EFSUMB Newsletter European Federation of Societies for Ultrasound in Medicine and Biology
EFSUMB Newsletter meets Russia Professor Vladimir Mitkov
Facts on Russia 3 3 3 3
The Russian Association of Specialists in Ultrasound Diagnostic in Medicine joined EFSUMB in 1996. The current interview between the president and delegate Professor Vladimir Mitkov and the Editor of the EFSUMB Newsletter, Professor Michael Bachmann Nielsen took place in March 2009. Professor Vladimir Mitkov is the director of Diagnostic Ultrasound Department of the Russian Medical Academy for Advanced Studies. "Our department is the biggest diagnostic ultrasound training centre in Russia - annually on various courses we train about 900 doctors not only from Russia, but from former Soviet Republics also. I ended up in diagnostic ultrasound by chance. After postgraduate course in nuclear medicine I did scientific research in order to receive the philosophy doctor degree. At the end of 1983 the nuclear medicine department got an ultrasound diagnostic system. It was Autofocus II (Technicare, USA). I was the youngest doctor in the department. So since then I involved in ultrasound."
The Russian Association of Specialists in Ultrasound 5 The Association has been founded in 1991. Doctors of any specialty can be members of our Association if they perform ultrasound examinations.
Area: 17,075,400 km² Capital and largest city: Moscow Population: 142 million EFSUMB members: 266
"By our calculations about a third of the doctors performing ultrasound daily are members of our Association. Currently we have more than 4,500 members and we are growing". Nearly all members are from Russia, only about 120 from the former Soviet republics. A lot of doctors do not know English and for them the idea of being a member of EFSUMB is not so attracting, therefore the number of Russian members who are also part of EFSUMB is considerably smaller. Like in most European countries most of the doctors in Russia are state employed, but the amount of private clinics has quickly grown the last 10-12 years in Russia.
The official Russian journal 5 „We have the official journal "Ultrasound and Functional Diagnostics", published 6 volumes a year (128 pages in volume)." The journal is in Russian. In the Russian Federation live more than 180 nationalities speaking different languages. Russian language is the State language and all inhabitants of Russia may read, write and speak it. A lot of doctors in Russia do not know English. We will try to organize subscription to Ultraschall in der Medizin/Euro-
pean Journal of Ultrasound, however, I do not think that the amount of copies will be big, perhaps 100-120 copies.“
Website 5 „Unfortunately we have no newsletter now, but plan to have one in the future. The Association has a website (www.rasudm.org) on which one can find the information about the Association, Russian and international congresses, conferences, information about educational centres in diagnostic ultrasound, etc. The website is in Russian.“
Training in ultrasound in Russia 5 The Association does not have educational courses. In Russia for postgraduate education special state medical academies, institutes or faculties licensed for this kind of activity are responsible. To be certified to do ultrasound the doctor (only doctors can carry out ultrasound in Russia) must pass special training (duration from 4 months till 2 years) and exam. Further to confirm certification one must pass the exam each 5 years. Training courses, which are spent by various educational centres, have a different level of complexity and focused on doctors with different level of competence. Duration of courses varies from 10 days till 1.5 months (depends on subject). Courses programs affirm Russian Ministry of Health, and they are not based on EFSUMB guidelines. Instead of educational courses we spend the congresses, conferences and seminars in various regions of our country. Russia is divided into 8 federal districts. In each district we try to have at least one congress every two years which sums up to 3-4 congresses a year. 300-500 doctors Ultraschall in Med 2009; 30
Congress in Chelyabinsk 2008
of the region participate in the district congresses. Every four years the All-Russia congress takes place. The latest was in Moscow two years ago with more than 4,000 doctors participating.
A EUROSON in Russia - maybe 5 "Have you considered trying to host a EUROSON congress? Moscow would probably be very attractive." "Yes, we considered such an opportunity. Unfortunately an expocentre available today is surrounded only by very expensive hotels (mainly 5*). Cheaper hotels are located far from expo-
Ultraschall in Med 2009; 30
Church of the Protecting Veil of the Mother of God on Nerly
centre and difficult to reach (traffic jams in Moscow are now terrible). The new expocentre with hotel and station of the underground will be soon finished. Then we'll make an application for the organization of the congress."
WFUMB 2009 in Sydney is off to a record-breaking start. See www.wfumb2009.com A record number of 700 abstract submissions have been received prior to the closing date of 23 January 2009 and the reviewers are actively working on them. Abstracts are still open for e-posters and they continue to come in from all around the world. The Program Committee has designed a comprehensive timetable. Delegates will have the choice of 285 Presentation Lectures, 4 plenary sessions, 112 workshops and 100 proffered papers presenting a grand total of more than 500 topics on the all aspects and the very latest for ultrasound in medicine.
Visas and Early Registration 5 There have been a number of enquiries about invitation letters to participants. If you have registered for the congress as an Legend?
exhibitor, delegate or presenter and require an invitation letter for the purpose of visa travel approval process, please email firstname.lastname@example.org. The host society, ASUM, will issue a letter provided that all the required information is supplied to us for notification to the approving Australian department.
All international visitors require a valid passport and visa for entry into Australia (New Zealand visitors require a valid passport only). A facility for electronically issuing visas, The Electronic Travel Authority (ETA) system, is currently available through international travel agents and airlines in over 30 countries including the US, UK, parts of Western Europe, Singapore, Japan, Hong Kong and Taiwan. This system also includes pre-clearance for entry that reduces the time needed to process
passengers on arrival. Your local Australian Embassy or Consulate can advise of the availability. For non-ETA countries, visas are issued from Australian Embassies and Consulates around the world. In non-ETA countries, we recommend that you apply early for 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 Medicine (ASUM) "PROMOTING EXCELLENCE IN ULTRASOUND" www.asum.com.au www.wfumb2009.com
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 listen to the lectures from the international lecturers. Ultraschall in Med 2009; 30
6 An update on WFUMB 2009 World Medical Ultrasound Congress
It’s time to plan your trip ‘downunder’ There isn’t a better time to book your trip to Sydney Australia than right now with the Australian dollar being extremely good value against other major currencies. Apart from the enormous value for money your attendance will be rewarded by an exciting and successful World Congress in medical ultrasound with a unique Australian flavour. Sydney is a world-class convention destination with temperate climate and stunning scenery in a friendly and safe social structure. ASUM is dedicated to ensuring a successful scientific, educational and social congress in this modern and beautiful city. We can promise you that! The 12th World Congress in Sydney will include exciting program topics such as: advanced imaging technology, quality assurance in radiology, medico-legal issues, 3D and 4D ultrasound, echocardiography, ultrasound contrast imaging, advances in therapeutic applications, hands-on work-
Ultraschall in Med 2009; 30
shops and live-demonstration sessions, pediatric cardiology, veterinary medicine, obstetrics and gynecology, musculoskeletal and emergency medicine. Visit www.wfumb2009.com for the full program. Delegates will also have the opportunity to meet with exhibitors who will be displaying their new, innovative and technical diagnostic and therapeutic equipment, supplies and services. Come and see what is new in the world of ultrasound. For the first time participants will be able to experience and choose from almost all disciplines of hands-on workshops with Sonographers and Doctors working together with the latest in imaging technology at this world medical ultrasound congress. I am delighted with the support we are getting from industry for this extremely unique Sydney Congress. ASUM is grateful to our major sponsors Toshiba, GE Healthcare, Philips and Medison for their conti-
nuing support and we welcome Supersonic, Siemens, Zonare and Qld X-Ray as new sponsors. Exhibition space is at a premium and has already been booked by companies such as Elservier Australia, Sonosite, I-Med Network, Lantheus Medical Imaging, BK Medical and the Department of State and Regional Development. As CEO of ASUM I am pleased with the progress and predict a great World Congress. Please join me and the ASUM Council in Sydney Australia on Sunday August 30 – till Thursday September 3, 2009, for a content-rich ultrasound meeting you don't want to miss. I look forward to meeting 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 Medicine (ASUM) "PROMOTING EXCELLENCE IN ULTRASOUND" www.asum.com.au www.wfumb2009.com
Ultrasound Courses in the Near and Middle East Ultrasonography is more and more discovered as an indispensable tool in clinical medicine. This holds true for both routine and for emergency/intensive care diagnostics. Looking by means of ultrasonography into abdomen, thorax, soft tissues, and heart is basically easy, and the technical equipment is comparatively low in price and safe in application. The true needlehole in a more widespread use of the beneficial potential of ultrasonography for our patients is in many a case the lack of expertise and systematical education. The following report is based on a personal experience of some fifteen years performing courses, seminars, and congress lectures in clinical ultrasonography in the Near and Middle East, and in some parts of francophone (west-) Africa. In some 35-40 journeys, the teaching and training periods ranged between one day and one week (the latter on a periodical basis since eight years in Rabat/Morocco on behalf of the World Gastroenterology Organization WGO at the Postgraduate Training Center at the Ibn Sina University Hospital, in cooperation with Profs. Naima Amrani and Mustapha Benazzouz, gastroenterologists). Other training and teaching sites
were in Syria (Dr.Fayez Sandouk), in Egypt (Dr.Nabil Elnahas ), and in Jordan, Iran, Sudan, Cameroun, Senegal, and others. The most striking feature of these teaching events was the learning effects for the teacher himself: both in the medical and ultrasound related field, and concerning the local health care systems and additional multicultural experiences. This was, however, not the main reason to perform these activities. The rationale was and is to give and to share as much as possible expertise in clinical ultrasonography with other and preferably younger colleagues, in order to spread the fine art of ultrasonography as intensively as possible and on a high quality level. The background of an extended three decades teaching experience in the network of the EFSUMB and the German speaking national societies of ultrasonography Ă–GUM, SGUMB, and DEGUM* was really and of course helpful, especially in transferring the courses certification rules and regulations. The teaching events and training courses were usually and as far as possible embedded in the local hospital environments
with hands on training. This was especially appreciated by all participants and trainees (Fig.1), and by the patients as well. As far as possible, the idea of a complete examination of e.g. all abdominal organs was underlined, and a systematic approach to the patient including the individual history and an initial physical examination were a continuous demand. These hands on exercises - in routine and even in emergency/ambulance settings - were without exception most attractive for all participants. In addition and as a rule, half of the total teaching times was dedicated to lectures on specific topics - be it organ related normal or pathological findings, or more generalized topics as e.g. focusing on the dynamic features in realtime ultrasound, an adequate examination technique, or variants of acute abdominal pain diagnosed with ultrasonography. Video movies quickly turned out to be an optimal teaching instrument in addition to static pictures. Hands on training turned always out to be the real challenge for the teachers and course supervisors in explaining again and again details of anatomy and pathology - as a rule meeting hard working and learning young colleagues with an intensive interest in learning more about the possibilities and limits of clinical ultrasonography. A considerable number of colleagues from all countries mentioned made their way to Germany to our hospital or to friends in the sono field elsewhere to continue with an individualized training, always in combination with endoscopy and endoscopic ultrasonography (EUS). And meeting the trained colleagues again in congresses of e.g. hepatology or in the setting of the UEGW (United European Gastroenterology Week) - this is always a true pleasure. Clinical ultrasonography is an important topic and message - and its further spread on a qualified basis is worth while any personal and more organized effort. The foundation of an officially acknowledged umbrella organization is considered with the precursor of the email address below, which might friendly be used for further comments and discussion.
Ultrasound Courses in the Near and Middle East
Ultraschall in Med 2009; 30
Lucas Greiner, MD email@example.com firstname.lastname@example.org
What's new about Time Intensity Curves In daily practice contrast-enhanced ultrasound (CEUS) has proven to be helpful for detection and characterisation of liver tumours [EFSUMB-Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) - Update 2008. Ultraschall Med 2008; 29:2844], ultrasound guided biopsy, and postablative monitoring after radio frequency ablation (RFA). With the introduction of second generation ultrasound contrast agents allowing real time imaging it is possible to describe the change of brightness over time as a function of ultrasound contrast agents in- and outflow in a certain region of interest, especially when used with current software methods allowing analysing signals of blood pool ultrasound contrast agents without disturbances of underlying tissue background information. In the literature there are many topics in which time intensity curves (TIC) may add substantial information to the information gained by conventional contrast enhanced ultrasound.
Assessment of tumour response 5 It is of special interest that time intensity curves may serve as a predictor of tumor response to medical treatment, e.g., to the tyrosine kinase inhibitor Imatinib [Am J Roentgenol 2006;187:1267-1273. Ultraschall in Med 2008; 5:S276-S277]. But it is also of interest that published guidelines so far have not recognized ultrasound as a recommended imaging method in the diagnosis and follow up of gastrointestinal stroma tumours (GIST). The panelists of the 2005 published guidelines agreed that currently available imaging techniques to evaluate GIST include computed tomography (CT), magnetic resonance imaging (MRI) and fluorine-18-fluoro-deoxyglucose (FDG) positron emission tomography (PET). It is also stated that the role of ultrasound is currently under investigation and CEUS was not mentioned at all [Consensus meeting for the management of gastrointestinal stromal tumors. Report of the GIST Consensus Conference of 20-21 March 2004, under the auspices of ESMO. Ann Oncol 2005;16:566]. This might be due to a so-called subjectivity of the ultrasound examination technique ("subjectivity" is certainly also true also
for CT and MRI but this might be less obvious). Similarly, in the RECIST (Response Evaluation Criteria In Solid Tumors) criteria used in cancer trials only CT and MR are allowed, ultrasound is not (for more details on RECIST see http:// www.eortc.be/).
Assessing hypervascularity and response to antiangiogenetic drugs 5 In contrast to most published reports focussing mainly on CT and PET it could be recently shown in some patients that ultrasound can be the only imaging method depicting small hypervascularized metastases and is, therefore, also the only imaging method in the follow up. In addition the early functional evaluation to optimize therapeutical strategies is a main goal of tumour evaluation using antiangiogenetic treatment. Treatment response can be predicted analyzing the vascularization before any volume reduction can be observed using the RECIST-criteria. CEUS might also be the only method identifying small lesions before and after treatment in patients with no evidence of metastases using CT, MRI and PET [Ultraschall in Med 2008; 29: S276-S277]. In an experimental animal study changes in vascularity could be detected within the first 24 hours after administration of an antiangiogenetic drug [Lavisse et al. Invest Radiol 2008; 43: 100-111]. Recognizing these patterns on CEUS in tumor response evaluation is important, since often, response in tumor size, particularly of the hepatic metastasis, is not apparent until late in therapy. The analysis of time intensity curves is, therefore, a promising method to overcome the subjectivity of contrast enhanced ultrasound. Several of the parameters in time intensity curves correspond statistically with microvessel density, especially the area under the curve [Du et al, J Ultrasound Med 2008; 27: 821-31].
Parameters used in Time Intensity Curves 5 TIC-parameters used are summarised in q Table 1.
Table 1 Parameters calculated from the time intensity curve and their explanation Parameter
Area under the
Calculated integral for
the time intensity curve [
Highest value of the cur-
sity value IMAX
Time from the rising of
the intensity up to decrease to 50% of maximum intensity
Area under the curve divi-
ded through mean transit time
Rise time RT
Time from 10% to 90% of maximum intensity
Time to peak TTP
Time from time point zero to maximum intensity
Reproducibility 5 When a new technique is applied to clinical indications and questions, basic research has to be performed including the validity of the parameters analysed (intraobserver stability, stability against external factors, reproducibility) and the comparability of different software sources used. Very few studies on the subject are available. The area under the curve may be less reproducible than other measurements; inter- and intra-observer variation of 2030 % have been observed (Grossjohann HS, unpublished observations). So far the amount of deviation for measuring TIC values at different depths is still remarkable. Rise time and time to peak seem to be the most stable parameters for depth positioning variations. For different sizes of the region of interest a reported mean deviation of 11 % is acceptable. For different shapes of the region of interest (circular, square, irregular) again time to peak, area under the curve and rise time are the most stable parameters when the mean deviation published is 6 %. Although there is a tendency for certain parameters (time to peak, area under the curve and rise time) to be more stable than others, all parameters had good values. It could be shown that when comparing more than one region of interest, e.g. in a tumour versus representative parenchyma they must be compared in the same depth [Ignee A, Jedrejczyk M, Schuessler G, Jakubowski W, Dietrich CF. Quantitative contrast enUltraschall in Med 2009; 30
influence results). Proximity to vessels will also have influence. In patient studies it is therefore very difficult to standardize the size and the location of the ROI. q Figure 1a-c reproducibility studies during different phases of contrast enhancement illustrating the problem of surrounding vessels. Some authors stress the use of raw data files as a basic source for analysing perfusion kinetics. Conventional video data files are non-linearly compressed and discretisised on an 8 bit base with 256 grey levels. Therefore the original data are thought to be more accurate in the time intensity curve analysis. Up to now the access to raw data in commercially available ultrasound machines is limited. In addition, not all parameters are theoretically influenced by the compression like pure temporal parameters like time to peak, rise time, and mean transit time. Further investigations are necessary to define the real impact of raw data analysis in direct comparison with conventional data files.
In conclusion 5 Concerning the work done so far we postulate that multicentre studies are needed in order to obtain large series of patients. Before multicentre studies on strictly defined issues are performed the standardisation of time intensity curves analysis is crucial. Among the necessary topics of the standardisation are:
3 3 3 3
Fig.1a-c reproducibility studies during different phases of contrast enhancement illustrating the problem of surrounding vessels.
hanced ultrasound of the liver for time intensity curves-Reliability and potential sources of errors. Eur J Radiol 2009, epub in advance]. The size of the region of interest (ROI) could also have influence on Ultraschall in Med 2009; 30
the reproducibility of the time intensity curves; theoretically a small ROI would show larger variation than a large (but it could be shown in the mentioned study that the size of ROI does not significantly
the manufacturer used the software used the parameters used the structure of the fundamental video source - raw data or for example conventional data structures like DICOM
Time intensity curves analysis is a promising tool with plenty of potential applications. Nevertheless not much basic work has been done so far although this is important before analysing clinical questions. Please feel free and be even more encouraged to perform studies or contact us and participate on this new technology. Cordially, Christoph F. Dietrich, EFSUMB Honorary Secretary Michael Bachmann Nielsen, Chairman EFSUMB Publications Committee