enjoyed the exposure tothe Asian culture and mingling withlocal professional colleagues. MUSTis one of the many affiliated societiesof the Asian Federation Society forUltrasound in Medicine and Biology(AFSUMB), which in turn is one ofthe six affiliated societies of the WorldFederation for Ultrasound in Medicineand Biology (WFUMB).ASUM members may claim pointsin MOSIPP for attending this meeting.ASUM Annual General MeetingAdelaide 1st OctThe AGM will be held in Adelaide atthe Adelaide Convention Centre onSaturday 1st October 2005 at 10.00am. At this meeting, the AnnualReport and Accounts will be adopted.Honorary Fellow and Life Memberawards will also be announced andpresented.China – SUM/CMA8th National Ultrasound MedicalConference 13–18th SeptThe 8th National Ultrasound MedicalConference organised by the Societyfor Ultrasound in Medicine of theChina Medical Association will beheld in Chengdu, Sichuan Province,on 13–18th September 2005.The ASUM President, the Chair ofAsia Link, CEO and Prof Ron Benziehave been invited to speak at thismeeting, following a successful visitto China in May this year. Dr DavidRogers, Dr Glenn McNally, Chairof Asia Link and I visited the GEHealthcare Technologies EducationCentre and we also presented at theSUM/CMA local meeting in Beijing.This meeting was chaired by Dr JiangYu Xin, the President of Society ofUltrasound in Medicine, ChineseMedical Association (SUM/CMA). DrJiang and Dr David Rogers discussedand exchanged information on societymatters, ultrasound education andacademic exchange. We are pleasedthat the relationship between the twosocieties remain strong.Dr Caroline HongChief Executive Officercarolinehong@asum.com.auSecond OverseasSonographerLecturerVision CollegeA second sonographer lecturerposition is now available at the newVision College in Kuala Lumpur.The successful applicant will needto be an experienced sonographer,with an ASUM DMU. A negotiableremuneration package is available.Expressions of interest and afull CV are to be directed to DrCaroline Hongemail carolinehong@asum.com.auASUM Ultrasound Bulletin 2005 August; 8 (3)13

LETTERSMid trimester biometric measurementsTo the Editor,We would like to bring to the attention of youand your readers our article entitled Ultrasonicfetal size measurements in Brisbane that wasrecently published in the peer reviewed sisterjournal, Australasian Radiology 1 . This articleconstructed population specific charts of fetalbiometry for 11 to 41 weeks gestation in relationto known gestational age from a large populationof normal Australian pregnancies wherethe examination was performed to an Australianand New Zealand (ANZ) standard protocol byexperienced operators. Motivation included thefact that overseas charts, up to 25 years old,are currently employed for many fetal parameterswithin ANZ 2,3 and that the development ofappropriate localised charts have been criticisedby some ultrasonic specialists and practitionersin Australia because of their suboptimalmethodological rigour 4 . To remedy this, we presentedmethodologically rigorous, current andpopulation appropriate biometric equations andtables of ultrasonic fetal measurement and 95%reference ranges for biparietal diameter (BPD),femur length (FL), abdominal circumference(AC) and head circumference (HC).We believe that this dataset can be used togenerate valid reference centiles for fetal size.In most respects, it meets Altman and Chitty's 5,6and Nisbet and de Crespigny's 4,7 criteria for design and isreadily exportable for statistical analysis, also consistentwith Altman and Chitty's recommendations. It has theadvantage of being a very large sample collected from anentirely Australian population using a customized database,PacUser TM 8 . All examinations were performed byvery experienced operators, yet none of the protocols formeasurement are beyond the capacity of any sonographer.An attempt should be made by each sonographer to achievethe same rigor with each examination. It is our belief thatneither fetal measurement nor gestational age should bedependent upon operator experience.In summary, we assert that the presented results are themost rigorously derived and applicable to the Australianpopulation. The resulting tables have been provided to theASUM Federal Council for their consideration with a viewto amending the current recommendations for fetal biometry.We would suggest that your readers investigate the useof these tables in their practice.We would also welcome readers to submit their deidentifieddatabases to us to increase the sample sizeand to check the reliability of these equations.We would like to thank the sonographers involved inthis project for their excellent work: Ms Teresa Clapham,Ms Helen Gofton, Ms Julie Naylor, Mr Neil Pennell andMs Sue Williams.For further information about the methodology, thestatistical analysis, the results and equations, readers areencouraged to access the journal articles 1,9 or to contact DrGary Pritchard directly.14 ASUM Ultrasound Bulletin 2005 August; 8 (3)Table 1 Ultrasonic fetal measurement means and 95% reference intervals (95% RI)by gestational age measured in weeks.Gestation BPD FL AC HC(weeks) mean (95%RI) mean (95% RI) mean (95% RI) mean (95% RI)11 21 (19, 23) 5 (2, 8) 53 (42, 63) 75 (66, 84)12 24 (21, 26) 8 (5, 11) 63 (52, 73) 85 (75, 94)13 26 (23, 29) 11 (8, 15) 73 (61, 84) 95 (84, 105)14 29 (26, 32) 14 (11, 18) 83 (71, 95) 105 (94, 116)15 32 (28, 35) 17 (14, 21) 94 (81, 106) 116 (104, 127)16 35 (31, 38) 20 (17, 24) 105 (92, 118) 126 (114, 139)17 38 (34, 41) 23 (20, 27) 116 (102, 130) 138 (125, 150)18 41 (36, 45) 26 (22, 30) 127 (112, 142) 149 (136, 162)19 44 (39, 48) 29 (25, 32) 138 (123, 154) 161 (147, 175)20 47 (42, 51) 31 (28, 35) 150 (133, 166) 172 (158, 187)21 50 (45, 55) 34 (30, 38) 161 (144, 178) 184 (169, 199)22 53 (48, 58) 37 (33, 41) 172 (154, 191) 195 (180, 211)23 56 (51, 61) 39 (35, 43) 184 (164, 203) 207 (190, 223)24 59 (54, 64) 42 (38, 46) 195 (175, 215) 218 (201, 235)25 62 (56, 68) 44 (40, 49) 206 (185, 228) 229 (212, 247)26 65 (59, 71) 47 (42, 51) 218 (195, 240) 240 (222, 259)27 68 (62, 74) 49 (45, 54) 229 (205, 252) 251 (232, 270)28 71 (65, 77) 51 (47, 56) 240 (215, 265) 261 (241, 281)29 74 (67, 80) 54 (49, 58) 251 (224, 277) 271 (250, 291)30 76 (70, 83) 56 (51, 61) 261 (234, 289) 280 (259, 301)31 79 (72, 85) 58 (53, 63) 272 (243, 301) 288 (267, 310)32 81 (74, 88) 60 (54, 65) 282 (252, 312) 297 (274, 319)33 83 (76, 90) 62 (56, 67) 292 (261, 324) 304 (281, 327)34 85 (78, 93) 63 (58, 69) 302 (269, 335) 311 (287, 334)35 87 (80, 95) 65 (59, 71) 312 (277, 347) 316 (292, 340)36 89 (81, 97) 67 (61, 73) 321 (285, 357) 321 (297, 346)37 90 (83, 98) 68 (62, 74) 330 (292, 368) 326 (300, 351)38 92 (84, 100) 70 (63, 76) 339 (300, 379) 329 (303, 355)39 93 (85, 101) 71 (64, 78) 348 (307, 389) 331 (305, 358)40 94 (85, 102) 72 (65, 79) 356 (313, 399) 332 (305, 359)41 94 (86, 102) 73 (66, 80) 364 (319, 406) 332 (305, 360)Prof Philip SchluterAuckland University of TechnologyDr Gary PritchardBrisbane Ultrasound for Women Email bufw@bigpond.comMs Margo Gill Brisbane Ultrasound for WomenReferences1 Schluter P, Pritchard G, Gill M. Ultrasonic fetal size measurementsin Brisbane, Australia. Australas Radiol 2004; 48: 480-486.2 Westerway S, Davison A, Cowell S. Ultrasonic fetal measurements:new Australian standards for the new millennium. Aust N Z J ObstetGynaecol; 40 (3): 297–302.3 Australasian Society for Ultrasound in Medicine. Statement on normalultrasonic fetal measurements. ASUM Ultrasound Bulletin 2001;4 (3): 28–31.4 Nisbet D, de Crespigny L. Policy Statement on normal ultrasonicfetal measurements. ASUM Ultrasound Bulletin 2002; 5 (4): 32.5 Altman D, Chitty L. Design and analysis of studies to derive chartsof fetal size. Ultrasound Obstet Gynecol 1993; 3 (6): 378–384.6 Altman D, Chitty L. Charts of fetal size: 1. Methodology. BJOG1994; 101: 29–34.7 Nisbet D, de Crespigny L. How should the ultrasound estimated duedate be calculated? ASUM Ultrasound Bulletin 2002; 5 (1): 20–21.8 Precise Accurate Convenient Ultrasound Examination Reporting(Pacuser) [computer program]. Version 1. Brisbane: Pacuser, www.pacuser.com.au; 1993.9 Schluter P, Pritchard G, Gill M. Corrigendum: Ultrasonic fetal size measurementsin Brisbane, Australia. Australas Radiol 2005; 49: 345.

ASUM Ultrasound Bulletin 2005 August; 8 (3): 15–17DIAGNOSTIC ULTRASOUNDAbnormal fetal feet – the differentialdiagnosesD Fauchon A AMS, S Watson BHA, Grad Dip Ultrasound A , RJ Benzie MBChB, FRCS(c), FRANZCOG, ARDMS ABAChristopher Kohlenberg Department of Perinatal Ultrasound, Nepean Hospital, University of Sydney,Penrith, New South Wales, AustraliaBCorrespondence to David Fauchon email FauchoD@wahs.nsw.gov.auFigure 1 2D Ultrasound at 21 weeks gestationIntroductionUltrasound diagnosis of fetal anomalies is not alwaysstraightforward. There are situations that are ‘black andwhite’, however, some ultrasound findings leave both theclinician and the patient in a ‘grey area’, the implications ofwhich are uncertain. This case report of abnormal feet is agood example.Case reviewA 29-year-old gravida 2 para 1 in her second pregnancyhad her first ultrasound at 19 weeks gestation. This was afetal anatomy scan, which revealed an isolated finding oflateral ventricles at the upper limits of normal (1.0 cm). Thepatient was referred to our unit two weeks later where weconfirmed that finding, and in addition diagnosed bilateralfeet deformities. It was unclear whether they were ectrodactylyin nature or fusion deformities. Two dimensionalultrasound images of both feet are demonstrated in Figures1 and 5. The fetal anatomy scan appeared otherwise normal.Further investigations revealed a normal karyotype and anegative TORCH screen. Antenatal genetic counselling wasinconclusive.Subsequent ultrasounds were essentially unchangeduntil 28 weeks gestation, when there was a marked increasein the size of the lateral ventricles to 2.0 cm. The right kidneywas noted to have pelvicalyceal dilatation with a dilatedright ureter. The left kidney was normal.Three-dimensional imaging of the fetal feet demonstratedthe abnormalities more clearly, particularly of the rightfoot (Figures 3 and 7). Postnatal photographs and x-rays areFigure 2 2D Ultrasound at 28 weeks gestationshown in Figures 4, 8 and 9.Ultrasounds at 32, 36 and 37 weeks gestation providedno additional information on the feet anomalies, however,they showed a gradual increase in dilatation of the lateralventricles up to 2.7 cm.Postnatal examinationsA live female baby was delivered by planned caesareansection at 38 weeks gestation in Nepean Hospital. Postnatalx-rays, MRI and ultrasound demonstrated the followingfindings:Head: Circumference above the 90th percentile withenlarged ventricles and agenesis of the corpus callosum.Heart: Patent foramen ovale.Limbs: Bilateral polysyndactyly of hands and feet.Kidneys: Right duplex collecting system withobstructed upper pole moiety and a normal left kidney.Hips: Bilateral mild-moderate hip dysplasia.Postnatal genetic review was important in reaching adifferential diagnosis.DiscussionThe incidence of major limb anomalies in newborns is 2 in1000 1 . Anomalies of the toes and metatarsals may be classifiedinto five broad categories including:Absence deformities : Ectrodactyly;Syndactyly;Polydactyly;Brachydactyly; andContracture deformities 2 .ASUM Ultrasound Bulletin 2005 August; 8 (3)15

Abnormal fetal feet – the differential diagnosesFigure 3 3D Ultrasound at 28 weeks gestationFigure 4 Postnatal photgraph of the right foot. Syndactyly betweenthe 2nd and 3rd toes can be clearly seenFigure 5 2D Ultrasound at 21 weeks gestationFigure 6 2D Ultrasound at 28 weeks gestationFigure 7 3D Ultrasound at 28 weeks gestationSome of these may be present simultaneously.Absence deformities: EctrodactylyEctrodactyly is a heterogenous group of hand/foot malformations,which range from partial or total absence of afinger or toe to the cleft hand or foot deformities 3 .SyndactylySyndactyly refers to the cutaneous and/or osseous fusion oftwo or more digits. It may also present as a manifestation ofa multiple malformation syndrome or chromosomal abnormalit3 . Simple cutaneous syndactyly involving the toes isFigure 8 Postnatal photograph of the left footsonographically difficult to detect, particularly at the timeof the 18–20 week anatomy scan. Unlike the fingers, thetoes cannot generally be seen to separate during an extendedreal time examination. The syndactyly of the hands and feetwere not detected prenatally in this fetus (Figure 10).PolydactylyPolydactyly is the partial or complete presence of an extra digit.It may arise from the hand or foot, or another digit. Polydactylymay present as an isolated anomaly with an autosomal dominantmode of inheritance or as a manifestation of a multiplemalformation syndrome or chromosomal abnormality. 316 ASUM Ultrasound Bulletin 2005 August; 8 (3)

D Fauchon, S Watson and R Benzieor syndrome, or with other limb anomalies including polydactylyand syndactyly. It may also occur as a result of ateratogenic insult 4 .An in utero diagnosis of brachydactyly was not madein this instance. Short toes on both feet can be seen on thepostnatal photographs.Figure 9 Postnatal x-ray of both feet. Malformation of the metatarsalsof the left foot were consistently identified in the prenatalultrasoundsFigure 10 Postnatal photographs of both hands. Syndactyly can benoticed between the 3rd and 4th fingers on the right hand and the2nd and 3rd fingers on the lefy handThe preaxial polydactyly on the right foot was evidentat the time of the 21 week scan (Figure 1) as an extra nubbinof tissue arising at an abnormal angle from the big toe.Follow up scans including 3D imaging at later gestations,clearly demonstrated the initial findings. Postnatal x-raysconfirmed the lack of an ossification centre.BrachydactylyBrachydactyly is the shortening of the digits resulting fromanomalous development of the phalanges or metatarsals/metacarpals. It may occur as a feature of a skeletal dysplasiaOral-facial-digital syndromeOral-facial-digital syndrome (OFDS) is comprised of aheterogenous group of disorders characterised by anomaliesof the face, oral cavity and digits. Abnormalities of otherorgan systems including the central nervous system, theurinary tract and tibial and radial defects have also beenidentified and associated with this syndromic spectrum. Todate 11 different types of the OFDS have been identified.Overlapping clinical features between OFDS and a widevariety of other syndromes make precise clinical identificationdifficult 5 .CNS anomalies occur in approximately 13% of cases withcomplete or partial agenesis of the corpus callosum the mostfrequently detected anomaly 6 . The digital anomalies of the handsand/or feet commonly seen in this syndrome include syndactyly,polydactyly, brachydactyly and clinodactyly. Bilateral bifidity ofthe great toe is a characteristic finding of OFDS II 7 .The child in this case was eventually thought to be amosaic within the broad spectrum of oral-facial-digitalsyndrome. To date, a definitive classification of the specifictype has not been made.ConclusionThe 18-week scan identified the bilateral hydrocephalusand malformation of the metatarsals of the left foot and preaxialpolydactyly of the right foot. The syndactyly andbrachydactyly were undetected prenatally as was the absentcorpus callosum, in spite of repeated ultrasounds.Three-dimensional imaging of the feet was helpful forthe parents to appreciate the likely anomalies. It alsoprovided more information for the clinician. Serial scanningmay reveal more information with increasing gestation. Thepostnatal findings have narrowed down the likely diagnosis,although, even at this stage a definitive diagnosis has notbeen reached. This case reminds us of the limitations ofantenatal ultrasound diagnosis. It also confirms the adage,“Find one anomaly, look for more!”AcknowledgementWe would like to acknowledge Dr. Linda Goodwin of theGenetics Department at Nepean Hospital for providing thepostnatal photographs for this case presentation.References1 Moore KL and Persaud TVN (1998) The Developing HumanClinically Oriented Embryology, WB Saunders, Philadelphia.2 Cotran RS, Kumar V and Robbins SL (1994 ) Pathological Basis forDisease, 5th Edition, WB Saunders, Philadelphia.3 Fanaroff: (2002) Neonatal-Perinatal Medicine: Diseases of the Fetusand Infant, 7th Edition, Mosby, USA.4 Platypus (1999) TKI Medcon, Canada.5 Sakai et al (2002) Oral Facial Digital Syndrome Type II: Clinical andGenetic Manifestations, Journal of Cranio Facial Surgery 13 (2): 321–326.6 Patrizi A, Orlandi C, Neri I, Bardazzi F and Cocchi G (1999) WhatSyndrome is This?, Pediatric Dermatology 16 (4): 329–331.7 Buyse ML, Birth Defects Encyclopaedia, Blackwell ScientificPublications, USA 1990.ASUM Ultrasound Bulletin 2005 August; 8 (3)17

website : www.asum.com.auWebsite: www.asum.com.auASUM extends a warm welcome to youASUM 2005 Meetings:30 Sept – 2 Oct Annual Scientific Meeting Adelaide Australia10 - 11 Nov ASUM Asia Link Program Bangkok ThailandASUM 2006 Meetings:22 - 26 Mar Multidisciplinary Workshop Gold Coast Australia14 - 17 Sept Annual Scientific Meeting Melbourne AustraliaWFUMB 2009 World Congress: Sydney5 - 9 Sept WFUMB2009 Congress to be hosted by ASUMFor details, please contact ASUMAddress: Suite 2, 181 High StreetWilloughby NSW 2068Sydney, AustraliaPhone: +61 2 9958 7655Fax: +61 2 9958 8002Email:asum@asum.com.auASUM CEO: Dr Caroline Hong : carolinehong@asum.com.auPROMOTING EXCELLENCE IN ULTRASOUND

ASUM Ultrasound Bulletin 2005 August; 8 (3): 19–21DIAGNOSTIC ULTRASOUNDFetal upper abdominal masses:a prenatal diagnostic dilemmaSharon Watson BHA, Grad Dip Ultrasound A , RJ Benzie MBChB, FRCOG, FRCS(C) FRANZCOG, ARDMS ABAChristopher Kohlenberg Department of Perinatal Ultrasound, Nepean Hospital, University of Sydney,Penrith, New South Wales, AustraliaBCorrespondence to Ron Benzie email rbenzie@wahs.nsw.gov.auFigure 1 Figure 2Figure 3 Figure 4IntroductionA definitive diagnosis may not always be apparent whena fetal upper abdominal mass is present. The sonographicappearances of a range of pathological conditions havesimilar features and may be difficult to differentiate for eventhe most experienced personnel.As illustrated by the following cases, a final diagnosismay only be made after birth, after ongoing serial sonographicreview.Case 1: Right upper quadrant massA 36-year-old primigravida, with preeclampsia and gestationaldiabetes was scanned repeatedly between 29 and 34weeks gestation. At approximately 32 weeks gestation, theantenatal scan demonstrated a well circumscribed echogenicmass, with apparently cystic components, in the region ofthe right adrenal gland. Blood flow within the mass couldnot be demonstrated with colour Doppler ultrasound. Nofeeder vessel was identified.Over the five-week period, the mass did not changesignificantly in size or sonographic appearance (Figures 1and 2). An adrenal tumour was considered the most likelydiagnosis.The child was delivered by emergency caesarean sectionfor maternal preeclampsia at 35 weeks gestation.The postnatal ultrasound examination confirmed theASUM Ultrasound Bulletin 2005 August; 8 (3)19

Sharon Watson and RJ BenzieFigure 5 Figure 6Figure 7 Figure 8antenatal findings, locating the hyperechoic mass in theright subdiaphragmatic area with possible extension intothe pleural space, with associated compression of the IVCand hepatic vasculature. The liver, right kidney and rightadrenal gland had a normal sonographic appearance (Figure3). A possible feeder vessel was identified on a subsequentscan. The lesion was thought to be an extralobar pulmonarysequestration (Figure 4).Given the location of the lesion andthe ongoing healthy status of the infant, surgical interventionhas not been indicated.Case 2: Left upper quadrant massA 22-year-old woman, gravida 4, para 2 presented for agrowth scan at 38 weeks gestation with a clinical historyof decreased fundal height. Fetal measurements were consistentwith appropriate growth for the stated gestation.However, within the fetal abdomen, a complex, predominantlycystic mass containing mobile septa and solid materialwas identified in the region of the left adrenal gland(Figure 5). A neuroblastoma or adrenal haemorrhage wasconsidered to be the most likely diagnosis.The mass was subsequently reviewed using both 2Dand 3D ultrasound four days later. The possibility of arenal mass was considered at this time. It appeared to haveincreased in both size and degree of complexity. Whilst stillpredominantly cystic in nature, the mass seemed to containmore solid components. The septations also appeared to bethicker and immobile. Colour Doppler evaluation demonstratedflow peripheral to the mass. There was otherwise noevidence of increased vascularity (Figures 6 and 7).Following normal vaginal delivery at 41 weeks gestation,the child remained well. There was no clinical evidence ofadrenal insufficiency or elevated catecholamines. The abdomenwas found to be soft with no palpable mass detected. Theinfant’s blood chemistry was essentially normal.Neonatal ultrasound examination demonstrated a welldefined rounded complex retroperitoneal mass in the leftupper quadrant, medial to and contiguous with, the leftadrenal gland. The mass dimensions were essentiallyunchanged from the examination performed four weekspreviously. The mass was now predominantly solid.No definite calcifications or vascularity could be identified.The liver, kidneys, spleen, biliary system and urinarybladder had a normal sonographic appearance (Figure 8).The differential diagnosis was thought to include adrenalhaemorrhage, lymphangioma and a retroperitoneal teratoma.The child has remained clinically well in the 12 months sincehis birth. The mass has been seen to diminish in size withongoing serial review by both CT and ultrasound.Surgical excision was considered unnecessary since all ofthe features suggest that the mass is an adrenal haemorrhage.DiscussionFetal abdominal tumours account for approximately 5%of abnormalities detected by prenatal ultrasound. The differentialdiagnosis of intraabdominal and/or retroperitoneal20 ASUM Ultrasound Bulletin 2005 August; 8 (3)

Fetal upper abdominal masses; a prenatal diagnostic dilemmaTable 1 Comparison of the sonographic features of upper abdominal massesIntraabdominal Extralobar Adrenal Haemorrhage 2–4 Neuroblastoma 3–5 Teratoma 6 Lymphangioma 7Pulmonary Sequestration(IEPS) 1Pathology Non-functioning lung Pathogenesis in utero is Most common malignant Tumours composed of Benign tumourstissue that does not communicate unknown. tumour in the neonate. tissues derived from of the lymphatic vesselwith bronchial tree. Total or segmental involve- Originating in neural the 3 germinal layers that are mostBetween diaphragm and liver/kidney, ment of the gland. crest cells. of the embryo. commonly diagnosedseparate from adrenal gland. Prenatal diagnosis 32 in the neonatal periodweeks+.or early infancy.Location 8–10% abdomen or Usually intracapsular. 50% associated with 60–65% sacrococcygeal 95% head, neckretroperitoneum. Extension into peritoneal Adrenal gland. region. and axilla.90% left sided cavity or retroperitoneum Retroperitoneal, thoracic 10–20% in the gonads. 63% of abdominalif ruptures. or cervical paravertebral Mediastinum, naso- lymphangiomas.3–4 x more common on regions. pharynx head and neck, occur on the left side.the right side.and the retroperitoneum.Sonographic Circumscribed, homogenous Changes over time. Homogenous hyperechoic, Variable appearance Well delineated,appearance echogenic mass, Initially hyperechoic 50% cystic, or mixed ranging from hypoechoic cystic± cystic components. becoming heterogenous echo pattern. completely anechoic masses of variablebefore finally anechoic. Occasional calcification to completely size. May be uni orMaybe round, triangular Frequently encapsulated hyperechoic. multiloculatedor crescent shaped. displacing kidney. 60% mixed appearance. with fine septations.May contain debris.Vascularity ± feeder vessel Rim shaped peripheral Low impedance Little or no flow on Little or no flow onfrom aorta. vascularity. waveform. colour Doppler.Associated Diaphragmatic hernia, bronchial Displacement of the kidney Hepatomegaly and/or Polyhydramnios fetal Skin oedema,findings agenesis, colonic duplication and caudally. fetal hydrops hydronephrosis hydrops fetalisvertebral anomalies. associated with metastases. and fetal hydrops. and polyhydramnios.Oligo/polyhydramnios.fetal hydrops.masses relies on the accurate evaluation of the size, positionand characteristic sonographic appearances.The most common differential diagnosis of intraabdominalmasses includes congenital neuroblastoma or adrenalhaemorrhage, renal tumours, teratomas and less commonlyintraabdominal extralobar pulmonary sequestration. It isessential that an accurate distinction is made in order thatpatient care be optimised.A comparison of the clinical and sonographic features ofthese conditions can be seen in Table 1.ConclusionIn both of our cases, the diagnosis was made ultimatelyfollowing serial sonographic review correlated with theclinical and biochemical findings. The children are well anddeveloping normally.While ultrasound is the imaging modality of choicewhen evaluating the fetal and neonatal abdomen, it cannotalways provide a definitive diagnosis in the first instance.A number of mostly benign conditions have features whichmay mimic those of masses of a more sinister nature andvice versa. In such cases, the role of the ultrasound examinationis to alert the referring clinician to the presence orabsence of pathology in order that effective clinical managementdecisions can be made.AcknowledgementsWe would like to acknowledge Prof Albert Lam and MrJoseph Lui from the New Children’s Hospital for theirassistance.References1 Pumberger W, Moroder W, Wiesbauer P. Intraabdominal extralobarpulmonary sequestration exhibiting cystic adenomatoid malforma-tion: prenatal diagnosis and characterization of a left suprarenal massin the newborn. Abdom Imaging 2001; 26: 28–31.2 Seigel. Paediatric Sonography 3rd ed. New York: LippincottWilliams and Wilkins; 2002.3 Schwarzler P, Bernard JP, Senat MV, Ville Y. Prenatal Diagnosisof Fetal Adrenal Masses: Differentiation between Hemorrhage andSolid Tumour by Colour Doppler Sonography. Ultrasound ObstetGynaecol 1999; 13: 351–355.4 Kesrouani A, Duchatel F, Seilanian M and Muray JM. PrenatalDiagnosis of Adrenal Neuroblastoma by Ultrasound: A Reportof Two Cases and Review of the Literature. Ultrasound ObstetGynaecol. 1999; 13: 446–449.5 Acharya S, Jayabose S, Kogan SJ, Tugal O, Beneck D, Leslie D,Slim M. Prenatally Diagnosed Neuroblastoma. Cancer 1997; 80 (2):304–309.6 Dahnert W. Dahnert’s Electronic Radiology Review [CD-ROM],Williams and Wilkins, 1998.7 Mentzel HJ, Schramm D, Vogt S, Reuter A, Mentzel T, KaiserWA, (1998) Intraabdominal Lymphangioma in a Newborn. J ClinUltrasound 1998; 26 (6): 320–322.ASUM Ultrasound Bulletin 2005 August; 8 (3)21

ASUM Ultrasound Bulletin 2005 August; 8 (3): 23–27DIAGNOSTIC ULTRASOUNDUltrasound guided chemical pleurodesiswith doxycyclineRP Davies MBBS, FRACR, MoHealth Law, MoHealth Services Management AB , T McClymont, MBBS A ,D Boshell, MBBS AADept of Radiology, Orange Base Hospital, Greater Western Area Health Service,New South Wales, AustraliaBCorrespondence to R Davies email rdavies@adelaide.on.netAbstractDiagnosis of pleural effusion by radiograph or ultrasound is reliable and accurate. Treatment ofmalignant pleural effusion remains problematic. Where a symptomatic pleural effusion fails to respondto systemic chemotherapy, options include palliative thoracentesis and pleurodesis. Palliative thoracentesisrequires multiple hospital attendances and may produce only short-term relief. Pleurodesisinvolves the instillation of a sclerosing agent into the pleural space resulting in a diffuse inflammatoryreaction with local activation of the coagulation pathway and fibrin deposition. Talc as a sclerosingagent can be administered as either a talc poudrage at the time of thoracoscopy using an atomiser oras talc slurry via a large bore intercostal tube. Common side effects reported are pleuritic chest painand fever. Chemical pleurodesis using tetracycline had a modest efficacy (reported success rate around65%), but was relatively inexpensive, well tolerated and the side effects were infrequent, mild andtransient. Production of tetracycline ceased in 1998.A locally developed pleurodesis protocol is described using doxycycline as the sclerosing agentadministered via ultrasound-guided small-bore intercostal cannula placement. Long-acting localanaesthetic is instilled into the pleural cavity to minimise post-procedure discomfort. The procedurecan be performed as a day case at low added cost compared with palliative ultrasound-guided thoracentesis.This preliminary report suggests the protocol described could be more widely applied, appears tobe well tolerated and has acceptable morbidity. Initial results are encouraging. A prospective trial isrequired to compare efficacy and morbidity with the currently used alternatives.IntroductionRecurrent pleural effusion is a recognised complicationof breast, lung and other malignancy sometimes resultingfrom the disruption and obstruction of lymphatic channelsby malignant cells1. The effusion and associated masseffect compressing the ipsilateral lung can result in ongoingrespiratory symptoms (dyspnoea and chest pain) andcan have a significant impact on a patient’s quality of life.Pleural effusions can be identified and quantified using radiography,ultrasonography or other cross-sectional imaging 2 .Once identified, the treatment options available for managingrecurring malignant pleural effusions vary accordingto local preferences and available expertise. Treatmentoptions include chemotherapy, palliative thoracentesis andpleurodesis 3 , depending on the patient’s well being, responseto previous treatments and life expectancy. Bonnefoi andSmith 4 found that chemotherapy could achieve symptomaticrelief in 78% of patients with malignant pleural effusion.However, if chemotherapy is contraindicated or the pleuraleffusion fails to respond to systemic chemotherapy, an alternatetreatment approach is often required 3.Repeated therapeutic thoracentesis (pleural aspiration)is used in treating recurrent pleural effusion as this obviatesthe need for routine hospitalisation and provides transientrelief for frail patients and those with a limited life expectancy3 . The main limitation of pleural aspiration withoutany additional therapy is the likelihood of rapidly recurrentpleural effusion 5,6 . Pleurodesis following pleural aspirationdecreases the chance of pleural effusion recurrence 6,7 , andhas been a widely used long-standing method of controllingrecurrent pleural effusions 8 . Pleurodesis involves the instillationof a sclerosing agent into the pleural space resultingin a diffuse inflammatory reaction with the local activationof the coagulation system with fibrin deposition 9 . Thisinflammatory process aims to obliterate the pleural space 8preventing re-accumulation of the pleural effusion. Despitethe use of a large number of agents no ideal sclerosingagent has been adopted. Talc was first used as a sclerosingagent in 1935 10 and can be administered as either a talcpoudrage at the time of thoracoscopy using an atomiser oras talc slurry via an intercostal tube. Success rates for talcrange from 80% to 100% 11–14 . The most common side effectsreported are pleuritic chest pain and fever. Adult respiratorydistress syndrome (ARDS) is a rare and potentially fatalcomplication of intrapleural talc 15 . Chemical pleurodesisusing tetracycline became less popular 16 but was performeduntil 1998 when production was discontinued. Tetracyclinehas a modest efficacy (average success rate of 65%), butASUM Ultrasound Bulletin 2005 August; 8 (3)23

RP Davies, T McClymont and D BoshellFigure 1 A longitudinal scan shows approximate dimensions of themalignant pleural effusion. There is dependant echogenic materialin keeping with altered bloodFigure 2 During ultrasound guided subcutaneous local anaestheticinjection the 25 g needle was visualised longitudinally, to ensuredelivery of fluid adjacent to the parietal pleural surface to minimisepatient discomfort during needle puncture of the pleural surfaceFigure 3 The sheathed cannula is visualised during entry to thepleural fluid. The angle is planned to allow continued drainageas the lung re-expands during fluid drainageit was relatively inexpensive, well tolerated and the sideeffects were infrequent, mild and transient 17 . The search fora chemical sclerosant to replace tetracycline, along with aneffective protocol for its use, has been the catalyst for thisstudy into the practicality and effectiveness of doxycyclineas a sclerosing agent.Case reportA 52-year-old female presented with dyspnoea on minimalexertion after walking five metres and orthopnea requiringsix pillows. There was a four-month history of cough,dyspnoea and right-sided chest pain. A chest x-ray and CTrevealed a right-sided pleural effusion, also demonstratedand measured by ultrasound (Figure 1). The diagnosisof non-small cell adenocarcinoma of primary pulmonaryorigin was made following pleural biopsy. Chemotherapywas commenced, initially with a standard protocol (taxotereweekly changed three months later to gemcitabinefortnightly). The pleural effusion increased and drainagefor symptom relief was requested. Ultrasound guided drainage(Figure 2) of 500 ml of pleural fluid was undertaken atpresentation and three weeks later ultrasound demonstrateda recurrent volume of approximately 250 cc. Six weeksafter the initial tap, a further 250 cc was drained underFigure 4 Ultrasound guided insertion of a small bore 5 Fr intercostalcannula was performed on multiple occasions with clearvisualisation of the echogenic side holes (arrowed) within themalignant pleural effusionultrasound guidance. Three weeks after that a further 160ml of pleural fluid was aspirated under ultrasound guidanceachieving only one week free from exertional dyspnoeaafter which recurrent progressive exertional dyspnoea wasagain reported by the patient.An ultrasound of the pleural space showed an estimated500 ml recurrent effusion. Doxycycline pleurodesis (as perthe protocol in the Table 1) was undertaken. Minor patientdiscomfort only was reported during subcutaneous localanaesthetic injection (lignocaine 2% 3–5 ml, Figure 3) andinsertion of a small bore 5 Fr intercostal cannula (5Fr. 10cm Yueh sheathed needle, WA Cook, Eight Mile Plains,Brisbane, Australia, Figure 4). There was no further discomfortwhile 360 cc of pleural fluid was drained over afour-hour period. The drain was then capped. CT indicatedan estimated residual volume of 70 cc remaining in thepleural space. With conscious intravenous sedation usinga narcotic/benzodiazepine protocol, intrapleural instillationof Marcaine 0.4% 150 mg in 30 ml (bupivicaine hydrochloride100 mg/20 ml, Astra Zeneca Pty Ltd, Sydney, NSW,Australia) and doxycycline 500 mg in 25 ml (Vibramycin100mg/5 ml, Pfizer, Germany) was injected via the intercostalcannula. The patient reported no discomfort duringthe procedure and four hours of post procedure monitoring24 ASUM Ultrasound Bulletin 2005 August; 8 (3)

Ultrasound guided chemical pleurodesis with doxycyclinewas uneventful. Admission overnight was then scheduled toavoid a four-hour return journey prior to chemotherapy thefollowing day.The patient was later admitted to hospital for six dayswith febrile neutropaenia related to her chemotherapy, butdid not have any significant effusion. Progress sonographicassessment as an outpatient six weeks after the previousprocedure revealed a recurrent effusion with an estimatedvolume of 500 cc. A further doxycycline pleurodesis wasperformed after drainage of 290 cc (Figure 4). Progressassessment after a further six weeks revealed a very smalleffusion of 20 cc, as well as peripheral echogenic materialin the pleural space, consistent with the development ofpleural adhesions. At this point the pleurodesis was consideredto be successful, and the patient was discharged fromfollowup. Intra-pleural instillation of the long acting localanaesthetic Bupivicaine hydrochloride prior to administrationof doxycycline appeared to entirely relieve symptomsof pleural discomfort during and after the procedure. Thelater repeat procedures were conducted with only subcutaneouslocal anaesthetic and no intravenous sedation.Hospital admissions had been required only due to the longdistance from home and pleurodesis was timed to coincidewith planned admissions for chemotherapy.Materials and methodsTable 1 below describes the protocol used in this case.DiscussionChemical pleurodesis using doxycycline as the sclerosingagent is one of the less widely used treatment options currentlyavailable for managing malignant pleural effusion.Doxycycline for intravenous injection is inexpensive (~$A16 for 500 mg) and readily available. The addition oflong acting local anaesthetic adds about $A11 to the costper procedure. This compares with the cost of the materialsused in talc poudrage of over $A100.Doxycycline use in this condition in Australia requiressubmission of an Australian Government Department ofHealth and Ageing Therapeutic Goods AdministrationCategory A Form Special Access Scheme. The limitationof doxycycline principally involves the requirement to offerup to four treatment cycles to achieve control of recurrentpleural fluid accumulation. Published descriptions involveinpatient based surgical insertion of a large bore catheterwith multi-day admission, significantly increasing the overallcost of treatment. The use of ultrasound guidance forpuncture of the pleural space with a small bore cannulaensures near 100% success, allows administration of localanaesthetic for immediate and post-procedural pain reliefand permits repeated outpatient treatments with minimalpatient morbidity and inconvenience. Patients with disseminatedmalignancy often seek to avoid unnecessary hospitaladmissions. The technique described avoids or overcomesmany of the limitations of existing pleurodesis options.The alternative of repeated pleural tapping is best performedwith direct ultrasound guidance to avoid inadvertentpuncture of the lung and to locate the largest locules offluid. The addition of bupivicaine hydrochloride/doxycyclineinstillation at the conclusion of palliative thoracentesisadds minimal additional morbidity and cost to a drainageprocedure. The protocol can therefore be readily added tothe existing practice of palliative thoracentesis.Table 1Doxycycline Pleurodesis ProtocolProcedureNotes/ Medication/ Cannula Equipment1 Insert a small bore 5 Fr intercostal cannula under ultrasound guidance. 5 F Yueh (Cook Inc) or another sheathed cannula of similar size withmultiple side holes to ensure complete evacuation of pleural fluidwithout the need for re-positioning. A small bore (6 Fr) pigtail cathetercould be used, particularly for patients with a thicker layer of extrathoracicadipose tissue.2 Evacuate the pleural fluid (at a rate of up to 500 cc/hour) until pleural Note symptoms of cough or dyspnoea require drainage to be susspaceis dry.pended or terminated. Limit the total drainage volume according tolocal experience or ~ 1500 cc.3 Confirm adequate fluid evacuation and re-expansion of the lung using Computed tomography may be used where ultrasound visualisationultrasound or CT.is limited by lung, bone, acoustic access.4 Optional administration of conscious sedation prior to pleurodesis for Typical conscious sedation protocol fentanyl in increments of 20–50anxious/paediatric patients.mcg to a maximum of 100 mcg and midazolam in 1 mg incrementsupto 3 mg with O 2 and monitoring.5 Instil long-acting local anaesthetic into pleural space followed by a normal Bupivicaine hydrochloride (Marcaine 0.5%, 2 mg/kg up to 150 mg)saline flush then Doxycycline sclerosant IV solution into the pleural cavity. doxycycline IV solution (Vibramycin 500mg in 25 cc) drawn up slowlyto avoid excess aeration. Check product information leaflet forsuitability and compatibility.6 Remove cannula/pigtail catheter. Imaging control not required.7 Monitor the patients pulse rate, temperature, blood pressure and respiratory Admission to hospital is organised if the patient becomes unstablerate for four hours then discharge if stable and pain free.or analgesic requirements remain significant. Chest radiographfor increasing dyspnoea.8 Follow-up ultrasonography to identify and quantify any recurrence of pleural Combine with chemotherapy cycle if applicable, to perform repeatfluid at 2–6 weekly intervals.aspiration/doxycycline installation immediately prior to next cycle.9 Repeat the procedure at 2–3 weekly intervals for up to six cycles OR until Efficacy demonstrated to improve for at least four cyclesthe effusion ceases to re-accumulate. Failure rate after four cycles ~ 20%.ASUM Ultrasound Bulletin 2005 August; 8 (3)25

RP Davies, T McClymont and D BoshellSelection and placement of the intercostalcatheterIn previous studies involving chemical pleurodesis, largebore intercostal catheters (24–32F) have been used 8 . Thelarge bore catheters are prone to causing significant discomfortand as a result smaller bore catheters (10F) have beenused with success 18. For this study a 5 F sheathed cannulawith multiple side holes was used to minimise patient discomfortand facilitate easy placement of the cannula withinthe largest accessible locules of pleural fluid.Placement of the catheter was guided by ultrasound.Ultrasound is well recognised as an effective means of rapidlylocalising pleural fluid collections and monitoring cannulaposition to ensure effective and complete drainage 5 .Evacuation of the pleural fluidDrainage of the pleural fluid was limited to around 1500 mland drainage was discontinued sooner if the patient developeda cough, chest pain or shortness of breath.Published guidelines on the management of pleuraleffusions state that the most important requirement forsuccessful pleurodesis is complete lung re-expansion toensure adequate apposition of the parietal and visceralpleura 3 . However, even if complete lung expansion was notachieved, Robinson et al. demonstrated a successful outcomein nine out of 10 patients when using doxycycline forchemical pleurodesis.Confirmation of successful drainage of the pleural fluidand lung re-expansion was achieved using ultrasound. Theuse of ultrasound also facilitated the measurement of anyresidual pleural fluid volume estimate as a baseline for latercomparison 2 .SedationTo control patient discomfort, or in some cases anxietyassociated with chemical pleurodesis, conscious sedationmay be added. A protocol including a narcotic (suchas fentanyl 50–100 mcg) with a benzodiazepine (such asmidazolam 1–3 mg) can be administered using a conscioussedation protocol (including the use of pulse oximetry andO 2 ) during installation of pleurodesis medications.AnalgesiaThe intrapleural administration of doxycycline is associatedwith chest pain 20 . Published results describing the useof intrapleural lignocaine 19 reported that 19% of patientsexperienced moderate pain requiring additional analgesia.The safety of lignocaine has been examined in two studies.Wooten et al. 2 1showed that following the intrapleuraladministration of 150 mg of lignocaine the serum concentrationof lignocaine (1.3 μg/ml) was significantly below thelevel associated with central nervous system side effects (>3 μg/ml). In another study patients received up to 250 mgof lignocaine, while maintaining serum levels within thetherapeutic range 22 . Side effects were reported by only onepatient who experienced transient paraesthesia.In order to increase the duration of pain relief providedby the intrapleural local anaesthetic agent, this study utilisedbupivicaine hydrochloride instead of lignocaine. The doseof 2 mg/kg up to 150 mg in 30 ml is in accordance with thedrug product information provided on the MICROMEDEXweb site 23 . Use of the MICROMEDEX drug interaction toolrevealed no reports of interactions between Bupivicainehydrochloride and Doxycycline.DoxycyclineDoxycycline has been used and evaluated in numerousclinical trails, achieving a mean success rate of 76% fromthe 85 pleural effusions evaluated 3 (although the 29 patientslost to follow up are not included in this analysis). Thesuccess rate of those patients evaluated at one month was79%. In all cases except one, a dose of 500 mg mixed withsaline was used. Prevost et al. used a dose of 2000 mg 24 in16 malignant pleural effusions with a reported success rateof 82%. The side effects reported were fever and mild tomoderate pleuritic chest pain (40 to 60% depending on theanalgesia used). Heffner et al. used narcotic therapy for thecontrol of pain 25 .The method used in this study involved the injectionof doxycycline as supplied for intravenous injection (500mg in a solute volume totalling 25 ml), while other authorsdescribe the use of an infusion of doxycycline diluted in 30ml of saline 26 . No advantage conferred by dilution is identifiedfrom other reports.The major disadvantages of using doxycycline in thepast have been the prolonged intercostal catheter dwellingtimes and the need for repeated doses to prevent the effusionfrom recurring. All the past studies have left the intercostalcatheter in situ until the effusion resolved. Indwelling pleuralcatheterisation may increase the risk of infection, patientdiscomfort and certainly increases the length of hospitaladmission. The added facility of using ultrasound guidanceto assist in cannula placement negates the requirement toleave a catheter in situ. The patient is then able to go homeafter the procedure and return for outpatient assessmentby ultrasound of the quantity of residual pleural fluid. Theneed to repeat the pleurodesis is determined by recurrenceof symptomatic dyspnoea at clinical follow-up.References1 Antunes G, Neville E. Management of malignant pleural effusions.Thorax 2000; 55: 981–983.2 Eibenberger KL, Dock WI, Ammann ME, et al. Quantification ofpleural effusions: sonography versus radiography. Radiology 1994;191: 681–684.3 Antunes G, Neville E, Duffy J, N Ali N. BTS [British ThoracicSociety] guidelines for the management of malignant pleural effusions.Thorax 2003; 58 at http://thorax.bmjjournals.com/cgi/content/extract/58/suppl_2/ii29 accessed 12/04/05.4 Bonnefoi H, Smith IE. How should cancer presenting as a malignantpleural effusion be managed? Br J Cancer 1996 Sep; 74 (5):832–835.5 O'Moore PV, Mueller PR, Simeone JF, et al.. Sonographic guidancein diagnostic and therapeutic interventions in the pleural space. AJR1987; 149: 1–5.6 Sorensen PG, Svendsen TL, Enk B. Treatment of malignant pleuraleffusion with drainage, with and without instillation of talc. Eur JRespir Dis 1984; 65: 131–135.7 Zaloznik AJ, Oswald SG, Langin M. Intrapleural tetracycline inmalignant pleural effusions. Cancer 1983; 51: 752–755.8 Hausheer FH, Yarbro JW. Diagnosis and treatment of malignantpleural effusion. Semin Oncol 1985; 12: 54–75.9 Antony VB. Pathogenesis of malignant pleural effusions and talcpleurodesis. Pneumologie 1999; 10: 493–498.10 Bethune N. Pleural poudrage: new technique for deliberate productionof pleural adhesions as a preliminary to lobectomy. J Thorac26 ASUM Ultrasound Bulletin 2005 August; 8 (3)

Ultrasound guided chemical pleurodesis with doxycyclineSurg 1935; 4: 251–261.11 Kennedy L, Rusch VW, Strange C, et al.. Pleurodesis using talcslurry. Chest 1994; 106: 342–346.12 Webb WR, Ozmen V, Moulder PV, et al.. Iodized talc pleurodesis forthe treatment of pleural effusions. J Thorac Cardiovasc Surg 1992;103: 881–885.13 Yim AP, Chung SS, Lee TW, et al.. Thoracoscopic management ofmalignant pleural effusions. Chest 1996; 109:1234–1238.14 Viallat J-R, Rey F, Astoul P, et al. Thoracoscopic talc poudragepleurodesis for malignant effusions. A review of 360 cases. Chest1996; 110: 1387–1393.15 York A, Bondoc P, Bach P, et al.. Talc pneumonitis: incidence, clinicalfeatures and outcome. Chest 1999; 116 (Suppl): 358–39S. 32.16 Heffner JE, Unruh LC. Tetracycline pleurodesis: adios, farewell,adieu. Chest 1992; 101: 64–66.17 Walker-Renard PB, Vaughan LM, Sahn SA. Chemical pleurodesis formalignant pleural effusions. Ann Intern Med 1994; 120: 56–64.18 Patz EF Jr, McAdams HP, Goodman PC, et al.. Ambulatory sclerotherapyfor malignant pleural effusions. Radiology 1996; 199: 133–135.19 Robinson L A, Fleming WH, Galbraith TA. Intrapleural doxycyclinecontrol of malignant pleural effusions. Ann Thorac Surg 1993; 55:1115–1121.20 Pulsiripunya C, Youngchaiud P, Pushpakom R, et al.. The efficacy ofdoxycycline as a pleural sclerosing agent in malignant pleural effusion:a prospective study. Respirology 1996; 1: 69–72.21 Wooten SA, Barbarash RA, Strange C, et al. Systemic absorption oftetracycline and lidocaine following intrapleural instillation. Chest1988; 94: 960–963.22 Sherman S, Grady KJ, Seidman JC. Clinical experience with tetracyclinepleurodesis of malignant pleural effusions. South Med J 1987;80: 716–719.23 http://micromedex.hcn.net.au accessed 12/04/2005.24 Prevost A, Nazeyrollas P, Milosevic D, et al.. Malignant pleural effusionstreated with high dose intrapleural doxycycline: clinical efficacyand tolerance. Oncol Reports 1998; 5:363–366.25 Heffner JE, Standerfer RJ, Torstveit J, et al..Clinical efficacy ofdoxycyline for pleurodesis. Chest 1994; 105: 1743–1747.26 Mansson T. Treatment of malignant pleural effusion with doxycycline.Scand J Infect Dis 1988; 53 (Suppl): 29–34.ASUM Ultrasound Bulletin 2005 August; 8 (3)27

CASE REPORTASUM Ultrasound Bulletin 2005 August; 8 (3): 28–30A 3D approach to antenatal diagnosis ofvasa previa with 2D ultrasound imagingHS Wong AC , K Burns B , L Strand B , S Parker BADepartment of Obstetrics and Gynaecology, Wellington School of Medicine and Health Sciences,University of Otago, Wellington, New ZealandBWomen’s Health Service, Capital and Coast District Health Board, New ZealandCCorrespondence to HS Wong email hsoowong @wnmeds.ac.nzAbstractAntenatal diagnosis of vasa previa has been reported with the use of 2D and colour Doppler imaging,and more recently with 3D and colour Doppler imaging. A case of vasa previa diagnosed with2D gray-scale and colour Doppler ultrasound imaging on combined transabdominal and transvaginalscans is described. The findings are compared with that in a case of placenta previa where blood vesselsare also found overlying the internal cervical os. The utilisation of three perpendicular planes on2D ultrasound imaging for a 3D impression of the area around the internal cervical os for differentiationof the two conditions is presented.IntroductionVasa previa is known to be associated with a poor perinataloutcome and a high fetal mortality of 50–60% where thereare intact membranes and 70–100% with ruptured membranes1,2 .Antenatal diagnosis allows the planning of elective deliverybefore onset of labour or rupture of membranes that maylead to tearing of fetal vessels and fetal exsanguination 3 .The use of 2D and colour Doppler ultrasound for prenataldiagnosis and, more recently, 3D ultrasound has beenreported. However, in many ultrasound units, 2D ultrasoundimaging is still the backbone for obstetric imaging becauseof its wide availability and simplicity of image acquisition.A case of vasa previa is presented and the diagnosticapproach utilising 2D gray-scale and colour Doppler imagingin three different perpendicular planes is described. Thesonographic findings are compared to a case of placentaprevia where a vessel could be identified overlying theinternal cervical os in association with placental tissue.Case reportThe patient, 42 years old, gravida 7 para 3, Samoan witha history of two previous caesarean deliveries, presentedfor an ultrasound scan at 17 weeks which showed that theplacenta was posterior, low-lying and covering the internalcervical os. Ultrasound examination was repeated at 36weeks gestation. The patient was scanned transabdominallyin sweeping sagittal and transverse sections targeting atthe internal cervical os. The main bulk of the placenta wasnoted to lie posteriorly, reaching the internal cervical os.However, there was a succenturiate lobe in the anterior wallof the uterus away from the internal os and vessels could beseen overlying the internal cervical os connecting the twolobes of placenta in both sagittal (Figure 1a) and transversesections (Figure 1b). These vessels were also demonstratedon transvaginal scan (Figure 1c). Placenta previa, succenturiatelobe and vasa previa were diagnosed. The patientwas scheduled for elective caesarean section. The baby wasdelivered in good condition. The placenta was examinedand the presence of succenturiate lobe and vasa previa wasconfirmed.DiscussionAntenatal diagnosis for vasa previa has been reported withthe use of 2D gray-scale imaging on transabdominal scan 4and colour Doppler imaging on transvaginal scan 5 . Morerecently, the use of 3D and colour Doppler ultrasound imagingin diagnosis of vasa previa has also been described 6 .We applied 2D gray-scale and colour Doppler ultrasoundscanning, sweeping in sagittal and transverse planestransabdominally and in sagittal and coronal sections transvaginallyto inspect the area around the internal cervical osin three perpendicular planes (Figure 1d) and obtained sectionssimilar to what could be obtained with 3D ultrasoundequipment 6 .We find that this approach can also depict those cases inwhich there are vessels running in the placental substanceoverlying the internal cervical os (as in placenta previa)rather than naked fetal vessels running in membranes only(as in vasa previa). In the former, the placental substancecan be seen as a layer between the vessel and the internalcervical os on sagittal section (Figure 2a) and along theside of the vessel on transverse section (Figure 2b and 2c).Particularly noteworthy is the sonolucent area around thefetal vessels at the internal os level on transverse sectionwith true vasa previa indicating the absence of any supportingplacental substance (Figure 1b), whereas in placentaprevia there is no sonolucent area around the vessels at thislevel (Figure 2c).Conclusion2D images are easy to acquire and study and, up to thepresent moment, 2D imaging is still more widely availableand commonly utilised than 3D. We find that sweeping in28 ASUM Ultrasound Bulletin 2005 August; 8 (3)

A 3D approach to antenatal diagnosis of vasa previa with 2D ultrasound imagingFigure 1aFigure 1cFigure 1bFigure 1dFigure 1 On colour Doppler imaging in the sagittal plane on transabdominal scanning, two blood vessels are shown running over the internal cervicalos in opposite directions side by side (Figure 1a). The long black arrow points to the internal cervical os in all the figures. In the transverse plane (Figure1b), two blood vessels running over the internal cervical os in opposite directions are evident. There is a sonolucent area around the fetal vessels inthis plane at this level indicating that the vessels are not surrounded by placental substance. The same findings are confirmed on transvaginal scanningwith the two vessels shown at the same time in an oblique sagittal section (Figure 1c). Placental substance can be seen just short of the internalos posteriorly and the anterior lobe is clear of the internal os. The three perpendicular planes used on 2D gray-scale and colour Doppler imaging incombined transabdominal and transvaginal scans are shown in Figure 1d.Figure 2aFigure 2cFigure 2 In a case of placenta previa (Figure 2a, 2b & 2c), a layer ofplacental tissue (double arrow) could be clearly seen between the vesseland the internal cervical os (single long black arrow) in the sagittal plane(Figure 2a). Placental tissue could be observed running along the sidesof the vessel in a serial transverse sweep (Figure 2b & 2c). This is stillobserved at the internal os level as indicated by double arrow in Figure 2c.Figure 2bASUM Ultrasound Bulletin 2005 August; 8 (3)29

HS Wong, K Burns, L Strand and S Parkerthree perpendicular planes targeting the internal cervicalos with 2D imaging (including the use of colour Doppler)gives a reliable equivalent 3D imaging of the area and canbe very useful in the diagnosis and differential diagnosis ofvasa previa.References1 Naftolin F and Mishell DR Jr. Vasa previa. Report of 3 cases. ObstetGynecol 1965; 26 (4): 561–565.2 Pent D. Vasa previa. Am J Obstet Gynecol 1979; 134 (2): 151–155.3 Fung TY and Lau TK. Poor perinatal outcome associated with vasaprevia: is it preventable? A report of three cases and review of theliterature. Ultrasound Obstet Gynecol 1998; 12 (6): 430–433.4 Gianopoulos J, Carver T, Tomich PG, Karlman R, Gadwood K.Diagnosis of vasa previa with ultrasonography. Obstet Gynecol 1987;69 (3 Pt 2): 488–491.5 Nelson LH, Melone PJ, King M. Diagnosis of vasa previa with transvaginaland color flow Doppler ultrasound. Obstet Gynecol 1990; 76(3 Pt 2): 506–509.6 Lee W, Kirk JS, Comstock CH, Romero R. Vasa previa: prenataldetection by three-dimensional ultrasonography. Ultrasound ObstetGynecol 2000; 16 (4): 384–387.30 ASUM Ultrasound Bulletin 2005 August; 8 (3)

ASUM Ultrasound Bulletin 2005 August; 8 (3): 31–32DIAGNOSTIC ULTRASOUNDA pictorial essay of left ventricular failureJustin O’Leary BExSc, DMURoyal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, AustraliaCorrespondence to Justin_Oleary@hotmail.comFigure 1 Figure 2Clinical historyA 74-year-old male presented for an outpatient cardiacassessment prior to surgical treatment of a left renal tumour.Reported symptoms included occasional episodes of centralchest tightness during rest as well as on exertion. There wasno past history of other cardiac disease. On examination,the pulse was 100 and regular with occasional extrasystoles,the systolic blood pressure was 120/95, the JVP was raisedat 8 cm with the cardiac impulse laterally displaced. Onauscultation there was an apical pan-systolic murmur anda third heart sound. The ECG showed sinus rhythm withleft axis deviation and diffuse T-wave abnormalities. Thechest x-ray showed cardiomegaly. An echocardiogram wasrequested to assess left ventricular systolic function.Materials and methodsThe echocardiogram was performed on a GE medical systemVivid 7. A multi-frequency (1.5 – 4.0 MHz) phasedarray transducer was used in real time for 2D (harmonicand non-harmonic), M-mode, colour flow, continuous andpulsed wave Doppler examination. A frequency of 1.7 MHzfrequency with harmonic imaging was selected for adequatepenetration and resolution. Depth settings, overall gain,TGC, colour and spectral Doppler settings and focal zoneswere set to allow optimal imaging of structures of interest.The mechanical index (MI) was 1.0 and the thermal index(TI) was 0.7–1.5. The total imaging time was 30 minutes.TechniqueParasternal long axis views of the left ventricle showedmild to moderately impaired systolic contraction with mildantero-septal wall hypokinesis and severe posterior hypokinesis.The mitral valve appeared mildly echodense withnormal leaflet excursion. The aortic valve appeared mildlyechodense with normal excursion and cusp separation.M-mode through the aortic valve demonstrated a normalsized aortic root and, superiorly, a normal ascending aortawith mild dilatation of the left atrium. M-mode across themitral valve showed an increase in the mitral valve E pointto septal separation (EPSS) indicating left ventricular dilatation.M-mode through the left ventricle showed a mildlyincreased left ventricular end-diastolic dimension andreduced systolic thickening of both the antero-septal andposterior walls. The calculated ejection fraction (afterTeicholtz and Simpson) was 37%. There was mild concentricleft ventricular hypertrophy.Colour Doppler revealed a very mild central jet of aorticregurgitation and mild mitral regurgitation.The right ventricular inflow view showed a normal tricuspidvalve with normal valve excursion. The right atriumappeared mildly dilated. Colour Doppler revealed a milddegree of tricuspid regurgitation. The continuous waveDoppler across the jet shows a pressure difference betweenthe right ventricle and right atrium of 39 mmHg with spectralbroadening indicating mild severity.The right ventricular outflow tract view with colourDoppler and continuous wave Doppler across the pulmonaryvalve showed normal outflow velocities.The parasternal short axis view showed the commissureof the non-coronary aortic cusp was mildly thickened. Theleft ventricle visualised at the level of the papillary musclesshowed a mild to moderate global impairment in systolicfunction.Apical views of the mitral valve and tricuspid valvesshowed normal excursion. The left ventricular lateral andseptal walls showed reduced contraction with impaired contractionof the lateral wall of the right ventricle, mild bi-atrialASUM Ultrasound Bulletin 2005 August; 8 (3)31

Justin O’learyFigure 3 Figure 4confirmed moderate left ventricular impairment and mild tomoderate mitral regurgitation.The subcostal four-chamber view showed no evidenceof pericardial effusion or an interatrial septal defect, a normalsized IVC with normal respiratory collapse (RAP =5–1O mmHg).Figure 4dilatation, and mitral regurgitation confirmed by continuoswave Doppler as mild to moderate.Pulsed wave Doppler in the right upper pulmonary veindemonstrated a normal pulmonary vein signal with no evidenceof systolic blunting or flow reversal.Colour Doppler of the tricuspid valve showed trivialtricuspid regurgitation with a pressure gradient of 40mmHg,indicating mildly increased pulmonary pressures.Rotating the transducer to a two-chamber view againDiscussionThe echocardiogram revealed a mildly dilated left ventriclewith moderately impaired contraction in keepingwith global dysfunction. The ejection fraction obtainedfrom the Simpsons method was approximately 37%. Asthe impairment was diffuse the ejection fraction measuredfrom M-mode (Teicholtz method) correlated closely withthe Simpson method value. The right ventricle appearednormal in size with normal systolic function. The atria weremildly dilated. The cardiac valves showed mild to moderatemitral regurgitation, mild aortic regurgitation and mild tricuspidregurgitation. The estimated pulmonary pressure wasapproximately 50 mmHg (calculated from a resting atrialpressure of 10 mmHg plus the valve gradient of 40 mmHg). These findings are typical of a cardiomyopathy mostprobably not caused by ischemic heart disease. The patientwas commenced on Digoxin, Aldactone, a beta blocker andLasix. Major surgery for the renal tumour was postponedpending an adequate response to medical management.2005 DDU Part 1pass candidatesPhilip Aplin SAKristine Barnden NSWJacqueline Chua VicPhillipa Cuttance NZCyrus Edibam WAMartha Finn NTBrendan Flaim VicAlexandra Ivancevic NZSubodh Joshi VicVasundhara Kaushik NSWPatricia Lai NSWChristopher Lewis VicDMU and DDU ExaminationsJustin Mariani VicKristy Milward NSWKaren Mizia NSWCarl Muthu NZWendell Neilson NSWMark Page VicEmma Parry NZDeirdre Percy NSWChristine Russell SANasser Shehata NZMedha Sule UKGreg Sweetman WAJoseph Thomas SAKa-Kit Wong NSW2005 DDU Part 2pass candidatesThushari Alahakoon NSWNagesh Anavekar VicNatalia Andreianova NZNeil Athayde NSWTerry Chang NSWMarilyn Fooks VicAdrian Goudie WALisa Hui NSWAllan Kruger QldFrancis Ponnuthurai VicJillian Spilsbury NSWAmarendra Trivedi VicDavid Walters SAApril 30 2005 DMU DiplomaGeneralMr Christopher PowersMr Vishwant SandeepObstetricMiss Wendy GellelVascularMs Carol Duncan32 ASUM Ultrasound Bulletin 2005 August; 8 (3)

POLICIES and STATEMENTSGuidelines for the Performance ofFirst Trimester UltrasoundMay 1995, Revised October 1999, Revised October 2002, Revised July 2005Introduction and equipmentStudies should be performed using anabdominal and/or vaginal approach.A high frequency transducer shouldbe used and the equipment should beoperated with the lowest ultrasonicexposure settings capable of providingthe necessary diagnostic information.A vaginal transducer should alwaysbe available and a transvaginal scanshould be offered to the patient whenit is anticipated that this would resultin a more diagnostic study. The patientmay choose to accept or refuse this offerand undue persuasion is inappropriate.Reference should be made to theGuidelines for the Performance of aGynaecological Scan regarding thefacilities and preparation for such anexamination.ASUM policy on disinfectionof vaginal transducers should befollowed.HistoryEstimate gestation based on last menstrualperiod or time of conception.Document symptoms and, if possible,the result and date of any pregnancytest – Human Chorionic Gonado-trophin(HCG).Gestation sacThe gestation sac should usually bevisible from four and one half (4.5) tofive (5) weeks using high frequencytransvaginal ultrasound.When a gestation sac-like structureis seen but no live fetus demonstrated,it is important to attempt to ensurethat it is not a 'pseudo gestational sac'.Look for the echogenic trophoblastrim and the yolk sac, and ensure thatthe fluid in the gestation sac is echofree.If a gestation sac is not visiblein the uterus of a patient believed tobe pregnant, the adnexa should becarefully examined looking for evidencesuggesting the presence of anectopic pregnancy – most ectopicscan be suspected with high frequencytransvaginal ultrasound.In a patient with a positive pregnanttest but either:■ no gestational sac is seen withinthe uterus or elsewhere in the pelvis■ an apparent sac is seen but no fetalstructures (including yolk sac) orheart movements are visibleconsider the following:■ pregnancy not as advanced asthought (e.g. delayed ovulationand conception in that cycle)■ ectopic pregnancy■ failed pregnancy including completemiscarriageInterpretation of the scan may bemore accurate if the result of the quantitativeHCG levels is known.There is more than one acceptedlaboratory standard for reporting HCGlevels. The units for the local serviceshould be taken into account whencorrelating sac development and HCGlevel. In general when the level is >2000 IU/1 a gestation sac should beseen in the uterus on transvaginalscanning. If no sac is visible an ectopicmust be considered.If the level is < 1000 IU/1 thenfurther follow up by serial HCG isappropriate and/or a repeat scan if thediagnosis is uncertain.Gestational ageThis is most accurately assessed in thefirst trimester. The earlier the crownrump length (CRL) is measured, themore accurate is the assessment of gestationalage. The CRL can be measuredfrom six weeks gestation. The compositeCRL chart in the ASUM Policiesand Statements Folder is recommended.From eleven (11) weeks multiparameterassessment can be used. Biparietal diameter(BPD) is the most often used secondmeasurement.Fetal heart movementsWith a high resolution vaginal transducer,fetal heart movements are oftenvisible from five (5) to six (6) weeks(i.e. CRL = 2 mm), but may not beseen until CRL = 3–4 mm (See paragraphon pregnancy failure).Fetal numberThe diagnosis of a multiple pregnancyrequires the visualisation of multiplesacs prior to six (6) weeks and subsequentlyvisualisation of multipleembryos.The first trimester is the optimumtime to determine chorionicity of thefetuses. The chorionicity of the fetusesshould be stated in the report.The presence of separate sacs and thethickness of the intervening membraneand the shape of its junction with theplacenta should be assessed. Be awarethat early in the first trimester anintervening amnion may not be visiblein diamniotic, monochorionic twins.Later in the first trimester the numberof placentas can be evaluated.Pregnancy failureAn experienced operator using highquality transvaginal equipment maydiagnose pregnancy failure undereither or both of the following circumstances:1 When no live fetus is visible ina gestation sac and the mean sacdiameter is 2.0 cm or greater.2 When there is a visible fetus witha CRL of 6 mm or more but nofetal heart movements can be demonstrated.The area of the fetalheart should be observed for aprolonged period of at least thirty(30) seconds to ensure that there isno cardiac activity.In situations where pregnancy failureis suspected by an operator whoeither does not have extensive experiencein making the diagnosis or doesnot have access to high quality equipmentor if there is any doubt about theviability of the fetus, a second opinionor a review scan in one week should berecommended in the report 1 .ASUM Ultrasound Bulletin 2005 August; 8 (3)33

POLICIES and STATEMENTSFetal structureThe following list of gestational agesat which various fetal structures maybe visualised is not intended to providea complete list of what shouldbe examined. However, using highresolution equipment (often only witha vaginal transducer) the followingstructures can commonly be seen:9 weeks Head, trunk and limbs10 weeks Some ossification oflong bones, jaw and skull11 weeks Stomach, spine, ossifiedcranium, four chamber heart12 weeks Mid gut herniation nolonger present, kidneys, bladder.Nuchal translucencyThe nuchal translucency measurementis a test to assess the risk of chromosomalabnormality, in particular of trisomy21. The measurement may alsobe abnormal in other fetal anomalies(e.g. some congenital heart disease). Ithas been estimated that first trimesterscreening by a combination of sonographyand material serum testing ofPAPP-A and free βhCG can potentiallyidentify 94% of trisomy 21 fetuseswith a false positive rate of 5% 2 .This study should be performedby adequately trained staff accordingto strict protocol. The outcomesof the test should be audited regularly.The recommendations of theFetal Medicine Foundation/ RoyalAustralian and New Zealand Collegeof Obstetricians and Gynaecologistsshould be noted.It may be performed between thegestational ages of eleven (11) weeksand thirteen (13) weeks plus six (6)days (CRL 45–84 mm). A measurementgreater than 2.5–3 mm is usuallyconsidered to be abnormal but mustbe correlated with gestational age.Reference values have been providedby Nicolaides 3 .The nuchal translucency measurementmay be performed at the requestof the referring Medical Practitioner.Due consideration should be given asto how and who is going to counselthe patient prior to the performance ofa nuchal translucency scan.Each practice should develop awritten protocol on the procedure tobe followed when the measurementis abnormal. This protocol shouldinclude guidelines for the immediatecare of the patient and how the referringdoctor will be informed. Usuallythe referring doctor should be notifiedso that appropriate counseling may begiven and the patient can be referredto a specialised unit where formal riskassessment and counseling processcan be undertaken.Method of measurement1 The nuchal translucency shouldbe measured on a sagittal midlinescan through the fetus.2 The fetus should be in neutral positionand occupy at least 75% of theimage.3 The amnion should be seen separateto the fetal skin line.4 Calipers should be positioned tomeasure the maximum diameter ofthe fluid at the back of the neck.Ovaries, uterus and adnexaEach ovary should be examined.The corpus luteum can vary greatlyin appearance during the first (andearly second) trimesters of pregnancy.Sonographic appearances includea solid, rounded target like lesionor a predominately cystic structure.Peripheral vascularity is usuallydetectable.The size of a corpus luteum is alsovariable, commonly measuring up to3 cm.Larger or unusual masses shouldassessed as in the non pregnantwoman.The uterus should be examined forevidence of a fibroids or uterine developmentaldefects. The uterine positionshould also be noted (anteverted,axial, retroverted).The adnexa should be examinedfor coexistent ectopics and free fluid.References1 Hately, Case and Campbell. Establishingthe death of an embryo by ultrasound.Ultrasound Obstet. Gynecol 1995; 5:353–357.2 Nicolaides KH Am J Obstet Gynecol 2004;191: 45–47.3 From Nicolaides group: Snijders et al..Assessmant of risk of Trisomy 21 bymaternal age and fetal nuchal-translucencythickness.34 ASUM Ultrasound Bulletin 2005 August; 8 (3)

POLICIES and STATEMENTSInterim Statement on the Appropriate Useof Diagnostic Ultrasound Equipment forNon-Medical Entertainment UltrasoundIssued July 2005Background/PreambleSince its introduction to medical practice and the biologicalsciences in the l950s, ultrasound has grown from being asubject of minor curiosity to probably the most widely usedimaging modality throughout the world across dozens ofclinical disciplines.A major initial clinical application was in the disciplineof obstetrics and this has continued through to the currentday where modern diagnostic ultrasound plays a major rolein the clinical management of pregnancy. The use of diagnosticultrasound in pregnancy has been underpinned by alarge volume of research into issues concerning bioeffectsand safety in human tissue. For many years, most of thelearned bodies, worldwide, concerned with imaging andobstetrics, have encouraged the appropriate and safe use ofdiagnostic medical ultrasound equipment.The recent widespread availability of good quality realtime three-dimensional diagnostic ultrasound equipmenthas seen the proliferation of businesses offering ultrasoundexaminations during pregnancy for the purpose of producing‘keep sake’ images of fetuses. This has been most prevalentin the United States where much effort is currently beingdirected toward regulating this phenomenon and restoringthe use of diagnostic medical ultrasound equipment to thearea of medical diagnosis as opposed to entertainment (seewebsites of United States Food and Drug Administration,American Medical Association).Confining the use of diagnostic medical ultrasoundequipment in pregnancy to examinations for the purpose ofproviding medical information useful to the management ofpregnancy is based on the following principles:1 Bioeffects and safetyIt is widely accepted that diagnostic ultrasound, whenused as per guidelines promoted by bodies such as theWorld Federation for Ultrasound in Medical and Biology,the American Institute of Ultrasound in Medicine andthe Australasian Society for Ultrasound in Medicine hasnot been demonstrated to be associated with deleteriouseffects in human tissue. Such statements do not guaranteethe absolute safety of diagnostic ultrasound but ratheremphasise that the long-term effects and the possibilityof subtle effects are not completely known. Prudent use istherefore recommended in order to minimise the chance ofsignificant bioeffects. It should be noted that recommendedpower output levels have been significantly increased inrecent years and much of the safety data relating to the useof diagnostic ultrasound precedes the increased permittedpower outputs for different ultrasound imaging modalities.In terms of exposure to diagnostic ultrasound, all learnedbodies emphasise the ALARA (as low as reasonablyachievable) principle. This principle emphasises that diagnosticmedical ultrasound equipment be used by trainedindividuals to seek relevant diagnostic information with theminimum of exposure, thereby minimising the potential forbioeffects and tissue damage.2 The trivialisation of diagnostic medicaltechnologyTrivialising diagnostic medical technology and the role oftrained technical and medical professional will inevitablyerode the significant relationship between health care providersand patients that currently exists. This will ultimatelybe to the significant detriment of the maintenance of thehigh standard of practice upon which optimum medicaloutcomes are based.3 Potential for misdiagnosisThe potential clearly exists for not detecting significantdiagnoses. Pregnant women may believe that this formof examination is an adequate substitute for a properlyconducted examination involving appropriately trainedsonographers and medical practitioners. A potential problemis also created where the abnormalities are incorrectlydiagnosed or doubt regarding normality is created, therebyproducing significant patient anxiety.4 General noteThere needs to be community discussion regarding theentitlement of a fetus to particular rights, including the rightnot to be exposed to a source of potential harm where nohealth benefit exists.ASUM Ultrasound Bulletin 2005 August; 8 (3)35

SOCIAL SCREENINGDraft of a letter sent from the President ofASUM to health departments, learned collegesand other medical and health organisationsI am writing to you on behalf of the Australasian Society ofUltrasound in Medicine regarding non medical 4D scanningof babies. ASUM is a peak body in ultrasound whose purposeis to promote excellence and safe practise in ultrasound. Ourmembership is comprised of Medical Imaging Specialists(mainly Obstetricians and Radiologists), Scientists involvedin the field, and technical personnel.Following similar trends in the United States, recentlyseveral entrepreneurial groups have begun setting up businesseswhose sole purpose is the non medical scanning ofbabies in utero to obtain 3D photographs and 4D video. Thereis no involvement of qualified medical or technical personnelto our knowledge. We understand clinics have been establishedin Adelaide and Melbourne, and undoubtedly more willfollow in other cities.The establishment of these clinics causes considerableconcern to ASUM. It has been an established policy of ourssince ultrasound scanning began, to keep fetal exposureto ultrasound as low as possible. Although no significant illaffects of ultrasound have yet been demonstrated, we feel wewould not be discharging our ethical responsibilities by notlimiting exposure. Clearly these clinics who are scanning forwhat could only be described as social reasons, contravenethis policy.Of greater concern however, is the very real probabilitythat patients will become confused as to what constitutes amedical scan and a non medical scan. The general populationmay in some circumstances believe they have had an ultrasoundscan of their baby and that all is satisfactory, confusingthis with a medical scan which actually looks at the developmentof the fetus. In addition, should abnormalities be found,the circumstances for the delivery of this news would be suboptimal,potentially disturbing, and probably quite unsafe.It is likely the Department of Health will see they have littlerole in this area as they will not be claimed upon for fundingin any way. They have indicated that they are not particularlyinterested by these developments.We are writing to request your consideration of this matter.We believe that if your members become involved in thisstyle of practise then they would be acting unethically byblurring the boundaries between medical imaging and nonmedical photography. We suggest it would be appropriate foryour board to censure any of your members who may becomeinvolved in this practise.We would appreciate you discussing this and formulatingan opinion. We believe we should renounce the development ofthese clinics, and should proceed with lobbying the Department ofHealth to legislate against the existence of such clinics. Attachedis a draft statement outlining our concerns.We look forward to hearing from you in the near future. Ifthere are any aspects to this matter or the statement youwould like to discuss, please do not hesitate to contact me.Dr David RogersPresident ASUMTo the EditorNon-medical applications of ultrasoundThe prudent use of medical ultrasound as advocated byASUM and other ultrasound societies usually refers to ‘medicallyindicated’ procedures, i.e., those where an improveddiagnostic outcome is expected from the procedure. The useof diagnostic imaging technology simply to view the fetus fordemonstration purposes or to obtain a personal photograph orvideo does not constitute a medical use, in its strictest sense.In response to increasing commercial interest in marketingnon-diagnostic ‘keepsake’ videos and photos, the AmericanInstitute of Ultrasound in Medicine (AIUM) issued cautionarystatements against what it describes as the non-medical use ofdiagnostic ultrasound (AIUM website).The FDA Centre for Devices and Radiological Healthhas also been quite outspoken, threatening regulatory actionagainst the practice of commercial imaging of fetuses for‘keepsake’ videos (FDA 2000). The FDA notified the medicalcommunity in the USA in 1994 regarding its concerns aboutthe misuse of diagnostic ultrasound equipment and sought todiscourage their patients from having sonograms for so-called‘non-medical’ reasons. The published FDA rationale states:‘Although there is no evidence that these physical effects canharm the fetus, public health experts, clinicians and industryagree that casual exposure to ultrasound, especially duringpregnancy, should be avoided. Viewed in this light, exposingthe fetus to ultrasound with no anticipation of medical benefitis not justified.’ (FDA 2000).The British Medical Ultrasound Society has publishedguidelines that permit the use of non-medical ultrasound,but only under conditions that significantly limit the ultrasoundoutput (BMUS 2000) and, hence reduce the risk tothe patient in the absence of known benefit. The BMUSdefines non-diagnostic use of ultrasound equipment as thatincluding repeated scans for operator training, equipmentdemonstration using normal subjects, and the productionof souvenir pictures or videos of a fetus. The BMUSguidelines for non-diagnostic uses of diagnostic ultrasoundprovide upper limits to the thermal index (TI < 0.5) andmechanical index (MI < 0.3). These are somewhat restrictivebut were chosen to provide a lower degree of risk forprocedures where there is no obvious clinical benefit. Notethat the FDA limits output on equipment (for use in theUSA) with an output display to MI < 1.9 for all examinationsexcept ophthalmic where MI < 0.23 applies. There isno limit on TI, but intensity (spatial peak temporal average)is limited to a maximum of 720 mW/cm2.It is a matter of debate whether, or not, live scanning maybe construed simply as an exercise in marketing the diagnosticability of a particular piece of ultrasound equipment.Stan BarnettChairman ASUM Safety CommitteeReferencesAIUM website. www.aium.org/stmts.htm#Prudent UseBMUS. British Medical Ultrasound Society, Guidelines for the safe useof diagnostic ultrasound equipment. BMUS Bulletin 2000; 8: 30–33.FDA CDRH. Centre for Devices and Radiological Health Consumerupdate on fetal keepsake videos. June 2000. www.fda.gov/cdrh/consumer/fetalvideos.htm36 ASUM Ultrasound Bulletin 2005 August; 8 (3)

Editor’s noteThe introduction by ultrasound operators in the USA andAustralia of a purely commercial ‘non-medical 3D ultrasoundimaging service to provide keepsake images of theunborn child has provoked a storm of controversy. TheAmerican Medical Association has weighed into the debatewith the following comments extracted from the article thatfollows.American Medical Association says ultrasoundin-utero ‘portraits’ are bad idea6/22/2005By: Reuters Health‘Recent advances in ultrasound technology, including3D image capacity, have made the ‘pre-birth’ portraitspopular, which prompted the Missouri delegation to theHouse of Delegates to ask the AMA to go public about therisks of the practice . . .The Missouri doctors said the ultrasound portraits areoften done by unqualified technicians in whose handsultrasound, which is generally a safe procedure, may haveunanticipated risks. During a reference committee hearing“testimony was overwhelmingly in support of this resolutioncalling for the responsible use of diagnostic ultrasoundduring pregnancy,” said Dr Daniel van Heeckeren, a thoracicsurgeon at University Hospitals, Cleveland, Ohio whochaired the Reference Committee . . .Dr Van Heeckeren noted that use of diagnostic ultrasoundfor ‘keepsake’ purposes puts the clinician at riskof potential legal liability since this imaging is often performedwithout parents receiving the standard counselingthat normally precedes ultrasound examinations.Editor’s noteASUM members also had plenty to say, including the followingedited comments extracted from various emailsto the Editor. Space precludes full publication of eachcommunication. Readers are invited to submit any furtherviews on this subject. ASUM does not endorse any of thesestatements. They are simply the opinions of individual correspondents.■ “How do bodies such as ASUM justify other non-medicaluses of ultrasound equipment, such as in live company-sponsoreddemonstrations and other ‘non-medical’activities? There is a far wider impact overall fromother non-medical uses compared to the 3D foetal photoscanner in [location omitted].If a 3D photo of the unborn child’s facial featuresduring pregnancy improves bonding (which it probablydoes on the face of it – no pun intended) and reducesthe incidence of postnatal family disruption by makingthe family-to-be appreciate the actuality of a child inthe making, or improves paternal postnatal care-giving(which it might), then a 3D photo has done more for thepregnancy than 99% of morphology scans, which seekto identify any abnormality which might prompt a latemid-trimester termination – an abhorrent 'treatment' inmy view. The reporting of an isolated so called ‘softmarker’ morphology scan finding which alone has nostatistical significance (such as an echogenic focus inthe heart, a choroid plexus cyst or a 5 mm renal pelvis)creates significant anxiety for many pregnant ladies andtheir partners and is arguably far more damaging than afew 3D images of an unborn baby’s face.”■ “Advocates perhaps might produce some evidencefor the statements made about the benefits of 3Dultrasound for families. One of our research Psychstudents has just concluded a randomised studywhich surprised us all by showing that comparedwith 2D scanning there is no difference in bondingas judged by the psychologic testing methodsshe employed. And not all foetal anatomy scans arepart of a search and destroy campaign. But we coulddebate the value of foetal abnormality scans (FAS)ad nauseam. We certainly do create angst but the softmarker chaos was initiated by well meaning groupsmainly in the USA extrapolating from high risk tolow risk groups. What I think worries most peopleabout entertainment scanning is [that] it is demeaningof the profession and the inference that what isgood for the greedy entrepreneurs [offering these 3Dservices] is necessarily good for their customers andtheir babies in utero.”■ “The BMUS guidelines for non-diagnostic uses of diagnosticultrasound provide upper limits to the thermalindex (TI < 0.5) and mechanical index (MI < 0.3). Theseare somewhat restrictive but were chosen to provide alower degree of risk for procedures where there is noobvious clinical benefit.”■ “Medicare is solely a payment system. It has nothingto do with setting standards of practice. There is noMedicare payment involved [in 3D ‘entertainment’ultrasound] so there is little interest [from legislators] incurbing the practice.”■ “ASUM must take the lead here as the peak ultrasoundbody in advising legislators and the publicthat this practice [of 3D ‘entertainment’ ultrasound]is inappropriate. The ALARA [as low as reasonablyachievable] rule applies to ultrasound as it does toother imaging modalities. It should only be performedwhere there is an appropriate medical indicationand exposure should be minimised. Just becausethere is no demonstrated effect to date, it does notmean ultrasound exposure is safe."■ “3D scanning is a commercial contract creating aduty of care. If the mother is warned of material biodangers(of which none are established) and understandsthat the scan is not for medical purposes, theduty of care is discharged. Where the operator doesnot hold themselves out to be providing a medicalservice, the provisions of the various State basedlegislative instruments controlling doctors and otherswho deliver medical care do not apply.”■ “[In relation to the concern of abnormalities either beingfound or missed on these social scans] the operators hadbetter be careful with the way they structure their business,get good legal advice and have good insurance!”■ “What about the right of the foetus to determine itsexposure to unnecessary risk [such as 3D ‘entertainment’ultrasound] for the enjoyment of others [its parentsand grandparents]”.ASUM Ultrasound Bulletin 2005 August; 8 (3)37

SOCIAL SCREENINGSonographerMelbourneMonash Ultrasound for Women provides services toMonash IVF (gynaecological and infertility ultrasound)as well as routine and tertiary obstetric ultrasound andprenatal diagnosis.A full or part-time position is available for an ASARaccredited Sonographer at our specialist Obstetric andGynaecological ultrasound practice. The successfulapplicant will have extensive experience in ultrasoundwith a special interest in O&G.This position will involve the provision of a highstandard of ultrasound service, the supervision andtraining of Sonographer staff and students as well ascontributing to our in house education program.Alternatively: Experience in O&G preferred but trainingcan be given to the right applicant with an interest inthis area of ultrasound.Enquiries to: Operations ManagerJo-Anne O’Connortel (03) 9420 8250 oremail joconnor@monashivf.edu.auwww.monashultrasound.com.auOBSTETRICAL &GYNAECOLOGICALULTRASOUNDSONOLOGIST REQUIREDMELBOURNEA unique opportunity exists for a Sonologist withexperience in this field to join the team workingat the clinics of Monash Ultrasound for Women,located across three Melbourne sites, at Richmond,Clayton and Box Hill in Victoria.For confidential enquiries please call:Ms Jo-Anne O’ConnorOperations ManagerMonash Ultrasound for WomenEmail: joconnor@monashivf.edu.auMobile: 0407 522 347Telephone: 03 9420 8250www.monashultrasound.com.auTo Dr Caroline HongChief Executive OfficerAustralasian Society for Ultrasound MedicineDear Caroline,Further to our conversation this morning I thought it appropriateto confirm the basis of our discussions regarding theMarketing of 4D (or equivalent) ultrasound systems foranything other than dlinical diagnostic purposes.GE Healthcare is tightly bound by the GE IntegrityPolicy on a Global Basis, which outlines, amongst otherthings, a very strong Code of Conduct and Ethics to beapplied when doing business in all countries. As a result ofthis policy, Omar lshrak, whom you have met, has mode itvery clear that the Voluson Ultrasound System (or equivalent]is not to be knowingly supplied in situations wherethe only intention is to provide an entertainment experienceassociated with pregnancy. These situations include, butare not limited to private individuals who ore not clinicallyqualified offering a scan to expectant parents without thebenefit of any clinical interactions.Within the Australian market we are beginning to seenon-clinical entrepreneurs considering such services andsubsequently approach GE for the purchase of Voluson systems.Given the above considerations and the fact that GEviews 4D technology as a significant clinical tool, which,when utilised correctly can offer amongst other things,increased diagnostic capabilities in fetal heart assessmentventricular development in the brain; argon dimensions andvolume calculation – GE Healthcare is taking the positionthat it will not be selling these systems to any physician notqualified to interpret and utilise such technology i.e. we willnot be selling systems to anyone that is not either DMU orsonographer qualified (with suitable medical support).If there is anything that I con do to work with ASUMto ensure that this becomes a ‘self Policing’ policy, pleaselet me know.David RadfordGeneral ManagerUltrasound, Australia and New ZealandGE Healthcare TechnologiesExpression of InterestDMU Practical ExaminersExperienced and qualified sonographers are required forselection and training as DMU Practical Examiners. Interestedapplicants will need to:■ Be ASAR accredited■ Attend ASUM DMU Practical Examiner Training/Accreditation days■ Be Financial ASUM members■ Be prepared to travel throughout Australia and NewZealand■ Commit to examine at least five candidates annually for threeyears■ Provide a full Curriculum Vitae■ Provide professional referencesPlease apply in writing with attachments (noted above) to:Chairperson ASUM DMU Board of Examiners2/181 High St Willoughby Sydney NSW 2068 Australia38 ASUM Ultrasound Bulletin 2005 August; 8 (3)

BOOKS AND CDsBook and CD reviewsAbdominal Ultrasound – How,Why and When (2nd Edition)Author Jane A BatesPublisher Elsevier ChurchillLivingston 2004Cost A$116.60 (incl gst)The second edition of AbdominalUltrasound – How, Why and Whenis a 284 page text written by the veryexperienced sonographer, Jane Bates,from the Ultrasound Department at StJames University Hospital, Leeds, UK.I reviewed the first edition of thistext in 1999 and subsequently includedit in recommended reading lists forstudent sonographers and referred toit often, particularly when teaching.It is a pleasure to review the updatedsecond edition.The general layout of the text andwriting style reflect the fact that theauthor is an experienced teacher ofultrasound to sonographers. The textaims to be a ‘practical and easilyaccessible guide to sonographers’ andin this it succeeds very well.This is an excellent text: well written,very well illustrated and easy andinteresting to read. The writing styleis almost conversational at times andone can easily imagine the author talkingto students in a lecture or tutorial.The author’s experience and interestin the topic is demonstrated in thenumerous tips and pitfalls mentionedthroughout.The content, while not a comprehensiveaccount of all pathologies thatmay be encountered in an ultrasoundexamination of the abdomen, is quiteextensive and is more than detailedenough for most general departmentsand for student sonographers.There are 11 chapters with anintroductory chapter on ‘General scanningand equipment issues’ which,while not comprehensive, makes somevalid and useful points and stronglyemphasises the operator-dependentnature of ultrasound and the need forcare and diligence on the part of thesonographer.Seven separate chapters deal witheach of the major areas of the abdomenin a logical, easy to follow format. Aswould be expected, the major emphasisis on the liver, biliary tree and the renaltract, with smaller overview chapterson the spleen and retroperitoneum andgastrointestinal tract.The text finishes with three goodsummary chapters dealing with paediatricabdominal pathology, the acuteabdomen, and interventional and othertechniques. The paediatric chapter isaimed at a general department andconcisely covers the major abdominalconditions that may be encountered ina general department. Further readingis suggested for those wanting moredetailed information relating to paediatricapplications.The ‘Interventional and other techniques’chapter includes good and upto-datesections on needle guidancetechniques, applications of intraoperativeand laparoscopic techniques and ultrasoundcontrast agents. Throughout therelevant chapters, there are well writtensections relating to shunts and transplanttechniques and their relevant ultrasoundassessments. I found these sections veryinformative and of good general interest.In summary, I found this to be avery attractive book, with very goodquality images and an easy to read andengaging writing style. The informationis aimed at student sonographersand it should meet the needs of thetarget audience well. I would highlyrecommend the text for students, anyoneinvolved in training sonographers,and teaching departments.Margo GillMAppSci GDipBusAdmin DMU AMSThe practice of ultrasound. Astep-by-step guide to abdominalscanningAuthor Berthold BlockPublisher Thieme 2004ISBN 3-13-1383615Cost $A121 (incl GST)This 253-page soft cover book isdescribed by the author as a self-studyguide for those beginning ultrasound.Its creation was brought about by thecontinuing problem of sonographersfinding time to train new studentsand also by the lack of any existingtexts solely aimed at beginners. Theauthor intends the trainee sonographerto have the text in the ultrasound roomwhile performing examinations, as aconstant reference.The text is divided into 13 chapters.The first is a very basic description ofthe ultrasound machine, its probes andkey functions. There is also a comprehensivedescription of the orientationof the ultrasound image.The second chapter, which isdevoted to the physics of ultrasound, isagain basic, but describes all the mainartefacts encountered when scanning.Each continuing chapter is thendevoted to a region of the abdomenand is divided into organ boundaries,organ details and relationshipsto other organs. The learning goal ofeach chapter is stated at the beginningand key points are listed to summarisemajor points learned.Handy tips are noted along the passagesfor scanning different regions.Each organ described and their scanningtechniques are complimented byultrasound images. They appear stepby-stepas they would if scanning.Chapter four on the liver is particularlywell written with excellent imagesdescribing the liver segments and theirboundaries. Chapter eight is also interestingas it describes the scanning ofthe stomach, duodenum and diaphragm,which are often not well covered inother texts. However, the chapter onthe bladder, prostate and uterus is briefand disappointing. Also, the diagramsin each chapter can be difficult to follow,as the labelling is confusing and notstandard. Reference is made to the mainpathologies affecting each organ, in eachchapter, with a basic description of thepathology and an ultrasound image todemonstrate its appearance.The final chapter is a summary,with a description of all the points tocover when scanning each region, alist of suggested terminology to usewhen describing an organ or pathologicalfinding and a suggested reportsheet and image documentation.In summary, when purchasing thistext, it must be remembered it is forbeginners and is aimed at a basic level.With this in mind, it is an excellentteaching tool to start a new sonographerscanning and has the most comprehensiveseries of images to date,to demonstrate normal anatomy andscanning techniques.Deborah MoirDipRad DMU AMSASUM Ultrasound Bulletin 2005 August; 8 (3)39

THE SOCIETYSUMCertified ISO 9001:2000ASUM is affiliated with WFUMBAUSTRALASIAN SOCIETY FOR ULTRASOUND IN MEDICINE • 2/181 HIGH ST. WILLOUGHBY NSW 2068 SYDNEY AUSTRALIAPh (61 2) 9958 7655 • Fax (61 2) 9958 8002 • asum@asum.com.au • http://www.asum.com.au • ACN 001 679 161 • ABN 64 001 679 161ADJUDICATION GUIDELINES FOR ORAL PRESENTATIONSresenter:Title of Presentation:ategory of presentation:❑ Descriptive clinical ❑ Literature review ❑ Original researchBSTRACT:NTRODUCTION:ONTENT:Correctly portrays the presentation,demonstrates the relevance of the topicand creates interestAcknowledges Chair and audience.Describes the contextual relevance ofthe topicAims/hypothesis/purpose clearly statedPOOR CREDITABLE OUTSTANDING1 2 3 4 51 2 3 4 5Well developed description oftopic/case1 2 3 4 5Relates topic/issues to local contextand conditions1 2 3 4 5Integrates own thought and refers toother work on the topic2 4 6 8 10Describes the problem/issue/techniquein detail2 4 6 8 10Discussion relates to, and is supportedby relevant literature2 4 6 8 10Literature is appropriate and current1 2 3 4 5Comprehensive coverageONCLUSION: Summarises major points/findings.Outlines recommendations for futureworkRESENTATION: Audiovisual well sequenced andrelevant to the presentation withappropriate image qualityPresentation well sequenced.Clear and audible presentation.Holds audience interestRIGINALITY:ALUE:1 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 5Original thought is evident in theselection of the topic1 2 3 4 5The methodology is appropriate andshows evidence of originality in itsdesign1 2 3 4 10The topic is relevant and beneficial tothe profession1 2 3 4 10MORE THAN 2 MINUTES OVERTIME DEDUCT 50 POINTS SCORE: /100

SUMCertified ISO 9001:2000ASUM is affiliated with WFUMBAUSTRALASIAN SOCIETY FOR ULTRASOUND IN MEDICINE • 2/181 HIGH ST. WILLOUGHBY NSW 2068 SYDNEY AUSTRALIAPh (61 2) 9958 7655 • Fax (61 2) 9958 8002 • asum@asum.com.au • http://www.asum.com.au • ACN 001 679 161 • ABN 64 001 679 161ADJUDICATION GUIDELINES FOR POSTER PRESENTATIONSenter:Title of Presentation:gory of presentation:❑ Descriptive clinical ❑ Literature review ❑ Original researchTRACT:RODUCTION:TENT:CLUSION:IGN:GINALITY:UE:Correctly portrays the presentation,demonstrates the relevance of the topicand creates interestDescribes the contextual relevance ofthe topicAims/hypothesis/purpose clearly statedPOOR CREDITABLE OUTSTANDING1 2 3 4 51 2 3 4 5Well developed description oftopic/case1 2 3 4 5Relates topic/issues to local contextand conditions1 2 3 4 5Integrates own thought and refers toother work on the topic2 4 6 8 10Describes the problem/issue/techniquein detail2 4 6 8 10Discussion relates to, and is supportedby relevant literature2 4 6 8 10Literature is appropriate and current1 2 3 4 5Comprehensive coverageSummarises major points/findings.Outlines recommendations for futurework1 2 3 4 51 2 3 4 5Logical and easy to followInformation presented concisely1 2 3 4 5Text is eye catching and easily viewedImportant points are well illustrated1 2 3 4 5Original thought is evident in theselection of the topic1 2 3 4 5The methodology is appropriate andshows evidence of originality in itsdesign1 2 3 4 10The topic is relevant and beneficial tothe profession1 2 3 4 10SCORE: /100

THE SOCIETYDiploma of Medical Ultrasonography Report2005 DMU Part I and Part II ExaminationApplicationsWhile the 2005 enrolments for the DMU are similar to thosein recent years, the numbers are slightly down and the mixof specialties and localities is changing. Eighty-nine (89)Part I Candidates and ninety-nine (99) Part II Candidatesapplied to sit the 2005 DMU Examinations.Table 1 shows the breakdowns:Tables 2 and 3 show a comparison of the 2004/2005candidate numbers by location and speciality:With the introduction of many university courses, whilethe number of General candidates in Australia is relativelystable, the number of General candidates from New Zealandis decreasing due to the fact that 2005 is the first year inwhich a new university course has been offered in Aucklandwhere most of the New Zealand candidates are located.Detailed 2005 numbers by location, speciality andexamination type are detailed on tables 4 and 5.It is expected that the New Zealand Unitec/AucklandUniversity course may have a further impact on NewZealand General numbers. The number of Cardiac candidatesis stable despite more universities offering cardiaccourses. I feel that many candidates underestimate theamount of work involved in undertaking a course of independentstudy towards a professional qualification with thehigh standards that the ASUM DMU maintains.2005 DMU Examination innovationsFrom 2005, Part I Candidates may now sit the WrittenExamination in July and/or November. This innovationTable 1 Breakdown comparisons 2004/2005 DMUapplications2004 2005Part I Part II Part I Part IICardiac 35 52 32 47General 59 41 44 38Obstetric 1 6 5 4Vascular 10 12 8 10TOTAL 105 111 89 99Table 2 Part I Candidate numbers – comparison 2004:2005Location Cardiac General Obstetric Vascular2004 2005 2004 2005 2004 2005 2004 2005NZ 6 4 25 9 0 0 2 1Qld 10 7 0 1 1 2 3 0NSW 5 4 15 23 0 1 1 3Vic 11 8 6 4 0 2 3 2Tas 0 0 0 0 0 0 1 0SA 0 2 0 0 0 0 0 0WA 3 7 12 4 0 0 0 2NT 0 0 0 0 0 0 0 0ACT 0 0 1 3 0 0 0 0TOTAL 35 32 59 44 1 5 10 8gives candidates and practices an increased flexibility toplan their sonographer training, as well as offering failedcandidates an early opportunity to re-sit their Part I examinationwithout having to wait a further 12 months.As in previous years, the 2005 Part II Examinationis offered annually and consists of three components:a Written Paper on Ultrasound Techniques, a PracticalExamination in Scanning Techniques and the Objectiveand Standardised Clinical Examination (OSCE) and OralExamination (Oral). The OSCE is in two sections comprisingClinical and Applied Physics answers stations; theOral Examination consists of Applied Physics and Clinicalrelated situations. Candidates must achieve satisfactorystandards in ALL sections of the examination to satisfactorilycomplete their DMU. The emphasis of the DMU PartII Examination is on the technical and practical considerationsof the profession of ultrasonography.The 2005 Written Examinations were conducted onSaturday 30th July in 26 centres throughout Australia andNew Zealand. Notwithstanding the practical examinationsthat have already been concluded, over the next threemonths all practical examinations will be conducted. TheOSCE/Oral Examinations will be held in early October,with the Cardiac and Vascular being held on Saturday8th October and the General and Obstetric being held onSaturday 15th October. It is intended to have all 2005 PartII examinations completed by the end of October. This year,the November sitting of the Part I Written Examination willbe Saturday 5th November. Applications are now open andwill close on Friday 30th September 2005.Practical examiners for the DMU are currently undergoingaccreditation training to help standardise the PracticalExaminations throughout Australia and New Zealand. Thisaccreditation process was introduced in 2004 and, by 2006,it is intended that all existing DMU practical examinersand additional, suitable, interested sonographers are fullyaccreditated by ASUM to conduct practical examinations.The ASUM DMU Board of Examiners continues toexchange New Zealand and Australian practical examinerson selected rotation by speciality so that both groups have achance to assess overall standards in each other’s countries.In addition, practical examinations, at the ASUM DMUTable 3 Part II Candidates numbers – comparison 2004:2005Location Cardiac General Obstetric Vascular2004 2005 2004 2005 2004 2005 2004 2005NZ 8 4 22 16 1 1 3 3QLD 10 14 3 1 0 0 1 3NSW 9 6 8 10 4 3 3 2Vic 13 9 2 4 1 0 3 1Tas 0 0 0 0 0 0 1 0SA 5 6 0 0 0 0 0 0WA 5 5 6 7 0 1 0 0NT 2 2 0 0 0 0 0 0ACT 0 0 0 0 0 0 1 1TOTAL 52 47 41 38 6 4 12 1042 ASUM Ultrasound Bulletin 2005 August; 8 (3)

Table 4 2005 – Part I Examination numbersSpeciality APP Common TotalPhysics CandidatesNZ Cardiac 4General 7ObstetricVascular 1 14 15ACT General 3 3 3NSW Cardiac 4General 19Obstetric 1Vascular 3 29 32NT General 1 1 1Qld Cardiac 7General 1Obstetric 2SA Cardiac 2 2 2Vic Cardiac 7General 3Vascular 1WA Cardiac 6General 3Vascular 2 10 11TOTAL 77 85 89Board of Examiners’ discretion, can now be held early forcandidates who are re-sitting their practical examinations.Four candidates were afforded this opportunity in 2005.The results of those practical examinations have been forwardedto the ASUM Council for its recommendation andapproval.In 2005, an enhanced oral examination will continueto be phased in as a part of the OSCE/Oral Examinations.From 2006, the OSCE, it its present format, will no longerbe offered; it will be incorporated into a revised, high quality,colour, written format and incorporated into an expandedwritten examination. Physics and Clinical Oral examinationswill replace the OSCE/Oral Examination format. The ASUMDMU Board of Examiners feels that an oral examinationaffords the examiners a better opportunity to assess whetherthe candidate has the knowledge required or is simply toonervous to perform well in an examination situation. Usinga combination of the Oral Examination and modern printingtechniques to add colour images to the written questions, wefeel that we can better assess a candidate’s knowledge.In 2005, three members of the ASUM DMU BoardTable 5 2005 – Part II Examination numbersLocation Speciality Written Practical OSCE / TotalOral CandidatesNZ Cardiac 3 3 4General 13 12 13Obstetric 2 3 2 24VascularACT Vascular – – 1 1NSW Cardiac 5 5 6General 9 7 8Obstetric 2 1 1Vascular 2 1 2 21NT Cardiac 2 – 2 2QLD Cardiac 14 10 10General – – 1Vascular 2 2 3 18SA Cardiac 6 4 5 6VIC Cardiac 7 5 8General 4 3 4Vascular 1 – – 15WA CardiacGeneral 4TOTAL 81 67 81 99of Examiners resigned. Louise Morris, Lucia PembIeand Cathy West have been tireless workers for ASUMand valuable contributors to the high quality of the DMUExamination. Their professionalism and dedication willbe missed. I thank them, personally, and on behalf of theASUM DMU Board of Examiners for all they have doneand wish them well in their future ventures. I am pleasedto welcome Margaret Condon (General), Robert Phillips(Cardiac), Alison White (Cardiac) and Robert Ziegenbein(Vascular) who were appointed to the ASUM DMU Boardof Examiners by the ASUM Council at its July 2005 meeting.The running of the DMU examinations could not beachieved without the voluntary professional assistanceoffered so generously by ASUM sonographer, medical andscientific members. Our gratitude is extended to all whoassisted in the recent written examinations.Ros SavageChairpersonASUM DMU Board of ExaminersResearch and Grants ApplicationNotice to MembersFinancial assistance is available to ASUM members from the Research and Grants Committee to supportmedical research into diagnostic ultrasound.For further information see www.asum.com.auApplications close 1st November 2005 and 1st May 2006. All applications will be acknowledged.Contact ASUMtel +61 2 9958 7655email asum@asum.com.auASUM Ultrasound Bulletin 2005 August; 8 (3)43

EDUCATIONExamination dates for 2005DMU examination datesand venuesDMU ExaminationsOral Examination & OSCE*Cardiac■ Date – Saturday 8th October 2005■ Time – 08.00 to 16.00■ Venue – Brisbane(Qld, NT, New Zealand and selected NSWcandidates)■ Venue – Melbourne(SA, VIC, WA and selected NSW candidates)General■ Date – Saturday 15th October 2005■ Time – 08.00 to 16.00■ Venue – Auckland(All New Zealand candidates)■ Venue – Sydney(All Australian candidates)Obstetric■ Date – Saturday 15th October 2005■ Time – 08.00 to 16.00■ Venue – Auckland(All New Zealand candidates)■ Venue – Sydney(All Australian candidates)Vascular■ Date – Saturday 8th October 2005■ Time – 08.00 to 16.00■ Venue – Brisbane(All candidates)*The DMU Board of Examiners determined the finallocations for the OSCEs after final candidate numbers,venue availability and Examiner requirements were known.Candidates are again reminded that while the dates forOSCEs are fixed, all modalities are not necessarily examinedat every centre. All candidates will be advised in writingof the specific location and time of their OSCE/OralExamination session approximately six (6) weeks prior tothe scheduled date.Practical Examinations■ Practical Examination are conducted at thecandidate's clinical practice, where possible, byarrangement between the ASUM DMU Boardof Examiners, the candidate and the PracticeManagers between April and October.DMU Practical Examiner Accreditation andTraining DaysAdelaide – Thursday 29th September 2005(Annual Scientific Meeting)Gold Coast – Thursday 23rd March 2006(Multidisciplinary Workshop)DMU Prep Course■ Gold Coast – Wednesday 22nd March toSunday 26th March 2006DMU Part I Written Examination (Supplementaryand November Applicants):■ Date – Saturday 5th November 2005■ Venues – Yet to be decided■ Time – 08.00 to 16.00The DMU Board of Examiners determined the finallocations for the OSCEs after final candidate numbers,venue availability and Examiner requirements were known.Candidates are again reminded that while the dates forOSCEs are fixed, all modalities are not necessarily examinedat every centre. All candidates will be advised in writingof the specific location and time of their OSCE/OralExamination session approximately six (6) weeks prior tothe scheduled date.DDU dates 2006DDU 2006 Part I■ Part I Applications close on Monday 20th March2006■ Part I Examination will be held on Monday 15thMay 2006DDU 2006 Part II■ Part II Casebook submissions close on Monday16th January 2006■ Part II Applications close on Monday 20 March2006■ Part II Written Examination will be held onMonday 15th May 2006■ Part II Oral Examination for Cardiology candidatesonly on Thursday 15th June 2006■ Part II Oral Examination (excluding Cardiologycandidates) on Saturday 17th June 2006■ The Annual DDU Board of Examiners meetingwill be held on Saturday 17th June 2006Your ASUM Examinationsquestions answeredDMU Matt Byrontel +61 2 9958 0317email dmu@asum.com.auDDU Marie Cawood tel +61 2 9958 7655email ddu @asum.com.au44 ASUM Ultrasound Bulletin 2005 August; 8 (3)

THE SOCIETYASUM – MUSS Meeting well attendedASUM delegates and MUSS members at the meeting in SingaporeThe ASUM Asia Link – MUSS(Medical Ultrasound Society ofSingapore) Meeting was held on 21–23rd May 2005 in Singapore. ASUMwas invited to nominate a speaker onthe topic of Ultrasound in EmergencyMedicine.The meeting was attended by about60 local radiologists and radiographersand was well supported by the localultrasound industry.The guest speakers were: MyronPozniak MD, Professor of Radiology,University of Wisconsin, MedicalSchool, Madison, Wisconsin, USA, DrPaul Sidhu, Consultant Radiologist,Kings College Hospital, London,UK and Dr Tony Joseph, EmergencyPhysician, Royal North Shore Hospital,Sydney, who also represented ASUM asthe Society's nominated speaker.TopicsThe topics covered included:■ Ultrasound imaging using contrastagents in the diagnosis of livermetastases and solid organ injury,■ The use of ultrasound in the assessmentof portal hypertension andTIPS,■ Ultrasound in the real-time localisationof cerebral arterio-venousmalformations during surgery.■ The application of ultrasound intrauma and other emergency uses.The Medical Ultrasound Society(Singapore) were most generous hostsand Singapore is an excellent venuefor a meeting.I would like to thank the MUSS andthe Conference Organiser, ChintanaWilde, for their kind invit-ation andgenerous hospitality.Tony JosephEmergency PhysicianRoyal North Shore HospitalOverseas sonographerlecturerVision CollegeSecond sonographer lecturer position available forDMU (Asia) located in Kuala Lumpur, MalaysiaA second sonographer lecturer position is now available to an ASUM member atthe new Vision College in Kuala Lumpur, to work with the chief sonographer lecturer,Alan Williams.The successful applicant will need to be an experienced sonographer, with anASUM DMU, who is culturally sensitive and interested in living and working inAsia.A negotiable remuneration and conditions package is available.Initial expressions of interest, together with a full CV, to be directed toDr Caroline Hong ASUM CEOemail carolinehong@asum.com.auASUM Ultrasound Bulletin 2005 August; 8 (3)45

THE SOCIETYThe 2004 Beresford Buttery OverseasTraineeship experienceNerida Russell in PhiladelphiaAs a long-term rural radiographer/sonographer, choosing to work andlive in Central Queensland, with onlyteleradiology and telephone support,but personally armed with a passionfor obstetrics and an ever increasingdemand for gynaecological ultrasound,I was thrilled to learn thatthe story of my personal journey toachieving ultrasound qualification andaccreditation had provided me withthe opportunity of a lifetime . . .the opportunity to study overseas, inPhiladelphia to be precise.Philadelphia, famous for its oldworld charm, the Declaration ofIndependence and the AmericanConstitution is the home of theLiberty Bell and also the JeffersonUniversity Hospital. This was myrecent destination as the winner ofthe 2004 Beresford Buttery OverseasTraineeship. Sponsored by GE andproudly supported by ASUM, I undertookthe 4.5 day Core Obstetrics andGynaecology Ultrasound Course atJefferson Ultrasound Research andEducation Institute (JUREI).The course commenced with theobligatory ‘get them while they’refresh’ physics and instrumentation andbioeffects for obstetrics and gynaecologypresented by Nathan Pinkey– the USA’s equivalent to our own MrRoger Gent.We were engaged for several hoursby Dr Oksana Baltarowich with anexcellent presentation on transvaginalscanning. Dr Baltarowich also chaireda challenging problem solving/caseanalysis session later in the week. Asa sonographer working in an isolatedregion, this was a particularly usefulsession and helped me to draw practicalconclusions from the measurementsand observations obtained froma particular scan, impacting on thepatient’s immediate care plan.Dr Jason Baxter’s presentation ofobstetrical Doppler applications wasparticularly useful for someone in mysituation. Now I can confidently andcapably explain the implication ofabnormal Dopplers when the localresident asks, “but what does thatmean?”Other presenters included DrAlfred Kurtz, a name familiar to usall, who spoke on fetal anomalies,with excellent images and Dr GeorgeBega on placenta and cervix – twoareas that sometimes are not given theattention they deserve when there is acute or troublesome fetus taking centrestage. Dr Bega also introduced usto 3D and 4D ultrasound at all stagesof pregnancy and its use in gynaecology,especially for congenital uterineanomalies. Again, some terrific imagesand video clips were provided.Other participants in the coursehailed mainly from the USA butNigeria, Barbados and Singapore werealso represented. Most were obstetricians,residents or radiologists. Therewas only one other sonographer and asole midwife.Philadelphia is conveniently locatedbetween New York and Washington.My husband and I were able to spenda few days wandering around a sunnybut chilly New York.Central Park was a sight to beholdwith snow on the ground and saffronwrapped by artist Christo.During my course, I befriended awonderful obstetrician from the potatostate of Idaho. She organised a personaltour of the Capital Building inWashington through her local representative,Budd Otto – what a great name!Philadelphia is the USA’s best keptsecret. Beautiful buildings, amazingmuseums and art galleries (rememberthe steps in Rocky I?) and the shopping. . .Philadelphia also turned on thewinter weather with a couple of daysof snowfalls and minus 12 degrees C.A pleasant change from the 38 degreesC we had left behind us.Receiving this award and theopportunity it provided, has been overwhelming.One of my main reasonsfor applying for this traineeship wasbecause I believe that rural peopledeserve as high a standard of care asour city cousins. I wanted to improvemy skills so I could be confident Iwas achieving this goal. The supportand words of congratulations from mylocal community was heart warming.Of course, I couldn’t have doneall this without the assistance of somevery important others:My husband Tom, a true rockalways there and always encouraging;my mentor and friend, Dr JohnWilliams, thank you for trusting inme all those years ago and thank youfor guiding and nurturing my enthusiasm;ASUM’s own Judy Vickress,behind the scenes tireless coordinator,thank you. Katie, James and MadelynKennedy from JUREI, thank you foryour hospitality and assistance duringmy stay in your wonderful city; andlast, but not least, to GE, thank you foryour generous support of this award.To anyone sitting out there wondering,should I apply? Just do it.Nerrida RussellSonographer/RadiographerCQMI, Emerald, Queensland46 ASUM Ultrasound Bulletin 2005 August; 8 (3)

ASUM NZ Branch Annual ConferenceThe 2005 ASUM NZ Branch AnnualConference was the second held asa combined conference with the NZBranch of the RANZCR. This seemsto be a successful combination. Thenext combined meeting is plannedfor 2007.The Conference was held at theMichael Fowler Centre, in the heart ofWellington. Dr David Gallaugh, whospecialises in intensive care, openedthe Conference, which, with close to300 registrants, was a well-attendedevent.The Organising Committee– Stephen Busby, Luke Newnham,Craig McQuillan and Paul Kendrick,all from the Nelson region, put togetheran exciting scientific program thatcatered for RANZCR, ASUM andRANZCR Radiation Oncology.The Saturday night conferencedinner, held at the Te Papa Museum,was a very successful social occasion.The night passed far too quickly, withmost getting up, at some point, toenjoy the dancing.The theme for Conference wasAbdominal Imaging and the invitedspeakers were chosen to reflect this.The Conference was well supportedby ultrasound equipment and servicessuppliers, it seems that the combinedmeetings are a great way for suppliersto showcase their products. Ourspecial thanks go to Philips and GE,both Platinum sponsors. The Silversponsors were Bard, Siemens and theNZ RANZCR Education Trust. TheBronze sponsors were Fujifilm andObex, with the Medical AssuranceSociety, Toshiba, Novartis Oncology,Fisher and Paykel Healthcare andAstraZeneca Oncology also providingsupport sponsorship.GE supported Prof Stephen Bakerfrom New Jersey, USA. His talks weredirected at the RANZCR.Philips supported Prof StephanieWilson from Toronto, Canada, whotalked enthusiastically on her specialties:microbubbles, chronic liver disease,assessment of RIF pain, the GItract and staging of rectal cancer.Dr David Hough, supported bySiemens, was originally from NewZealand and is presently based at theMayo Clinic in Minnesota, USA.Other invited international speakerswere Prof Howard Galloway,Prof Richard Mendelson, both fromAustralia, and Prof Sanjay Saini fromGeorgia, USA.The 2005 ASUM NZ Branch prizeswere awarded to:Best Proffered Paper – RathanSubramaniam.Best Sonographer Paper – AnitaHumphriesBest Student Paper – SusieHamiltonBest Poster – Cheryl HirshbergWe now look forward to nextyear’s conference in Napier from July14–16th 2006 and hope to see youthere.Yvonne TaylorChairmanASUM NZ BranchDavid Rogers and Yvonne TalyorDr Stephen BusbyThe ASUM New Zealand Branch Annual Committee (L–R) Cushla King, Dianne Kiss, Anita Humpries, Jo McCann, Yvonne Taylor and Martin NecasASUM Ultrasound Bulletin 2005 August; 8 (3)47

OBITUARYJames Robert Syme MD, FRACP, DDR, FRCR, FRANZCR, DDU, HonMIRDMU EXAMINATIONSMatt Byron tel +61 2 9958 7655email dmu@asum.com.auwill answer your questions aboutthe DMUDDU EXAMINATIONSMarie Cawoodtel +61 2 9958 7655 email ddu@asum.com.auwill answer your questions aboutthe DDUJim Syme, a much respected member ofASUM for some 30 years and a formerChairman of the Board of Examinersof the Diploma of DiagnosticUltrasound, died in Melbourne onNovember 30, 2004, at the age of 76years. Throughout his membership, hewas a strong supporter of and a tirelessworker for the Society. He was electedto Life Membership at the Society’sAnnual General Meeting in 2001, towidespread acclaim.A Queenslander by birth, Jim’s parentswere first generation Australians.His father was of Scottish extractionand his mother’s parents werePrussian.His intellectual prowess was revealedearly on. He was dux of SandgateState School, Brisbane, in 1941 and in1945 was dux of Brisbane State HighSchool. Jim graduated MBBS from theUniversity of Queensland in 1951 havinggained five distinctions and six creditsduring the medical course.Postgraduate qualifications followedwith an MD (University ofMelbourne) in 1959; Membershipof the Royal Australasian Collegeof Physicians in 1959 (Fellowship,1971); Diploma of DiagnosticRadiology (University of Melbourne)in 1961; Fellowship of the now RoyalCollege of Radiologists, London, in1964; Membership of the now RoyalAustralian and New Zealand Collegeof Radiologists in 1962 (Fellowship,1969); Diploma of DiagnosticUltrasound (ASUM) in 1982.Radiology became Jim’s chosenspecialty and a distinguished careerfollowed during which time he heldmany offices within The RoyalAustralian and New Zealand Collegeof Radiologists. He was the recipientof several notable honours fromthe College. He was the ThomasBaker Memorial Fellow in 1964,Rohan Williams Travelling Professorin 1979, received the Gold Medal ofthe College in 1984 and was elected toLife Membership in 1993.Jim was a member of the RANZCRCouncil from 1968 to 1991 and wasPresident of the College from 1989 to1990. He was Warden of the membershipof the RANZCR from 1970 to1988.His interest in ultrasound waskindled during a sabbatical tour ofNorth America in 1972 when he metand observed the work of two notablepioneers in ultrasound – GeorgeLeopold in general ultrasound andRaymond Gramiak in echocardiography.He became involved personallyin the practice of ultrasound in thelate 1970s.Jim was a member of the ASUMCouncil from 1984 to 1987 and representedASUM on the UltrasoundLiaison Committee from 1984 to1987. He was a member of the Boardof Examiners of the DDU from 1987to 2000. He succeeded the late DrPeter Verco as Chairman of that Boardin 1989 and held the position until2000 when he handed over to Dr ChrisWriedt.The appointment of a person ofJim Syme’s make-up and considerableadministrative and clinical experienceto the chairmanship of the DDUBoard was a fortunate one for ASUM.During his time as Chairman, Jimconsolidated the widespread respectfor the DDU both as a diploma worthhaving and for the rigour of its administrativeprocesses and conduct of theactual examination. During his timeas Chairman the DDU was awarded to136 medical practitioners.In 1957, Jim married HelenFitzgerald, a radiographer, and theyhad two sons, David and Cameron.He was a devoted family man whodoted on his two grandchildren. Hewas also a religious man to whomchurch life meant a lot. From Lutheranorigins, he joined the Anglican Churchafter he married and for many yearswas the ‘welcoming committee’ at the8 am Sunday service at his church.Jim collected stamps from childhoodand was very interested in coinageand history (especially Australianand European). But his real passion inlife was medical imaging in all areasand ASUM was very much a beneficiaryof this passion.His work for the DDU Board wascarried out in his own time with thewilling support and help of Helento whom the Society is also greatlyin debt. In both his private and professionallife he was a perfectionist,intensely loyal, had a healthy reserveand could be counted on never tobetray a confidence.Jim was a shy person but washappy to go to meetings where heknew people – he never missed aCollege or ASUM Annual ScientificMeeting. Despite his incapacitatingterminal illness he registered for boththe ASUM and RANZCR ASMs inlate 2004 but in the end was too ill toattend.An icon of probity, Jim Syme wasa giant in medical imaging in Australiaand New Zealand. The internationalreputation of the DDU was underpinnedduring his stewardship and successivepresidents of the Society feltprivileged to have had ready access tohis advices and experience as ASUM’saffairs became more sophisticated andinternational.To Helen and her family, the membershipof ASUM extends its sinceresympathy.48 ASUM Ultrasound Bulletin 2005 August; 8 (3)

Reach Sonographersthrough theUltrasound Bulletin✔ Appointments✔ Locums✔ Partnerships✔ Conferences✔ Workshops✔ Rooms/ EquipmentAdvertising salesMinnis Communicationstel +61 3 9824 5241fax +61 3 9824 5247email minnis@minniscomms.com.auPractical Ultrasound TrainingWith the AIUEDUCATION FOR THE MEDICALPROFESSION SINCE 1985HOME STUDY COURSES IN ALLASPECTS OF DIAGNOSTIC MEDICALULTRASOUND INCLUDING:BREAST, MUSCULOSKELETAL,ABDOMEN, OBSTETRICS,GYNAECOLOGY,ECHOCARDIOGRAPHY,NEUROSONOLOGYAND VASCULARVISIT OUR WEBSITE:WWW.BURWIN.COMFor 10 years the AustralianInstitute of Ultrasound hasoffered a range of proven, ‘handson’, intensive workshops for theUltrasound PractitionerCourses Coming Up Soon■ 3D Ultrasound Techniques■ Intensive Vascular FastTrack■ Advanced Vascular Techniques■ Practical Echocardiography Workshop■ O&G ultrasound FastTrack■ Specialist workshops for various Point ofCare options – see the website for detailsCome and join us in 2005Check the website or your annual booklet fordates, or just give us a callFind out more, contact us:On-line www.aiu.edu.auEmail: tony@aiu.edu.auPhone: (07) 5526 6655Fax: (07) 5526 6041ASUM Ultrasound Bulletin 2005 August; 8 (3)49

THE SOCIETYCorporate Members 2005Australian Imaging & UltrasoundDistributorsMedical Imaging SolutionsSharmaine Crooks 02 9888 1000aiud@audist.com.auAustralian Medical CouchesCouch ManufacturerMarcus Egli 03 9376 0060claudia@australianmedicalcouches.comBambach Saddle Seat Pty LtdSue Johnston 02 9939 8325sjohnston@bambach.com.auBristol-Myers Squibb Medical ImagingUltrasound Contrast & Nuclear ImagingAgentsWayne Melville 02 9701 9108mob 0409 985 011wayne.melville@bms.comCentral Data Networks P/LCDN. Affordable PACS & Medical ImagingNetworksRobert Zanier 1300 722 632mob 0407 069 307info@cdn.com.auFocus Medical TechnologiesLaurence Heron 02 9209 4530info@focusmedical.com.auGE HealthcareTsui Lian 02 9846 4850tsui_min.lian@med.ge.comGeneral Manager David RadfordInsight Oceania Pty LtdAloka/SonoSiteJohn Walstab 1800 228 118jwalstab@insight.com.auMeditron Pty LtdAcoustic Imaging, Dornier, KontronMichael Fehrmann 03 9879 6200michaelf@dornier.meditron.com.auPeninsular Vascular DiagnosticsVascular Ultrasound EducationClaire Johnston 03 9781 5001pvdvic@austarmetro.com.auPhilips Medical SystemsAustralasia P/Lincorporating formerly ATL, HP, AgilentLiz Jani 03 9945 2026liz.jani@philips.comGeneral Manager Wayne SpittleQueensland X-RayRadiologyJames Abbott 07 3343 9466James.abbott@qldxray.com.auRentworks LtdMedical Leasing EquipmentDon Hardman 02 9937 1074don.hardman@rentworks.comSchering Pty LtdEthical PharmaceuticalsJohn Peace 02 9317 8666jpeace@schering.com.auSiemens UltrasoundAcusonNick Kapsimallis 02 9491 5863nick.kapsimallis@siemens.comGeneral Manager Kevin FishSonosite Australasia Pty LtdPortable UltrasoundGreg Brand 1300 663 516greg.brand@sonosite.comSound Medical EquipmentDistribution of ultrasound scannersRon Mellenbergh 02 8437 3555contact@soundmedical.com.auToshiba (Aust) P/L Medical DivisionToshibaDavid Rigby 02 9887 8063drigby@toshiba-tap.comGeneral Manager Rosina DaviesNew members April – June 2005April 2005Full membersAlison Courtney NSWKatherine Karakalpakis VicVivian Morrow NSWPeter Nowill QldJack Spencer VicAssociate membersColin Burke NZRussell Coutts NSWMing Gin NSWJulie Hong VicBelinda Lee QldCassandra Lee NSWFreya Lees QldFerrie Li NSWChristopher Maughan NSWShareni Moodley NZChau Nguyen VicKathy Robertson QldLisa Wolffenbuttel QldMay 2005Full membersOlwen Clarke NZJoseph Graiche NSWDavid Harberts VicBasil Sher VicFika Vucago NZAssociate membersStuart McGregor NZCarrie Morgan QldTrainee membersNatalya Gontsova NSWJune 2005Full membersAdriana Arron NZDorothy Blumhardt NZShauna Fraser NZJames Gotting SAElaine Hampton NZCushla King NZMargaret McSweeney NZSarah Seager NZBridget Sparks NZBing Zeng NZAssociate membersKathy El-fil NSWJohn Garland NSWReach Sonographers through the Ultrasound BulletinAdvertising salesMinnis Communications tel +61 3 9824 5241 fax +61 3 9824 5247email minnis@minniscomms.com.au50 ASUM Ultrasound Bulletin 2005 August; 8 (3)

CALENDAR2005April Onwards DMU Part IISupplementary Practical ExaminationsContact James HamiltonDMU CoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002Email dmu@asum.com.auAug – Oct DMU Part II PracticalExaminationsContact James HamiltonDMU CoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002Email dmu@asum.com.auThu 1 Sep 2005 ASUM VictorianBranch Meeting – Ultrasound LectureSeries – Michael Bethune, "SoftMarkers"Venue Latrobe Lecture Theatre, 2nd FloorThe Royal Melbourne HospitalTime 6.30 pm Refreshments – 7.00 pmPresentationContact Monica PahujaEmail mpahuja@mercy.com.auFri 9 Sep 2005 – 6 Days The Vascular2005 ConferenceVenue Sydney HiltonContact Vanessa RussellConference ManagerTel +61 3 9645 6311Fax +61 3 9645 6322Email vanessa@wsm.com.au. Website:www.vascular2005.comSun 25 Sep 2005 – 5 Days 15th WorldCongress on Ultrasound in Obstetricsand GynecologyVenue Vancouver CanadaContact Congress Secretariat – ConcordeServices Ltd42 Canham Road London W3 7SRUnited KingdomTel +44 20 8743 3106Fax +44 20 8743 1010Email isuog@concorde-uk.comWebsite www.isuog2005.comThu 29 Sep 2005 ASUM DMU PracticalExaminer Accreditation Training DayVenue Adelaide Convention Centre,AdelaideContact James HamiltonDMU CoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002,Email dmu@asum.com.auThu 29 Sep 2005 – 4 Days ASUM 200535th Annual Scientific Meeting of theAustralasian Society for Ultrasound inMedicineVenue Adelaide Convention CentreAdelaide.Contact ASUM, 2/181 High Street,Willoughby NSW 2068 AustraliaTel +61 2 9958 7655;Fax +61 2 9958 8002Website www.asum.com.au/asum2005Sat 1 Oct 2005 ASUM Annual GeneralMeetingTime 10.30 am to 11.0 0amVenue Adelaide Convention CentreAdelaideContact ASUM 2/181 High StreetWilloughby NSW 2068 AustraliaTel +61 2 9958 7655;Fax +61 2 9958 8002Website www.asum.com.au/asum2005Sat 8 Oct 2005 DMU OSCE Cardiac +Vascular ExaminationsVenue TBAContact James HamiltonDMU CoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002,Email dmu@asum.com.auSat 15 Oct 2005 DMU OSCE General +Obstetrics ExaminationsVenue TBAContact James HamiltonDMU CoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002,Email dmu@asum.com.auThu 20 Oct 2005 ASUM VictorianBranch Meeting – Ultrasound LectureSeries – Speaker and Topic – TBAThis is another combined meeting thatwill be Broadcast via Video ConferenceVenue Latrobe Lecture Theatre 2nd Floor,The Royal Melbourne HospitalTime 6.30 pm Refreshments 7.00 pmPresentationContact Monica PahujaEmail mpahuja@mercy.com.auThu 20 Oct 2005 – 3 Days ECHOAustralia 2005 – Cardiac ConferenceVenue Four Seasons Hotel 199 GeorgeStreet, SydneyContact Linda RattrayTel +61 2 9846 4735Fax +61 2 9846 4002Email Echo.Australia2005@ge.comWed 5 Nov 2005 DMU SupplementaryPart 1 Written ExaminationVenue TBAContact James HamiltonDMU CoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002Email dmu@asum.com.auThu 10 Nov 2005 – 2 Days ASUMMUST Asia Link 2005 – Excellence inUltrasound MeetingVenue Bangkok, ThailandContact ASUM, 2/181 High Street,Willoughby NSW 2068 AustraliaTel +61 2 9958 7655;Fax +61 2 9958 8002Email asum@asum.com.auThu 22 Nov 2005 ASUM VictorianBranch Meeting – Ultrasound LectureSeriesInteresting Cases (Combined meetingwith ASA)Venue Latrobe Lecture Theatre 2nd FloorThe Royal Melbourne HospitalTime 6.30 pm Refreshments 7.00 pmPresentationContact Monica PahujaEmail mpahuja@mercy.com.au2006Fri 3 Mar 2006 – 5 Days ECR 2006(European Congress of Radiology)Venue Vienna, AustriaWebsite www.ecr.org Email info@ecr.orgWed 22 Mar 2006 – 5 Days ASUMMultidisciplinary WorkshopIncorporating:– DMU Preparation Course – 5 Days– DDU Technical Seminars – 2 Days– O&G Meeting – 2 Days– Vascular Workshop – 2 Days– Musculoskeletal Workshop – 1–2 Days– Point of Care Courses – 1 DayVenue Conrad Jupiters Gold CoastQueenslandContact ASUM 2/181 High StreetWilloughby NSW 2068 AustraliaTel +61 2 9958 7655;Fax +61 2 9958 8002Website www.asum.com.auThu 23 Mar 2006 ASUM DMU PracticalExaminer Accreditation & Training DayVenue Conrad Jupiters, Gold CoastQueenslandContact James Hamilton DMUCoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002Email dmu@asum.com.auThu 18 May 2006 – 3 Days WorldCongress of Echocardiography andVascular Ultrasound.Venue Marrakesh MoroccoContact Navin C Nanda, MD PresidentISCU PO Box 323 GardendaleAL 35071 USATel +1 205 934 8256Fax +1 205 934 674Email isuc@iscu.orgSun 28 May 2006 – 5 Days 11thTriennial Congress World Federationfor Ultrasound in Medicine andBiology(WFUMB)Venue Seoul KoreaASUM Ultrasound Bulletin 2005 August; 8 (3)51

CALENDARContact Byung Ihn Choi MDCongress SecretariatTel +82 2 760 2515Fax + 82 2 743 6385Emailchoibi@radcom.snu.ac.krWebsite www.wfumb2006.comMon 12 Jun 2006 – 3 Days DanishSociety: 9th International Congress onInterventional UltrasoundVenue Copenhagen DenmarkInformation Website: www.interventionalultrasound.orgEmail secretary@interventional-ultrasound.orgThu 14 Jul 2006 – 3 Days ASUM (NZBranch) 2006 Annual MeetingVenue Hawkes Bay New ZealandContact TBASat 29 Jul 2006 DMU Part I and Part IIWritten Examinations – ProvisionalVenue TBAContact James HamiltonDMU CoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002Email dmu@asum.com.auThu 14 Sep 2006 ASUM 2006 SkillsDay Venue Melbourne ConventionCentre, MelbourneContact ASUM 2/181 High StreetWilloughby NSW Australia 2068Tel +61 2 9958 7655Fax +61 2 9958 8002Email asum@asum.com.auFri 15 Sep 2006 – 3 Days ASUM 200636th Annual Scientific Meeting of theAustralasian Society for Ultrasound inMedicineVenue Melbourne Convention CentreMelbourneContact ASUM 2/181 High StreetWilloughby NSW 2068.Tel +61 2 9958 7655Fax +61 2 9958 8002Email asum@asum.com.auSun 5 Nov 2006 – 5 Days XVIII FIGOWorld Congress of Gynaecology andObstetricsVenue Kuala Lumpur, MalaysiaWebsite www.figo2006kl.com2007March 2007 – 5 Days ASUMMultidisciplinary WorkshopVenue SydneyContact ASUM 2/181 High StreetWilloughby NSW 2068 AustraliaTel +61 2 9958 7655Fax +61 2 9958 8002Website www.asum.com.auSat 28 Jul 2007 DMU Part I and Part IIWritten Examinations – ProvisionalVenue TBAContact James HamiltonDMU CoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002,Email dmu@asum.com.au2008Sat 26 Jul 2008 DMU Part I and Part IIWritten Examinations – ProvisionalVenue TBAContact James HamiltonDMU CoordinatorTel +61 2 9958 0317Fax +61 2 9958 8002,Email dmu@asum.com.au2009Thu 5th Sep 2009 – 4 Days ASUMhosts: WFUMB 2009 World Congressin Sydney, AustraliaVenue Sydney Convention and ExhibitionCentreContact Dr Caroline Hong ASUM CEOEmail carolinehong@asum.com.au orasum@asum.com.auASUM Head Office: 2/181 High Street,Willoughby NSW 2068 Sydney AustraliaIf you would like furtherinformation on any of the eventslisted, contact ASUM by email toasum@asumcom.auAs ASUM relies uponinformation supplied bymeeting organisers to compilethis calendar, no responsibility istaken for the accuracy ofinformation published andmembers are advised to checktimes, dates and venues directlywith meeting organisers.‘MUST ATTEND’ ASUM MEETINGS200529 September – 2 October ASUM 35th Annual Scientific Meeting Adelaide Australia10–11 November ASUM Asia Link Program Bangkok ThailandJoint meeting with Medical Ultrasonic Society of Thailand200622–26 March Multidisciplinary Workshop Gold Coast Australia14–17 September 36th Annual Scientific Meeting Melbourne Australia20095–8 September WFUMB 2009 World Congress Sydney AustraliaCongress to be hosted by ASUMContact ASUM tel +61 2 9958 7655 Fax +61 2 9958 8002 Email asum@asum.com.au Website www.asum.com.auDMU Practical ExaminerTraining and Accreditation DaysASUM Council has appointed the Australian Institute of Ultrasound to provide two courses per year for three years to train andaccredit DMU Practical Examiners. These courses will be held in conjunction with the Multidisciplinary Workshops and the ASUMScientific Meetings.Numbers are strictly limited for each DMU Practical Examiner Training and Accreditation Day. Initially, the DMU Board ofExaminers will offer places for the training program on the basis of immediate DMU Practical Examination requirements.52 ASUM Ultrasound Bulletin 2005 August; 8 (3)

ASUM MEMBERSHIPBENEFITSBIG DISCOUNTSfor Registrations to AllASUM MeetingsONLINE CLINICALHANDBOOKA reference collection of images,cases and differentialdiagnosesNETWORKINGConnect with otherUltrasound Professionalsand ManufacturersPROFESSIONALEXAMINATIONS &QUALIFICATIONSDDU, DMU & CCPUPROFESSIONALADVANCEMENTPublish in ASUM Bulletindistributed in Australia,NZ & AsiaSPECIAL RATESEducational Resources(Video/CD/DVD)For HirePARTICIPATEEligibility to participate inASUM Council andCommitteesINSURANCEOptional SonographersProfessional IndemnityInsuranceON-LINEEDUCATIONFree Physicsto DDU/DMUMOSIPPRecordingCPD/CME PointsFREEEmploymentAdvertising on theASUM WebsitePOLICIES &STATEMENTSGuidelines, Updates &WorksheetPROFESSIONALADVANCEMENTSpeaking Opportunitiesat Meetings in Australia,NZ & AsiaBULLETINQuarterlyDelivered to your DoorSPECIALHome Loan PackagesJoin Now!SPECIALCar Rental RatesRENT A CARFOR FURTHER INFORMATION:www.asum.com.au

ASUM ULTRASOUND BULLETIN VOLUME 8 NUMBER 4 NOVEMBER 2005