3EFSUMB Newsletter

Ultraschall in Med 2009; 30

EFSUMB NewsletterEuropean Federation of Societies for Ultrasound in Medicine and Biology

EFSUMB Newsletter meets Russia

Facts on Russia

3 Area: 17,075,400 km²3 Capital and largest city: Moscow3 Population: 142 million3 EFSUMB members: 266

The Russian Association of Specialists inUltrasound Diagnostic in Medicine joinedEFSUMB in 1996. The current interviewbetween the president and delegate Pro-fessor Vladimir Mitkov and the Editor ofthe EFSUMB Newsletter, Professor Micha-el Bachmann Nielsen took place in March2009. Professor Vladimir Mitkov is the di-rector of Diagnostic Ultrasound Depart-ment of the Russian Medical Academy forAdvanced Studies.

"Our department is the biggest diagnosticultrasound training centre in Russia - an-nually on various courses we train about900 doctors not only from Russia, butfrom former Soviet Republics also. I endedup in diagnostic ultrasound by chance. Af-ter postgraduate course in nuclear medi-cine I did scientific research in order to re-ceive the philosophy doctor degree. At theend of 1983 the nuclear medicine depart-ment got an ultrasound diagnostic sy-stem. It was Autofocus II (Technicare,USA). I was the youngest doctor in the de-partment. So since then I involved in ul-trasound."

The Russian Association of Specia-

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lists in Ultrasound

The Association has been founded in 1991.Doctors of any specialty can be membersof our Association if they perform ultra-sound examinations.

"By our calculations about a third of thedoctors performing ultrasound daily aremembers of our Association. Currently wehave more than 4,500 members and weare growing". Nearly all members arefrom Russia, only about 120 from the for-mer Soviet republics. A lot of doctors donot know English and for them the idea ofbeing a member of EFSUMB is not so at-tracting, therefore the number of Russianmembers who are also part of EFSUMB isconsiderably smaller.

Like in most European countries most ofthe doctors in Russia are state employed,but the amount of private clinics hasquickly grown the last 10-12 years in Rus-sia.

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The official Russian journal

„We have the official journal "Ultrasoundand Functional Diagnostics", published 6volumes a year (128 pages in volume)."The journal is in Russian. In the RussianFederation live more than 180 nationali-ties speaking different languages. Russianlanguage is the State language and all in-habitants of Russia may read, write andspeak it.

A lot of doctors in Russia do not knowEnglish. We will try to organize subscrip-tion to Ultraschall in der Medizin/Euro-

pean Journal of Ultrasound, however, I donot think that the amount of copies will bebig, perhaps 100-120 copies.“

5

Website

„Unfortunately we have no newsletternow, but plan to have one in the future.The Association has a website (www.ra-sudm.org) on which one can find the in-formation about the Association, Russianand international congresses, confe-rences, information about educationalcentres in diagnostic ultrasound, etc. Thewebsite is in Russian.“

5

Training in ultrasound in Russia

The Association does not have educationalcourses. In Russia for postgraduate educa-tion special state medical academies, in-stitutes or faculties licensed for this kindof activity are responsible. To be certifiedto do ultrasound the doctor (only doctorscan carry out ultrasound in Russia) mustpass special training (duration from 4months till 2 years) and exam.

Further to confirm certification one mustpass the exam each 5 years. Training cour-ses, which are spent by various educatio-nal centres, have a different level of com-plexity and focused on doctors with diffe-rent level of competence. Duration ofcourses varies from 10 days till 1.5 months(depends on subject). Courses programsaffirm Russian Ministry of Health, andthey are not based on EFSUMB guidelines.Instead of educational courses we spendthe congresses, conferences and seminarsin various regions of our country.

Russia is divided into 8 federal districts. Ineach district we try to have at least onecongress every two years which sums upto 3-4 congresses a year. 300-500 doctors

Professor

Vladimir Mitkov

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Ultraschall in Med 2009; 30

of the region participate in the districtcongresses. Every four years the All-Rus-sia congress takes place. The latest was inMoscow two years ago with more than4,000 doctors participating.

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A EUROSON in Russia - maybe

"Have you considered trying to host a EU-ROSON congress? Moscow would probab-ly be very attractive." "Yes, we consideredsuch an opportunity. Unfortunately an ex-pocentre available today is surroundedonly by very expensive hotels (mainly 5*).Cheaper hotels are located far from expo-

centre and difficult to reach (traffic jamsin Moscow are now terrible). The new ex-pocentre with hotel and station of the un-derground will be soon finished. Thenwe'll make an application for the organi-zation of the congress."

Congress in Chelyabinsk 2008

Church of the Protecting Veil of the Mother of

God on Nerly

Advertisment

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Ultraschall in Med 2009; 30

WFUMB 2009 in Sydney is off to a record-breaking start. See www.wfumb2009.com

A record number of 700 abstract submis-sions have been received prior to the clo-sing date of 23 January 2009 and the re-viewers are actively working on them. Ab-stracts are still open for e-posters andthey continue to come in from all aroundthe world. The Program Committee hasdesigned a comprehensive timetable. De-legates will have the choice of 285 Presen-tation Lectures, 4 plenary sessions, 112workshops and 100 proffered papers pre-senting a grand total of more than 500 to-pics on the all aspects and the very latestfor ultrasound in medicine.

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Visas and Early Registration

There have been a number of enquiriesabout invitation letters to participants. Ifyou have registered for the congress as an

exhibitor, delegate or presenter and requi-re an invitation letter for the purpose ofvisa travel approval process, please emailasum@asum.com.au. The host society,ASUM, will issue a letter provided that allthe required information is supplied to usfor notification to the approving Austra-lian department.

All international visitors require a validpassport and visa for entry into Australia(New Zealand visitors require a valid pass-port only). A facility for electronically is-suing visas, The Electronic Travel Authori-ty (ETA) system, is currently availablethrough international travel agents andairlines in over 30 countries including theUS, UK, parts of Western Europe, Singapo-re, Japan, Hong Kong and Taiwan. This sy-stem also includes pre-clearance for entrythat reduces the time needed to process

passengers on arrival. Your local Austra-lian Embassy or Consulate can advise ofthe availability.

For non-ETA countries, visas are issuedfrom Australian Embassies and Consula-tes around the world. In non-ETA coun-tries, we recommend that you apply earlyfor your visa. For further information,please visit http://www.immi.gov.au

Dr Caroline Hong

BDS(Uni Adel) Grad Dip HA(SA) MHA(Uni

NSW) AFCHSE CHE FADI FSAE FAICD

Chief Executive Officer

Australasian Society for Ultrasound in Me-

dicine (ASUM)

"PROMOTING EXCELLENCE IN ULTRA-

SOUND"

www.asum.com.au

www.wfumb2009.com

Legend?

Legend?

News from the EFSUMB website

Please take another look at our website www.efsumb.org.

We have included a microsite with information from the latest CEUS EUROSON SCHOOL course in Hannover. You can watch and listento the lectures from the international lecturers.

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Ultraschall in Med 2009; 30

It’s time to plan your trip ‘downunder’

There isn’t a better time to book your tripto Sydney Australia than right now withthe Australian dollar being extremelygood value against other major currencies.Apart from the enormous value for moneyyour attendance will be rewarded by anexciting and successful World Congress inmedical ultrasound with a unique Austra-lian flavour.

Sydney is a world-class convention desti-nation with temperate climate and stun-ning scenery in a friendly and safe socialstructure. ASUM is dedicated to ensuring asuccessful scientific, educational and soci-al congress in this modern and beautifulcity. We can promise you that!

The 12th World Congress in Sydney willinclude exciting program topics such as:advanced imaging technology, quality as-surance in radiology, medico-legal issues,3D and 4D ultrasound, echocardiography,ultrasound contrast imaging, advances intherapeutic applications, hands-on work-

shops and live-demonstration sessions,pediatric cardiology, veterinary medicine,obstetrics and gynecology, musculoskele-tal and emergency medicine. Visitwww.wfumb2009.com for the full pro-gram.

Delegates will also have the opportunityto meet with exhibitors who will be dis-playing their new, innovative and techni-cal diagnostic and therapeutic equipment,supplies and services. Come and see whatis new in the world of ultrasound. For thefirst time participants will be able to ex-perience and choose from almost all disci-plines of hands-on workshops with Sono-graphers and Doctors working togetherwith the latest in imaging technology atthis world medical ultrasound congress.

I am delighted with the support we aregetting from industry for this extremelyunique Sydney Congress. ASUM is gratefulto our major sponsors Toshiba, GE Health-care, Philips and Medison for their conti-

An update on WFUMB 2009 World Medical Ultrasound Congress nuing support and we welcome Superso-nic, Siemens, Zonare and Qld X-Ray asnew sponsors.

Exhibition space is at a premium and hasalready been booked by companies suchas Elservier Australia, Sonosite, I-MedNetwork, Lantheus Medical Imaging, BKMedical and the Department of State andRegional Development.

As CEO of ASUM I am pleased with theprogress and predict a great World Con-gress. Please join me and the ASUMCouncil in Sydney Australia on Sunday Au-gust 30 – till Thursday September 3, 2009,for a content-rich ultrasound meeting youdon't want to miss. I look forward to mee-ting you there.

Dr Caroline Hong

BDS(Uni Adel) Grad Dip HA(SA) MHA(Uni

NSW) AFCHSE CHE FADI FSAE FAICD

Chief Executive Officer

Australasian Society for Ultrasound in Me-

dicine (ASUM)

"PROMOTING EXCELLENCE IN ULTRA-

SOUND"

www.asum.com.au

www.wfumb2009.com

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Ultraschall in Med 2009; 30

Ultrasound Courses in the Near and Middle East

Ultrasonography is more and more disco-vered as an indispensable tool in clinicalmedicine. This holds true for both routineand for emergency/intensive care diagno-stics. Looking by means of ultrasonogra-phy into abdomen, thorax, soft tissues,and heart is basically easy, and the techni-cal equipment is comparatively low in pri-ce and safe in application. The true need-lehole in a more widespread use of the be-neficial potential of ultrasonography forour patients is in many a case the lack ofexpertise and systematical education.

The following report is based on a perso-nal experience of some fifteen years per-forming courses, seminars, and congresslectures in clinical ultrasonography in theNear and Middle East, and in some parts offrancophone (west-) Africa. In some 35-40journeys, the teaching and training peri-ods ranged between one day and oneweek (the latter on a periodical basis sinceeight years in Rabat/Morocco on behalf ofthe World Gastroenterology OrganizationWGO at the Postgraduate Training Centerat the Ibn Sina University Hospital, in co-operation with Profs. Naima Amrani andMustapha Benazzouz, gastroenterolo-gists). Other training and teaching sites

were in Syria (Dr.Fayez Sandouk), in Egypt(Dr.Nabil Elnahas ), and in Jordan, Iran, Su-dan, Cameroun, Senegal, and others.

The most striking feature of theseteaching events was the learning effectsfor the teacher himself: both in the medi-cal and ultrasound related field, and con-cerning the local health care systems andadditional multicultural experiences. Thiswas, however, not the main reason to per-form these activities. The rationale wasand is to give and to share as much as pos-sible expertise in clinical ultrasonographywith other and preferably younger col-leagues, in order to spread the fine art ofultrasonography as intensively as possibleand on a high quality level. The back-ground of an extended three decadesteaching experience in the network of theEFSUMB and the German speaking natio-nal societies of ultrasonography ÖGUM,SGUMB, and DEGUM* was really and ofcourse helpful, especially in transferringthe courses certification rules and regula-tions.

The teaching events and training courseswere usually and as far as possible embed-ded in the local hospital environments

with hands on training. This was especial-ly appreciated by all participants and trai-nees (Fig.1), and by the patients as well. Asfar as possible, the idea of a complete ex-amination of e.g. all abdominal organswas underlined, and a systematic ap-proach to the patient including the indivi-dual history and an initial physical exami-nation were a continuous demand. Thesehands on exercises - in routine and even inemergency/ambulance settings - werewithout exception most attractive for allparticipants.

In addition and as a rule, half of the totalteaching times was dedicated to lectureson specific topics - be it organ related nor-mal or pathological findings, or more ge-neralized topics as e.g. focusing on the dy-namic features in realtime ultrasound, anadequate examination technique, or vari-ants of acute abdominal pain diagnosedwith ultrasonography. Video moviesquickly turned out to be an optimalteaching instrument in addition to staticpictures. Hands on training turned alwaysout to be the real challenge for theteachers and course supervisors in explai-ning again and again details of anatomyand pathology - as a rule meeting hardworking and learning young colleagueswith an intensive interest in learningmore about the possibilities and limits ofclinical ultrasonography.

A considerable number of colleagues fromall countries mentioned made their wayto Germany to our hospital or to friends inthe sono field elsewhere to continue withan individualized training, always in com-bination with endoscopy and endoscopicultrasonography (EUS). And meeting thetrained colleagues again in congresses ofe.g. hepatology or in the setting of theUEGW (United European Gastroenterolo-gy Week) - this is always a true pleasure.

Clinical ultrasonography is an importanttopic and message - and its further spreadon a qualified basis is worth while anypersonal and more organized effort. Thefoundation of an officially acknowledgedumbrella organization is considered -with the precursor of the email addressbelow, which might friendly be used forfurther comments and discussion.

Lucas Greiner, MD

lucas@prof-greiner.de

ultrasonography@flyingfaculty.de Ultrasound Courses in the Near and Middle East

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Ultraschall in Med 2009; 30

What's new about Time Intensity Curves

In daily practice contrast-enhanced ultra-sound (CEUS) has proven to be helpful fordetection and characterisation of liver tu-mours [EFSUMB-Guidelines and Good Cli-nical Practice Recommendations for Con-trast Enhanced Ultrasound (CEUS) - Up-date 2008. Ultraschall Med 2008; 29:28-44], ultrasound guided biopsy, and posta-blative monitoring after radio frequencyablation (RFA). With the introduction ofsecond generation ultrasound contrastagents allowing real time imaging it ispossible to describe the change of bright-ness over time as a function of ultrasoundcontrast agents in- and outflow in a cer-tain region of interest, especially whenused with current software methods allo-wing analysing signals of blood pool ultra-sound contrast agents without distur-bances of underlying tissue backgroundinformation. In the literature there aremany topics in which time intensity cur-ves (TIC) may add substantial informationto the information gained by conventionalcontrast enhanced ultrasound.

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Assessment of tumour response

It is of special interest that time intensitycurves may serve as a predictor of tumorresponse to medical treatment, e.g., to thetyrosine kinase inhibitor Imatinib [Am JRoentgenol 2006;187:1267-1273. Ultra-schall in Med 2008; 5:S276-S277]. But it isalso of interest that published guidelinesso far have not recognized ultrasound as arecommended imaging method in thediagnosis and follow up of gastrointesti-nal stroma tumours (GIST). The panelistsof the 2005 published guidelines agreedthat currently available imaging tech-niques to evaluate GIST include computedtomography (CT), magnetic resonanceimaging (MRI) and fluorine-18-fluoro-de-oxyglucose (FDG) positron emission to-mography (PET). It is also stated that therole of ultrasound is currently under inve-stigation and CEUS was not mentioned atall [Consensus meeting for the manage-ment of gastrointestinal stromal tumors.Report of the GIST Consensus Conferenceof 20-21 March 2004, under the auspicesof ESMO. Ann Oncol 2005;16:566]. Thismight be due to a so-called subjectivity ofthe ultrasound examination technique("subjectivity" is certainly also true also

for CT and MRI but this might be less ob-vious). Similarly, in the RECIST (ResponseEvaluation Criteria In Solid Tumors) crite-ria used in cancer trials only CT and MRare allowed, ultrasound is not (for moredetails on RECIST see http://www.eortc.be/).

Assessing hypervascularity and re-

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sponse to antiangiogenetic drugs

In contrast to most published reports fo-cussing mainly on CT and PET it could berecently shown in some patients that ul-trasound can be the only imaging methoddepicting small hypervascularized meta-stases and is, therefore, also the only ima-ging method in the follow up. In additionthe early functional evaluation to optimi-ze therapeutical strategies is a main goalof tumour evaluation using antiangioge-netic treatment. Treatment response canbe predicted analyzing the vascularizati-on before any volume reduction can beobserved using the RECIST-criteria. CEUSmight also be the only method identifyingsmall lesions before and after treatment inpatients with no evidence of metastasesusing CT, MRI and PET [Ultraschall in Med2008; 29: S276-S277]. In an experimentalanimal study changes in vascularity couldbe detected within the first 24 hours afteradministration of an antiangiogeneticdrug [Lavisse et al. Invest Radiol 2008; 43:100-111]. Recognizing these patterns onCEUS in tumor response evaluation is im-portant, since often, response in tumor si-ze, particularly of the hepatic metastasis,is not apparent until late in therapy. Theanalysis of time intensity curves is, there-fore, a promising method to overcome thesubjectivity of contrast enhanced ultra-sound.

Several of the parameters in time intensi-ty curves correspond statistically withmicrovessel density, especially the areaunder the curve [Du et al, J UltrasoundMed 2008; 27: 821-31].

Parameters used in Time Intensity

5

Curves

TIC-parameters used are summarised inq Table 1.

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Reproducibility

When a new technique is applied to clini-cal indications and questions, basic rese-arch has to be performed including the va-lidity of the parameters analysed (intra-observer stability, stability against exter-nal factors, reproducibility) and the com-parability of different software sourcesused.

Very few studies on the subject are availa-ble. The area under the curve may be lessreproducible than other measurements;inter- and intra-observer variation of 20-30 % have been observed (Grossjohann HS,unpublished observations).

So far the amount of deviation for measu-ring TIC values at different depths is stillremarkable. Rise time and time to peakseem to be the most stable parameters fordepth positioning variations. For differentsizes of the region of interest a reportedmean deviation of 11 % is acceptable. Fordifferent shapes of the region of interest(circular, square, irregular) again time topeak, area under the curve and rise timeare the most stable parameters when themean deviation published is 6 %. Althoughthere is a tendency for certain parameters(time to peak, area under the curve andrise time) to be more stable than others,all parameters had good values. It could beshown that when comparing more thanone region of interest, e.g. in a tumour ver-sus representative parenchyma they mustbe compared in the same depth [Ignee A,Jedrejczyk M, Schuessler G, JakubowskiW, Dietrich CF. Quantitative contrast en-

Table 1 Parameters calculated from the time in-tensity curve and their explanation

Parameter Explanation

Area under the

curve AUC

Calculated integral for

the time intensity curve [

Maximum inten-

sity value IMAX

Highest value of the cur-

ve

Mean transit

time MTT

Time from the rising of

the intensity up to decre-

ase to 50% of maximum

intensity

Perfusion index

PI

Area under the curve divi-

ded through mean tran-

sit time

Rise time RT Time from 10% to 90% of

maximum intensity

Time to peak TTP Time from time point

zero to maximum intensi-

ty

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Ultraschall in Med 2009; 30

hanced ultrasound of the liver for time in-tensity curves-Reliability and potentialsources of errors. Eur J Radiol 2009, epubin advance]. The size of the region of in-terest (ROI) could also have influence on

the reproducibility of the time intensitycurves; theoretically a small ROI wouldshow larger variation than a large (but itcould be shown in the mentioned studythat the size of ROI does not significantly

influence results). Proximity to vesselswill also have influence. In patient studiesit is therefore very difficult to standardizethe size and the location of the ROI. q Fi-

gure 1a-c reproducibility studies duringdifferent phases of contrast enhancementillustrating the problem of surroundingvessels.

Some authors stress the use of raw data fi-les as a basic source for analysing perfusi-on kinetics. Conventional video data filesare non-linearly compressed and discreti-sised on an 8 bit base with 256 grey levels.Therefore the original data are thought tobe more accurate in the time intensitycurve analysis. Up to now the access to rawdata in commercially available ultrasoundmachines is limited. In addition, not all pa-rameters are theoretically influenced bythe compression like pure temporal para-meters like time to peak, rise time, andmean transit time. Further investigationsare necessary to define the real impact ofraw data analysis in direct comparisonwith conventional data files.

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In conclusion

Concerning the work done so far we po-stulate that multicentre studies are nee-ded in order to obtain large series of pati-ents. Before multicentre studies on strict-ly defined issues are performed the stan-dardisation of time intensity curves ana-lysis is crucial. Among the necessary to-pics of the standardisation are:

3 the manufacturer used3 the software used3 the parameters used3 the structure of the fundamental video

source - raw data or for example con-ventional data structures like DICOM

Time intensity curves analysis is a promi-sing tool with plenty of potential applica-tions. Nevertheless not much basic workhas been done so far although this is im-portant before analysing clinical questi-ons. Please feel free and be even more en-couraged to perform studies or contact usand participate on this new technology.

Cordially,

Christoph F. Dietrich,

EFSUMB Honorary Secretary

Michael Bachmann Nielsen,

Chairman EFSUMB Publications Committee

Fig.1a-c reproducibility studies during different phases of contrast enhancement illustrating the pro-

blem of surrounding vessels.

a

b

c