2010-issue01 by EFSUMB

EFSUMB Newsletter

EFSUMB Newsletter European Federation of Societies for Ultrasound in Medicine and Biology

Contents

Editorial Michael Bachmann Nielsen

2009 was a busy year for EFSUMB. You can read about it all in this issue of the Newsletter where you will find the reports from the officers and committees. New members of the Executive Bureau and the Committees were elected in December; you will find a list of the current officers on one of the following pages. 2009 was also the year we were proud to welcome the membership country number 30 into the EFSUMB family. Welcome to Lithuania. We had a successful EUROSON congress in Edinburgh in December, and I know all in

EFSUMB are grateful to our friends in BMUS for all the hard work put into making the congress such a fantastic event. The next EUROSON congress will be in Copenhagen in August 2010. We have chosen a charming and atypical location for the conference, the School of Architecture of the Royal Academy of Fine Arts, in the center of the city. You will really enjoy this. The website www.euroson2010.org is up and running and you can find all the information there. Some of the information is also given in this issue of the Newsletter. I look forward to welcome all of you to my hometown – Wonderful Copenhagen – in August. Michael Bachmann Nielsen Chairman EFSUMB’s Publications Committee Editor EFSUMB Newsletter

Editorial

Welcome to Lithuania

President’s column

EFSUMB Calendar

Report of the President of EFSUMB to the Board of Directors’ Meeting

Report of the Honorary Secretary to the Board of Directors’ Meeting

Report of the Honorary Treasurer to the Board of Directors’ Meeting

Chairman of ECMUS to the Board of Directors’ Meeting

Report of the Chairman of EPSC to the Board of Directors’ Meeting

Report of the Chairman of Publications Committtee to the Board of Directors’ Meeting

Report on Ultraschall in der Medizin/ European Journal of Ultrasound (UiM/EJU)

Welcome to Lithuania

The International School of Clinical Ultrasonography Flying Faculty

During the Board of Directors’ meeting in Edinburgh in December 2009 Dr Algirdas Tamosinas presented the application from The Ultrasound Association of Lithuania for membership of EFSUMB. It was unanimously accepted and Lithuania was welcomed as a member of EFSUMB. The Ultrasound Society currently has 51 members.

Learning, Training, and Teaching Ultrasonography – Problems and

Dr Algirdas Tamosinas (left) and Professor Michael Bachmann Nielsen, December 2009.

Perspectives

Perineal ultrasound

Euroson 2010

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EFSUMB Newsletter

President’s column Dear friends, colleagues and members of EFSUMB, Two years ago when I was nominated for the President-elect position I felt deeply honoured and accepted with tremendous pleasure and almost zero worries. The closer we got to the “Presidential take over” at EUROSON in Edinburgh, however, the more the ratio between the two – i.e. pleasure and worries – shifted and thus it was with a little bit of shakiness of the hand that I accepted the president’s medal during the opening ceremony. To tell you the truth my deepest concern throughout the last year was that I knew our wonderful, hard-working but still always smiling and high spirited “Jack of all trades” General Secretary Gianna would retire during this congress – with no one to replace her, and poor little me acting as new President. Then luckily, a few months ago, “Around came Lynne”, a barrister by education, with a bag full of all the skills we needed, plus a whole lot more and in addition a smiling and winning attitude. Well, then suddenly my gut feelings for this endeavour is much, much better and I think I am back where I started out: lots of pleasure expected and very few worries. I know the job does not do it by itself and I promise you all, that I will work hard and do my utmost to fulfil my duties to the very best for EFSUMB as an educational and scientific society and for each of you as individual members. I take this opportunity to thank our Past General Secretary Gianna Stanford for all her efforts and hard work to facilitate and make possible the many functions of our society and its different committees, since she took up her important position back in 1996. Gianna, you have been the very heart of EFSUMB for 13 years and we wish you a happy retirement. You really deserve it. Founded back in 1972 EFSUMB now is only 38 years old, and despite a generally excellent and healthy condition we have faced the need for a heart transplantation: Lynne Rudd allow me to welcome you in

Ultraschall in Med 2010; 31

our midst as the new General Secretary. You are the only person in the EFSUMB organisation with the potential of providing continuity. The rest of us come and go. Your position is extremely important to the life of EFSUMB and our expectations of you are high. Despite this, working with you for 3 months now, I dare say, you exceed them by far and I wish you and EFSUMB a prosperous future together. 2009 has been an extremely turbulent year. Big companies and banks have collapsed around the globe and some countries have been, or are, on the verge of bankruptcy. The world economy, as we know it, is at stake. In this very unfortunate scenario, EFSUMB, as you can read in the Honorary Treasurers report elsewhere in this newsletter, is happy to be in a strong financial position. EFSUMB has no interest in accumulating money. According to our constitution we are put in this world to promote the exchange of scientific knowledge in the field of medical ultrasound. This is one of the major objectives of EFSUMB. Our aim is to build an educational portal on the web for the use of ultrasound in medicine and biology. It is therefore a great pleasure that our beneficial financial situation gives us the economic power to invest time and money in providing free education not only to our numerous members, but actually to anybody who has internet access. I wish to direct a sincere thank to all members of the EFSUMB Executive Bureau (ExB) and our three committees: Education and Professional Standards Committee (EPSC), Publications Committee and European Committee of Medical Ultrasound Safety (ECMUS) for all the hours and hard work each of you has put in throughout this last term. Particularly the joint efforts to establish a strong educational database is noteworthy and must be emphasized in the future. Throughout the last two terms I have had the pleasure of serving on the EPSC. During my first term with David Linsell as chairman I saw the list of guidelines and

recommendations grow towards its present stage where it covers most major ultrasound subspecialties. As a consequence of this, during the chairmanship of Odd Helge Gilja, the focus this past year has changed towards the creation of an ultrasound educational web portal and also to strengthening the EUROSON School concept. Thus, 2009 saw a total of six EUROSON Schools three of which were part of a newly established series of CEUS post graduate courses facilitated by BRACCO sponsorship. The success continues as several courses are scheduled for next year. This has been paralleled by the Publications Committee initiative of developing a web-based EFSUMB Course Book (ECB) to provide educational material for EUROSON Schools. As you read this the ECB will be under way with Christoph Dietrich as editor. ECMUS has its own Micro Site with tons of information about safety of medical ultrasound and the literature thereof. The Micro Site is accessed from the main EFSUMB page, and it is continuously updated. Please, click your way to the world of ultrasound safety and educate yourself on this important issue. I intend to make it my major goal for the coming term to support the efforts of creating a superb educational portal and focus on expanding the material found on our homepage. Our aim is to have a free accessible database with educational multimedia materials of all kinds. Guidelines, tutorial articles, picture gallery, case reports, “State-of-the-art” presentations, “how-to-do-it-videos” etc should be available on all major topics in medical ultrasound. Some of it you can already find at our website www.efsumb.org. A lot of it needs to be implemented. If you have not yet tried it, I urge you to have a look for yourself at what is already there. On the front page you will find 2 of the most popular hits of our web site. The flash presentations from the “EUROSON School – Contrast Enhanced Ultrasound in Liver, Biliary, Pancreatic and Gastrointestinal Disease” in Bologna, September 2009 with Fabio Piscaglia and Luigi Bolondi as course directors and “Case of the Month” most of which up until now has been provided by Christoph Dietrich. We hope for the future that you, the members of EFSUMB, will be so kind and share your exciting cases with the rest of us. We

EFSUMB Newsletter strongly encourage you to do so by contacting EFSUMB Newsletter Editor, Michael Bachmann Nielsen. Building a European ultrasound community is the EFSUMB motto, and we are right at it. During EUROSON 2009 in Edinburgh the Board of Directors voted for accepting Lithuania as a new member. This brings our numbers to 30 member societies and a total of 19,527 individual members. Allow me to express a warm welcome to the Ultrasound Society of Lithuania and its 51 members. You are now a part of the world’s largest ultrasound society. If you go to the web site and click on the left side, number 2 down, menu point “Membership” you can read what advantages this includes for you as a society as well as individual members. Among other things, each year you will receive the first issue of EFSUMB official journal “Ultraschall in der Medizin/European Journal of Ultrasound” (UiM/EJU). This is the world’s highest-ranking interdisciplinary ultrasound journal with an Impact Factor of 2.394. Eleven of the 30 EFSUMB member societies have signed up to bulk subscription at a greatly reduced price, making UiM/EJU the official national journal of these societies and delivering the journal to the front door of each individual member 6 times annually. I strongly suggest the Ultrasound Society of Lithuania, along with the other nonbulk-subscribing societies, consider joining this advantageous arrangement.

Allow me to take this opportunity to thank my immediate predecessors in the President position for all their efforts to promote EFSUMB. Norbert Gritzmann is now serving on the ExB as Past-President and I am looking forward to our continued collaboration. David H Evans as the previous Past-President has left the ExB. David is now Honorary Secretary to WFUMB and I am sure he will do an equally excellent job there as he did in EFSUMB. It has been a great pleasure working with both of you, and I think back to many memorable situations and fun hours in between all the hard work. I especially remember my first ExB meeting. It took place in Salzburg on January 5th 2008 – my birthday! At this point you may think I found the meeting per se so interesting I can’t get it out of my head. Sorry to disappoint you, not so. This, however, was my first physical encounter with one of my professional heroes Christian Andreas Doppler. I met him at the Salzburg Science Museum. He was all stoned, as you can see from the picture.

EFSUMB Officers and Committees

Finally, I wish to congratulate BMUS and President Julie Walton for a highly professional and well organised EUROSON 2009. On behalf of EFSUMB please accept our sincere thanks to you and your staff at BMUS and all the persons in your organisation for all the efforts and hard work you all put into making this project a memorable and successful event.

Chairman: O H Gilja (Norway) Secretary: H Strunk(Germany) Members: G Mathis (Austria) J Tuma (Switzerland) J Walton (UK) Co-opted: B Brkljačić (Croatia) Co-opted: F Drudi (Italy) Co-opted: CF Dietrich (Germany) Ex-officio: F Piscaglia (Italy)

Next stop is Wonderful Copenhagen, August 22–25. Please, mark your calendars. Come see us at www.euroson2010.org. Let me know if you have visions for EFSUMB. Christian Pállson Nolsøe EFSUMB President Email: cnolsoe@dadlnet.dk

Executive Bureau 2009–2011

President: C Nolsøe (Denmark) President Elect: Fabio Piscaglia (Italy) Past-President: N Gritzmann (Austria) Honorary Secretary: C F Dietrich (Germany) Honorary Treasurer: I Sporea (Romania)

ECMUS – European Committee for Medical Ultrasound Safety Chairman: G ter Haar(UK) Members: M Delius (Germany) L Doležal (Czech Republic) C Kollmann (Austria) K Salvesen (Norway) L Valentin (Sweden)

Education And Professional Standards Committee

Publications Committee

Chairman: M Bachmann Nielsen (Denmark) Members: L Greiner (Germany) J Y Meuwly (Switzerland) Torben Lorentzen (Denmark) Co-opted: Paul Sidhu (UK) Co-opted: Adrian Saftoiu (Romania) Ex officio: CF Dietrich (Germany)

EFSUMB Newsletter

Editor: M Bachmann Nielsen (Denmark)

Secretariat

Doppler’s effect on EFSUMB’s new President

Mrs Lynne Rudd, EFSUMB General Secretary 36 Portland Place, London W1B 1LS, U K Email: efsumb@efsumb.org Website: www.efsumb.org

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EFSUMB Newsletter

EFSUMB Calendar EUROSONS and EUROSON Schools

Committee Meetings in 2010

▶▶22–25 August 2010–EUROSON Congress in Copenhagen, Denmark ▶▶19–23 April 2010 Abdominal Ultrasound in Tropical Medicine and Infectious Diseases Pavia, Italy ▶▶21 May 2010 Musculoskeletal Ultrasonography Sibiu, Romania ▶▶27–30 May 2010 Interventional Sonography Berlin, Germany ▶▶7–19 June 2010 Abdominal Ultrasound Focus on CEUS and EUS Bergen, Norway ▶▶24–26 June 2010 Ultrasound in Gastroenterology and Oncology Sigmaringen,Germany ▶▶29 September–2 October 2010 CEUS Lille, France ▶▶11–13 November 2010 A CEUS and Doppler Ultrasound Course Kosice, Slovakia ▶▶November 2010 CEUS School Hannover, Germany

▶▶23 April 2010 Publication Committee Meeting in Copenhagen ▶▶22–25 August 2010 Publication Committee Meeting at EUROSON in Copenhagen ▶▶24 April 2010 ExB Meeting in Copenhagen ▶▶21 August 2010 ExB Meeting at EUROSON in Copenhagen ▶▶25 April 2010 EPSC Committee Meeting in Copenhagen ▶▶22–25 August 2010 EPSC Committee Meeting at EUROSON in Copenhagen ▶▶22–25 August 2010 ECMUS Committee Meeting at EUROSON in Copenhagen ▶▶10 October 2010 ECMUS Committee Meeting in Prague

5 December 2009 – EDINBURGH –UK

Report of The President of EFSUMB to the Board of Directors’ Meeting Prof Norbert Gritzmann EFSUMB President 2007–2009

The membership of EFSUMB increases steadily and will soon reach 20.000 members, making EFSUMB one of the biggest interdisciplinary medical societies. Also our financial situation allows us to support further educational activities. One major aim is to concentrate on the individual benefits of being an EFSUMB member. We have created a leaflet that summarizes the individual benefits of being an EFSUMB member and each participant of EUROSON 2009 will receive this.

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In May EUROSON 2008 was held in Timisoara in the western part of Romania. With a total number of more than 2000 participants this congress which was held in conjunction with the meeting of the Romanian Ultrasound society was a tremendous success. Ioan Sporea and his team really organised a remarkable event. I want to thank him and all of his team for doing such a great and successful job. We all were impressed be the generous hospitality of the Romanian organisers. Both the Romanian ultrasound society and EFSUMB have supported young authors. To encourage young scientists to present innovative papers the congress fee was waived for all accepted first authors below 35years. As we know Ultrasound Congresses are going to have a more educational background. At the same time new science will be presented especially dealing with contrast agents. In this area ultrasound gets a giant boost.

Another big success is our scientific journal European Journal Ultrasound /Ultraschall in der Medizin. Due to the efforts of the Editors, the Review Board and especially of the publishing scientists, the impact factor of the journal continues to rise and is now 2.394, the highest number for a multidisciplinary ultrasound journal. I really hope that we can continue with this success and EFSUMB will support the journal whenever possible. Another major event was the presentation of the new version of the guidelines for contrast enhanced sonography in the first issue of UiM/EJU by the EFSUMB study group for USCA. It was decided to re-evaluate the guidelines at least every three years. President Elect Christian Nolsøe will steer this group. The style of the newsletter and the homepage of EFSUMB have changed and a case of the month was introduced in the EFSUMB website. This has been often visited by our members. Michael Bachmann Nielsen of Denmark takes care of this important publication and communication medium. Michael also chairs the Publication Committee. A case of the month has been introduced; this publication is frequently visited on our homepage. Prof. Christoph F Dietrich edits the case of the month on our website. One important goal will be to optimise the communication with our members, so the National Societies are asked to provide email addresses of all their members. Up to now we have about 6000 email addresses; I do hope that this number can be increased within the next year. EFSUMB offers a membership certificate to all the member of the National Societies each year. On demand each national society can obtain a bulk supply of personalised certificates for all their members. We have produced a EFSUMB folder in which all important facts, history, congresses meetings and publications have been summarised. This folder can be downloaded from our homepage. EFSUMB introduced a new series of EUROSON Schools regarding contrast enhanced ultrasound. H.P. Weskott organised two courses of this series in Hannover. These highly specialised educational courses proved to be a big success with more than 80 participants per course. This new type of courses is supported by BRACCO. For 2010 a new contract with BRACCO has been signed. The Education and Professional Standards Committee was very active last year so that guidelines and recommendations for

EFSUMB Newsletter education in nearly all areas of ultrasound have been published. These guidelines are often the basis for the national guidelines of the member societies. EFSUMB is going to publish a European Ultrasound Course Book. Prof Dietrich will be the editor of this publication. The continuous work of the safety committee (ECMUS) reviewing the literature regarding safety aspects of ultrasound is of significant importance to all of us to enable us to practice this technique safely. However, since new techniques like contrast techniques are spreading into daily routine, we have to be even more alert to potential side effects. The Committee has recommended that Doppler ultrasound examinations should not be used routinely in the first trimester of pregnancy. EUROSON 2009 is held in conjunction with the British Medical Ultrasound Society in Edinburgh from 6 -8 of December 2009. I am convinced that we have organised an interesting congress with educational and scientific highlights. Again EFSUMB wants to support young scientists to present their papers by reducing or waiving their Congress fee and by holding the Young Investigator’s Award at the EUROSON congress. I do hope that this congress will be well attended and will continue to be one in a successful line of EUROSON congresses. Another important task is the replacement of our General Secretary Gianna Stanford. She will retire after the Edinburgh congress. It is well known that Gianna did an excellent job over thirteen years and she did much more for our society that could be expected. Thank you Gianna for all yours efforts you provided for our Society. We have found a new General Secretary Lynne Rudd and we welcome her on board of the EFSUMB ship. To ensure a smooth hand over Gianna and Lynne have been working together since September 2009. In Edinburgh a new Executive Bureau and new committee members will be elected.

5 December 2009 – Edinburgh – UK

Report of the Honorary Secretary to the Board of Directors’ Meeting Christoph F Dietrich

The task of the Honorary Secretary was challenging in the last period especially to keep in touch with the member national societies which is sometimes not so easy. It is exciting being a member of the Executive Bureau and to work together with the Board of Directors, and the various EFSUMB committees (being also a member of the Publication Committee), and most importantly with individual members of the national societies with the consequence of interesting discussions. In these days, retiring after the Edinburgh congress, another challenge is the replacement of our General Secretary Gianna Stanford. I wish to thank you, dear Gianna, for all your excellent work, daily support and perfect good relationship. I am happy to announce that Lynne Rudd has joined EFSUMB as the new general secretary, cordially welcome, dear Lynne. The good relationship to the industry was also strengthened as important partners for improved patients care and innovative technology.

Membership Status

Some national societies develop better than others with respect to their number of individual members, their scientific and educational activities and their representation within EFSUMB. The oral report in Edinburgh will comment on few points regarding the Membership Status 2009, ▶▶ Membership evolution in Belgium May 2009. ▶▶ Difficulties to contact respective members (including membership payment). ▶▶ Decline in Russian members.

Kind requests for the membership societies

On behalf the Executive Bureau, we kindly ask (again and again) all members and especially the secretaries of each national society to provide us with email addresses of active members. Finally, a society but also a federation is as much alive as its members – so please do not hesitate to get in touch with us (www.efsumb.org). ▶▶ Each membership society is kindly asked to supply the email addresses of their members to the EFSUMB bureau for improved communication regarding EFSUMB activities. ▶▶ Each membership society is kindly asked to updating the EFSUMB website with their Society’s Board changes and photographs.

Website statistical data

EFSUMB Monthly Statistical Data for 5 October to 5 November 2009 Top 10 Page Hits

Top 10 Countries Geographical data

Search Engine Referrals

Top 10 Keywords used for Search

EFSUMB Home Page

24,701

United Kingdom

26%

Google

efsumb

Building up a European Ultrasound Community is a very important task for all of us and we try to do our best in promoting science and education in ultrasound.

Latest News Items

12,456

Italy

22%

Yahoo

ultrasound

EFSUMB Guidelines

8,293

Germany

12%

Yandex

European

Latest Newsletters

7,119

France

11%

AOL Netfind

euroson

EUROSON Schools

4,899

Romania

Virgilio.it

medicine

Best regards Norbert Gritzmann EFSUMB President

Case of the Month

2,247

Spain

Compuserve

guidelines

EUROSON School Main Page

1923

Denmark

5 %

Ask Jeeves

congress

CEUS Recommendations

894

Sweden

4 %

AltaVista

federation

Future

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EFSUMB Newsletter Top 10 Page Hits

Top 10 Countries Geographical data

Search Engine Referrals

Top 10 Keywords used for Search

Member Societies List

562

Netherlands

3 %

MSN

Us scan

Bylaws

323

Norway

2 %

Others

Anomaly scan

Clinical Safety Statements

503

Clinical Safety Statement For Diagnostic Ultrasound (2008)

312

Souvenir Scanning (2006)

Tutorial Papers

117

Identity of EFSUMB, European Course book (ECB)

On February 11, 1972, the delegates of 13 European societies met in Basel (Switzerland) for the formal foundation of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). The Federation‘s purpose shall be to promote the exchange of scientific knowledge and development in the medical and biological professions as applied to ultrasound. The Federation shall propose standards and give advice concerning criteria for the optimum apparatus and techniques, and concerning presentation and interpretation of results. This aim is to be served by arrangement of congresses and study and development meetings on an international level, as well as the exchange of information both in and outside Europe by the member organisations. EFSUMB has strengthened the interdisciplinary collaboration in the field of diagnostic ultrasound and for safety of ultrasound in medical use. The EFSUMB has also proposed minimal training requirements for the practice of medical ultrasound in Europe (www.efsumb.org). These identify three levels of training and expertise. The boundaries between the three levels are difficult to define precisely and should be regarded as a guide to different levels of competence and experience. There is a demand to incorporate ultrasound experience into clinical courses and accreditation. It is of interest that up to now no EFSUMB dedicated Course Book (ECB) has been considered and published so far.

Intention of the book

The planned EFSUMB Course Book (ECB) is intended to supplement and complete the educational purposes of EFSUMB. The ECB might, therefore, strengthen the evolution and power of EFSUMB and to improve the identity of its members. The

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(http://www.efsumb.org/). This site has approximately 10,000 visitors’ hits on a regular basis. This is an opportunity to discuss interesting cases on a well known platform. Please participate actively and submit your cases of the month to efsumb@efsumb.org. The Instructions for Authors have been recently published in the EFSUMB Newsletter.

Identity of EFSUMB, Scientific Corner course book is devoted to the interdisciplinary approach of the multinational societies of EFSUMB. The book might be especially helpful for countries which have not created so far their own course system. The ECB will incorporate the minimum training recommendations for the practice of medical ultrasound published by EFSUMB. The book will be published on the website in close collaboration with the EFSUMB Publication and Education Committees whereas the European Committee for Medical Ultrasound Safety (ECMUS) has published recommendations so far. If you might be a possible contributor a few ECB-details are added below. Test chapter A Test chapter presenting the format and headings is prepared and could be sent to the interested contributor. Chapter planning All chapters should be written by three authors. All three authors should be from different European countries (exceptions might be discussed with the Editor and by Editors decision). The first author is the corresponding (responsible) author. Every chapter should be peer reviewed by at least two referees. Since this is a web publication there is no strict limitation of the respective chapters. Videos Up to 10 videos (10 seconds) will be integrated into each chapter. Responsible Editor and corresponding address Prof. Dr. med. Christoph F. Dietrich, EFSUMB Honorary Secretary Caritaskrankenhaus Bad Mergentheim, Medizinische Klinik 2, Uhlandstr. 7, D-97980 Bad Mergentheim, Telefon: +49(0)7931/58 2201, Fax: +49(0)7931/582290 E-Mail: christoph.dietrich@ckbm.de

Case of the month

In March 2008 we initiated the “Monthly case reports” which is actually displayed on the EFSUMB website including videos

The scientific ultrasound community is challenged to perform more multicenter and interdisciplinary studies in the upcoming years to increase the influence of ultrasound techniques in daily practice. In that regard it is of interest that “our” (EFSUMB) scientific journal Ultraschall in der Medizin/European Journal of Ultrasound has been dramatically improving over the last years. Additionally the successful CEUS-guidelines have been published early this year as well. For the scientist it might be also of interest to find a forum where to ask colleagues about rare and interesting case reports which might be published together by EFSUMB members of the different European countries. We have to prove all together that ultrasound is effective and also cost effective, including the emergency room and other access routes to the hospital, in the out patients care setting and under many other circumstances.

Honorary Secretary’s Agenda for discussion

▶▶The proposition that membership of EFSUMB be open to more than one Society from one country ▶▶Raise for discussion biannual EUROSON Congress alternating with WFUMB Please refer to EFSUMB and the Honorary Secretary for support and discussion. The future looks bright. Cordially, Christoph F. Dietrich EFSUMB Honorary Secretary

EFSUMB Newsletter 5 December 2009 – Edinburgh – UK

Report of the Honorary Treasurer to the Board of Directors’ Meeting Prof Ioan Sporea EFSUMB Honorary Treasurer

In my position of Honorary Treasurer, I would like to inform you on the finalized financial balance of 2008 (which ended on the 31th of December 2008), that proved to be positive, as well as in the last few years. We are happy to have a positive balan-

ce during the current difficult worldwide economical situation. A part of this positive balance is due to the fact that the Euro’s value increased as compared to the English Pound. On the other hand, the profit from EUROSON 2008 from Timisoara was larger than expected. Concerning the balance of 2009, the final report will be finalized in the near future and will be published in the Newsletter (the accounting year ends on the 31st of December 2009). But the preliminary data shows that we are in budget. Considering the structure of the past recent budgets and the budget of 2009, we can see that the most important financial support originates in the membership fees, and I believe that it is very important

to try to maintain, even to increase the number of EFSUMB members. In 2009, the EUROSON membership fee of 8 Euros was paid by more than 19,000 members (more than last year). Future policies of EFSUMB must have as a main purpose to keep or maybe to increase the number of members (maybe by reaching 20,000 in the next future). As a conclusion of the financial balance of the last years, I must inform you that EFSUMB has a healthy financial status. Regarding the budget of 2010, we will try to build one in which the income will be at the same level with the costs, to keep EFSUMB running. More precise information about the accounted budget and on the budget of 2010 can be found on the EFSUMB website, www.efsumb.org. Ioan Sporea, EFSUMB Honorary Treasurer

5 December 2009 – Edinburgh – UK

Chairman of ECMUS to the Board of Directors’ Meeting Prof Gail ter Haar ECMUS Committee Chairman

1. Rationale for the addition of a sentence about the use of first trimester Doppler to the EFSUMB safety statement. ▼▼

The ECMUS safety statement feels that pulsed Doppler ultrasound should only be used in the first trimester when exposure levels and times are carefully controlled (see yellow highlight in statement below). The introduction of the 11–13+6 weeks scan to screen for fetal chromosomal anomalies has challenged this safety statement. Pulsed Doppler of the fetal tricuspid valves, and in the ductus venosus, can be used to refine risk assessment for Down’s syndrome and other trisomies. This practice may be of benefit to the fetus if

the use of pulsed Doppler will reduce the need for invasive testing, and, thus, reduce the risk of procedure related spontaneous abortions. However, it must be remembered that high mechanical and thermal indices are associated with pulsed Doppler, and thermal effects at bone/soft tissue interfaces of high exposure levels cannot be excluded. While this may present an acceptable risk if Doppler is used after serum screening and/or measurements of nuchal translucency have revealed a high risk, we consider it unacceptable for pulsed Doppler to be used routinely in all pregnancies, or for extended times in normal pregnancies for the purpose of training, qualifying for accreditation, or where there is no perceived medical benefit for the fetus. If Doppler were to have an adverse fetal effect, we could hypothesize that it would be most likely to be caused at early gestation where there is most rapid cell division, and where the fetal blood flow is less well developed than later and hence less likely to dissipate heat induced by Doppler examinations. Further, these examinations are at the level of the ductus venosus or fetal heart very close to a forming bone (i.e. spine)/soft tissue interface

where a heating effect would be greatest. The main reasons for advocating restricted use of routine Doppler ultrasound in early gestation is that we don’t know whether Doppler ultrasound is safe, that the first trimester is a particularly vulnerable period of fetal life, and no medical benefit to such routine examinations has been demonstrated.

European Committee of Medical Ultrasound Safety (ECMUS)

This document is the 2006 revision of the EFSUMB Clinically Safety Statement. A Safety Statement has been published by EFSUMB annually since 1994. The text is deliberately brief, and gives a concise overview of safety in the use of diagnostic ultrasound. The 2008 Statement is the fifth revision of the Statement, the previous revisions being those published in 1998, 2002, 2003 and 2006.

Clinical Safety Statement for Diagnostic Ultrasound

Diagnostic ultrasound has been widely used in clinical medicine for many years

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EFSUMB Newsletter with no proven deleterious effects. However, if used imprudently, diagnostic ultrasound is capable of producing harmful effects. The range of clinical applications is becoming wider, the number of patients undergoing ultrasound examinations is increasing and new techniques with higher acoustic output levels are being introduced. It is therefore essential to maintain vigilance to ensure the continued safe use of ultrasound. Ultrasound examinations should only be performed by competent personnel who are trained and updated in safety matters. It is also important that ultrasound devices are appropriately maintained. Ultrasound produces heating, pressure changes and mechanical disturbances in tissue. Diagnostic levels of ultrasound can produce temperature rises that are hazardous to sensitive organs and the embryo/ fetus. Biological effects of non-thermal origin have been reported in animals but, to date, no such effects have been demonstrated in humans, except when a microbubble contrast agent is present. The Thermal index (TI) is an on-screen guide to the user of the potential for tissue heating. The Mechanical index (MI) is an on-screen guide of the likelihood and magnitude of nonthermal effects. Users should regularly check both indices while scanning and should adjust the machine controls to keep them as low as reasonably achievable (ALARA principle) without compromising the diagnostic value of the examination. Where low values cannot be achieved, examination times should kept as short as possible. Guidelines issued by several ultrasound societies are available. Some modes are more likely than others to produce significant acoustic outputs and, when using these modes, particular care should be taken to regularly check the TI and MI indices. Spectral pulse wave Doppler and Doppler imaging modes (colour flow imaging and power Doppler imaging) in particular can produce more tissue heating and hence higher TI values, as can B-mode techniques involving coded transmissions. Tissue harmonic imaging mode can sometimes involve higher MI values. 3D (three dimensional) imaging does not introduce any additional safety considerations, particularly if there are significant pauses during scanning to study or manipulate the reconstructed images. However, 4D scanning (real-time 3D) in-

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volves continuous exposure and users should guard against the temptation to prolong examination times unduly in an effort to improve the recorded image sequence beyond that which is necessary for diagnostic purposes.

Ultrasound exposure during pregnancy

The embryo/fetus in early pregnancy is known to be particularly sensitive. In view of this and the fact that there is very little information currently available regarding possible subtle biological effects of diagnostic levels of ultrasound on the developing human embryo or fetus, care should be taken to limit the exposure time and the Thermal and Mechanical Indices to the minimum commensurate with an acceptable clinical assessment. Temperature rises are likely to be greatest at bone surfaces and adjacent soft tissues. With increasing mineralisation of fetal bones, the possibility of heating sensitive tissues such as brain and spinal cord increases. Extra vigilance is advised when scanning such critical fetal structures, at any stage in pregnancy. Based on scientific evidence of ultrasound-induced biological effects to date, there is no reason to withhold diagnostic scanning during pregnancy, provided it is medically indicated and is used prudently by fully trained operators. This includes routine scanning of pregnant women. However, Doppler ultrasound examinations should not be used routinely in the first trimester of pregnancy. The power levels used for fetal heart rate monitoring (cardiotocography – CTG) are sufficiently low that the use of this modality is not contra-indicated on safety grounds, even when it is to be used for extended periods.

Safety considerations for other sensitive organs

Particular care should be taken to reduce the risk of thermal and non-thermal effects during investigations of the eye and when carrying out neonatal cardiac and cranial investigations.

Ultrasound contrast agents (UCA)

These usually take the form of stable gas filled microbubbles, which can potentially produce cavitation or microstreaming, the risk of which increases with MI value. Data from small animal models suggest

that microvascular damage or rupture is possible. Caution should be considered for the use of UCA in tissues where damage to microvasculature could have serious clinical implications, such as in the brain, the eye, and the neonate. As in all diagnostic ultrasound procedures, the MI and TI values should be continually checked and kept as low as possible. It is possible to induce premature ventricular contractions in contrast enhanced echocardiography when using high MI and end–systolic triggering. Users should take appropriate precautions in these circumstances and avoid cardiac examinations in patients with recent acute coronary syndrome or clinically unstable ischaemic heart disease. The use of contrast agents should be avoided 24 hours prior to extra-corporeal shock wave therapy.

ECMUS 2009. 2. 2nd Edition of Safety of Medical Ultrasound

BMUS and BIR (British Institute of Radiology) published the 1st edition of this book in 2000. This was sent free of charge to all BMUS members, and has become a well referenced text. It is now necessary to update this volume as safety issues have moved on. BMUS needs some sponsorship to be able to publish a 2nd edition. EFSUMB will make a contribution to the typesetting cost to have the book published on our website. The printing element assumed that we would distribute the book to all BMUS members and EUROSON 2010 delegates. If fewer copies are required then the cost could be significantly reduced. Clearly if it were web based this would disappear completely. The National Physical Laboratories in UK have agreed to provide some sponsorship. This might be used to print the hard copy, while EFSUMB could perhaps prepare a web based version.

3. Ongoing ECMUS activities ▼▼

ECMUS has met recently in Timisoara and Vienna in 2008 and in La Cadiere (France) in 2009. The next meeting will be in Edinburgh in December 2009.

EFSUMB Newsletter List of tutorial articles in preparation:

Past tutorial articles that are to be updated as necessary/republished in near future

Sonothrombolysis:

Complete

Acoustic Cavitation & Capillary Bleeding (1999)

Keepsake scanning:

In draft

Color Flow imaging – safety aspects (1996)

Cellular effects:

In draft

Epidemiology (2002)

TI/MI Indices:

In draft

Genetic Aspects (1994)

Opthalmology:

In draft

Non-linearity and finite amplitude effects (1994)

QA & Safety:

In preparation

Principles & Methods of field measurements (1994)

Neonatal Doppler:

In preparation

Pulsed Doppler devises – safety aspects (1991/2)

Diagnostic exposures: revision of 2003 version

In preparation –

Radiation Stress and its bio-effects (2000)

HIFU & Prostate:

To be written

Safety of Ultrasonic Contrast Agents (1999) Terms used in describing ultrasound exposures (1997) Thermal and mechanical indices (1996/7) Thermal Teratology (1999) Transvaginal ultrasonography – safety aspects (1993–95) What happens when you alter the settings on your diagnostic ultrasound machine – Safety considerations (1990– 95)

28 safety related articles are currently under review. These are published in the EFSUMB newsletter, and on the website. III. Maintenance of Safety statements Existing safety statements are reviewed annually and revised as necessary. (Clinical safety statement; Souvenir scanning statement) IV. Congresses A safety debate on the wisdom of using Doppler in the first trimester has been organised for EUROSON in Edinburgh. (Christoph Brezinka against; Yves Ville for). Post it pads with a safety message, advertising safety on the EFSUMB website have been prepared for EUROSON. Gail ter Haar ECMUS Committee Chairman

I. Tutorial Articles: These are designed to be teaching articles aimed at the clinical user without a background in Physics. Suggestions for future topics will be gratefully received! II. Literature reviews

5 December 2009 – Edinburgh – UK

Report of the Chairman of EPSC to the Board of Directors’ Meeting Prof Odd Helge Gilja EPSC Committee Chairman

EUROSON Schools ▼▼

The Education and Professional Standards Committee has as one of its main tasks to promote more EUROSON Schools to be arranged throughout Europe. In 2009, EUROSON Schools were arranged in Pavia, Italy, in Bad Boll, Germany, and in Opatija, Croatia. I will take this opportunity to thank all the hard-working organisers of the EUROSON Schools for their tremendous efforts in making these successful educational events. Since Europe is a lea-

Year

January– March

April–June

July–Sept.

Oct–December

2009

Timisoara 15/5

Bologna 17–19/9

Hanover 27–29/11

2010

Bergen 17–19/6

Lille

Hanover

2011

London

Copenhagen

Hanover

ding force in clinical applications of CEUS, we have also started to arrange EUROSON Schools on the subject of CEUS. Up till now 3 different post-graduate courses on CEUS have been arranged in Hanover, Timisoara, and Bologna. Looking at the programs and the responses these EUROSON Schools have been a great success. We have made a formal agreement with BRACCO, securing practical and financial support for the CEUS courses in the future. The schedule is as follows: For 2010 Schools, BRACCO will in addition sponsor 4 international speakers for Romania, 2 in Timisoara and 2 in Bucharest. State-of-the-art lectures from these courses have been published on the EFSUMB web-site for your free access.

Stay tuned in on the EFSUMB web site (www.efsumb.org) to view also the coming presentations. We have made a dedicated “start package”, that can be downloaded from our website, to help new organisers of EUROSON Schools getting started. The EFSUMB Course Book, with Prof. Dietrich as main editor, is under construction and right now several experts around Europe are writing chapters to this novel educational resource. The intensions are to integrate the course book with the EUROSON Schools and provide the educational material for our members through the EFSUMB website.

Ultraschall in Med 2010; 31

EFSUMB Newsletter Status of the Minimum Training Recommendations for the Practice of Medical Ultrasound in Europe ▼▼ The different guidelines and recommendations can be viewed online at the EFSUMB website. The Intensive Care Ultrasound recommendations (Appendix 13) is being finalised for publication in the Newsletter. The EPS Committee has decided also to have Minimum Training requirements on CEUS, This new Committee, chaired by Dr Hans-Peter Weskott, is now

writing the document and we are planning publication in first half of 2010. EFSUMB continuously works to expand our website with educational material. We invite you to send interesting ultrasound cases that can be published on the website. At the EUROSON meeting in Edinburgh, there is a session “Ultrasound on the Web”, in which an overview of ultrasound web resources will be given and also practical hints on how to design and publish ultrasound cases. Odd Helge Gilja EPSC Committee Chairman

5 December 2009 – Edinburgh – UK

Report of the Chairman Of Publications Committtee to the Board of Directors’ Meeting Prof Michael Bachmann Nielsen Publications Committee Chairman and Editor of EFSUMB Newsletter

The Publications Committee met in Lausanne in May 2009, and the newly elected committee will meet in Edinburgh during EUROSON 2009.

In 2008 we changed the contents of the Newsletters and expanded the number of pages. As a result 2009 brought a new challenge i.e., we had more material than we could print and we have had to hold back some material for the 2010 issues. The interview series, „EFSUMB Newsletter meets ...“ in 2009 brought the latest information about the status of ultrasound in the United Kingdom, Russia, Denmark, Norway, Germany and Switzerland. Technology update articles, literature reviews, information from the committees and training requirements were also to be found in the Newsletter in 2009. If you missed some of these then hurry to the

Ultraschall in Med 2010; 31

EFSUMB website where the Newsletters are available as pdf-files for free download. The Committee was very happy with the further increase in Impact Factor for the UiM/EJU. The website changed its design and layout in 2008 and now has an impressive hit rate in the statistics. For the EUROSON congress in Edinburgh in December 2009 the Publications Committee was responsible for a scientific session “Know-how in publishing a scientific article”. I would like to thank the other members of the committee Christoph Dietrich, Lucas Greiner, Jeff Bamber and Jean-Yves Meuwly for their work in the committee, their contributions to the Newsletter and for all the hours of fun we have spent together during the last two years. In Edinburgh a new committee will be elected. A particular thanks to Mrs Gianna Stanford for her outstanding work for EFSUMB and for helping with so many things during the year, we will miss you. And finally a big warm welcome to Mrs Lynne Rudd, the new General Secretary in EFSUMB, we look forward to working with you. Michael Bachmann Nielsen Publications Committee Chairman

Board of Directors‘ Meeting

Report on Ultraschall in der Medizin/ European Journal of Ultrasound (UiM/EJU)

The Ultraschall in der Medizin/European Journal of Ultrasound has been the official journal of EFSUMB since 2004. In 2009 an additional 2 national societies joined bulk subscription making it the official journal of 11 national ultrasound societies (the German, Swiss, Austrian, Norwegian, Danish, Latvian, Flemish, Macedonian, Croatian, Slovenian and Romanian). I would greatly recommend the remaining EFSUMB member countries to consider joining the bulk subscription. Issue 1 is distributed to all approximately 20,000 EFSUMB members. The remaining five issues are only sent to around 13,000 subscribers. Ultraschall has five editors: Karlheinz Seitz, Eberhardt Merz, Kurt Jäger, Gerhard Mostbeck and myself. Each is responsible for specific topics within the journal. The Impact Factor for 2008 showed small increase for the UiM/EJU – from 2.303 to 2.394. The journal is the highest-ranking interdisciplinary ultrasound journal. More than 50 percent of the published articles are in English and the rest all have an extended English abstract and captions in English. The EFSUMB Newsletter can be found in each issue of the journal, for those who do not receive the journal the Newsletter is also available at the EFSUMB website at www.efsumb.org. The Newsletters of all subscribing societies in their own national language are also in each issue. At EUROSON 2010 in Copenhagen Denmark Ultraschall in der Medizin will hold its own scientific session. Michael Bachmann Nielsen Publications Committee Chair and Co-Editor of UiM/EJU

EFSUMB Newsletter

The International School of Clinical Ultrasonography Flying Faculty Prof Lucas Greiner

Dear colleagues A friendly welcome to you from the International School of Clinical Ultrasonography (ISCUS) and its Flying Faculty! ISCUS offers a range of programs in clinical ultrasonography training in internal medicine with all its subspecialties. These programs comprise any type of teaching: basic Seminars and courses (with a preferably high hands on proportion); workshops or courses for the advanced; teach the teachers programs. The Flying Faculty is the ISCUS mobile “task force”. It consists of an international faculty of experienced physicians specia-

lized in clinician performed ultrasonography. They provide any type of lecturing and hands on training experience. The Flying Faculty is traveling worldwide to the institutions and medical doctors asking for education in clinical ultrasonography. We found teaching and training in the trainee‘s environment to be the most efficacious way. The website www.flyingfaculty.de will provide you with information on the International School of Clinical Ultrasonography (ISCUS) and on the Flying Faculty. In case you are interested in ISCUS and Flying Faculty activities, or you would like to comment on our work, don‘t hesitate to contact us on ultrasonography@FlyingFaculty.de . Sincerely yours, Lucas Greiner, MD Professor of Internal Medicine and Gastroenterology Seminar Leader of DEGUM (German Society of Ultrasonography) Director of ISCUS lucas@prof-greiner.de

Learning, Training, and Teaching Ultrasonography – Problems and Perspectives Looking into the body by means of ultrasonography (US) has found a multitude of medical applications – it is much shorter a list on medical areas which can do without US as compared to those who need it. Since its first tentative steps in medicine in the late sixties of the last century, ▶▶ knowledge on and expertise in US has grown in a snowballing manner, ▶▶ US machines developed to multifunctional high tech devices, ▶▶ producing real time information on function and morphology in a unique discrimination power, an ▶▶ evolution driven by inventive and imaginative engineers and physicists – as a rule, professional users intelligence lagged behind technical creativity; and last but not least,

▶▶ US – when accessible and available – has gained a firm place in public perception. So – what about us as US operators, as professional users – how and by which means can newcomers and (semi-)professionals acquire, train, and learn more on US in all its complexity? 1. First and foremost, novices in US can learn and understand US only by own performance, best on “their” clinical patients, in daily practice, and under competent guidance. This is as trivial as it is true, and it applies for any other practical skill as well. In US, however, specific situations of frustration (“I do not see anything on the screen”) and of challenge (“to see or

not to see!”), have to be accepted and conquered – to start with, preferably in hands-on teaching and sessions. This is time consuming for trainee and teacher – an effort needed and rapidly paying back. Fears regarding responsibility in US examination – to overlook or misclassify – are constant companions. Shortcomings in anatomy knowledge must be overcome. Spatial perception in even small anatomical and functional regions of interest must be understood, and then 2. referred properly to other team member‘s understanding and acceptance. Precise and preferably standardized wording of US real time findings and interpretations is another requirement – as a rule, one good picture saying more than hundred words, and one US movie saying more than numerous pictures. And by the way, a simple picture in moderate printer size and quality is not really fancy. 3. All this can be like a steep mass of rocks difficult to climb on without getting lost. Nevertheless, number one invitation – do it, perform US on your own – is the leading challenge. 4. A systematic approach is desirable, with a mix of expert controlled learning, preferably hands on and theoretical education by lectures and reading. As a rule, such concentrated training is available in courses only, best performed in hospital settings with a high grade of integrated clinical US expertise. Such concentrated learning phases will strengthen and encourage the operator to meet everyday clinical challenge in US-guided patient care. 5. With growing personal US expertise, any form of learning communication is needed, as for an example by ▶▶looking into an abdomen – previously scanned by US – as a guest in the surgical operation theatre, or – even better – being the US performing surgeon oneself; ▶▶making use of US textbooks, journals, e-literature, case-of-the-month pages (from EFSUMB, DEGUM, Sonoworld, and others), etc.; ▶▶participating in any form of Seminar, workshop, congress in US; ▶▶sending specific questions for a second opinion to another physician ultrasonographer or even by using other sectional imaging modalities; ▶▶etc.!

Ultraschall in Med 2010; 31

EFSUMB Newsletter

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Ultraschall in Med 2010; 31

Learning and performing US in this manner will be more and more a pleasure for the performer, intensifying and enriching all virtues of physical examination by ecoscopia (“looking by means of sound”, the truly adequate expression for US used in Italy). 6. Teaching US always means learning more for the teacher, too. This especially holds true for teaching not in the well known at home environment, but abroad, in a different setting and in a no-routine situation. The ideal teacher is experienced with a long own history of growing US expertise, preferably with experiences not limited to Europe. 7. Teaching will be efficient rather in a systematic than in an incidental manner, of course. In my three decades in teaching medical doctors, visiting their own environment with a “Flying Faculty” meets much better with the needs of the trainees as compared to (expensive and time consuming) invitations to the teacher‘s place. 8. As in any skill, some of the beginners will acquire US examination technique and interpretation (very) quickly, some will need maybe a bit more time and – sad but true – a few will maybe stay with an insurmountable problem with US. 9. Elaborate course programs are highly appreciated with the trainees – however, learning by doing is as a controlled process less an only tolerable than rather a necessary part of the US learning process – no one is born a master. Learning by doing is a specific need with US training, best in an individualized manner. Supervision by the teacher working with a small group of trainees hands on and in interactive lecturing which preferably is based on US movie clip material. In my practice and idea, US is always directly embedded in the wholesome process of diagnostic and therapeutic care of the patient. And this is done by the medical doctor clinically in charge of the patient him/herself. Since any interface inevitably leads to a loss of time and information, and thus hamper performance quality, the do it yourself manner undoubtedly is the more efficacious one. 10. Moreover Doctor performed US does not only improve and speed up markedly decision making and therapy follow up – US examination scenario means some minutes of exclusive de-

dication of the doctor to the patient. This is well understood and appreciated by the patients examined, experiencing their doctor personally operating a high tech device with all its attractivity and to some extent even its magic. And of course, modern patients demand such a mixture of technical tools and man provided medical care – at least in richer areas of the globe. 11. However claiming US performance for one medical specialty exclusively – as some radiologists might have tried – is misleading. Benefits from and impact of US as a whole are too strong for such restrictions. No one is a sole possessor of this fine method. US will be in an adequate position when it is accessible to all those who make use of it in a responsible way for any form of patient care, preferably by medical doctors, or by well trained and supervised paramedical staff members. Luca Neri, founder of WINFOCUS and father of emergency US, once reported on his experience in introducing a simple US device to an outpost of medical care which he was running for some years in a rural setting in equatorial East Africa. Within a very short period of time, he was overrun by people who wanted to have a look into their bodies with this machine, performed by the doctor capable of operating it. These citizens, these patients – knowing all in animal anatomy – directly understood the vast potential of US, not needing teaching or other information. The majority of our global population (>80 %, L. Neri), however, has no access at all to US at all. This is another story? Not really – it is part of the integral problems in US use and under-use (which is sort of no-good-practice as well). Compared to its key benefits, US is grossly underused worldwide – and this is understood more and more, which again increases the need for qualified teaching of the fine arts of ultrasonography. lucas@prof-greiner.de ultrasonography@FlyingFaculty.de

EFSUMB Newsletter Indications ▼▼

Perineal ultrasound Perineal ultrasound (PNUS) is an effective, inexpensive, easily available but so far not well known diagnostic tool.

Examination technique ▼▼

PNUS requires profound knowledge of the anatomy and topography of the pelvic floor and sphincters. The examination does not require specific preparations of the patient. For better contrast and orientation, the urinary bladder should be well filled. A probe coverage (e.g., custom made coating or a latex investigation glove filled with ultrasound gel) should be used for hygienic reasons. Conventional transabdominal convex 3–7 MHz probes are used first for orientation including colour Doppler imaging. Higher-frequency linear probes (5–17 MHz) can be used after orientation providing higher resolution imaging of the perianal region. The patient can be examined in a left sided position but other examination positions are possible as well. Anatomical structures and landmarks should be used for better orientation. Images should be documented using the corresponding system for endorectal ultrasound (ERUS). PNUS is more flexible than endorectal ultrasound, particularly when oblique orientated transsphincteric fistulas are to be examined. For best results, examination should be started using low frequency ultrasound probes, subsequently followed by the use of high frequency probes. Additional techniques can be used (e.g., panoramic view, 3-D ultrasound, sono-elastography). The localisation of inflammatory and neoplastic lesions should be described in relation to the sphincter apparatus. Detected fistulas can be further differentiated by ultrasound examination in inter sphincteric, transsphincteric and extra sphincteric forms.

Comparison to other imaging modalities ▼▼

Compared with other cross-sectional imaging procedures (e.g. computed tomography (CT), magnet resonance tomography (MRI)) ultrasound technology has the

disadvantage that documentation of findings (e.g., by overview images) is limited. One way to make subjective analysis of the findings accessible to other investigators is the use of 3D-ultrasound. The so called “free-hand”-3D-method works with correlation algorithms and uses several sensor-supported steps (data acquisition, correlation algorithms with segmentation, visualization and quantification of the recorded data sets) until a three-dimensional image is constructed. This method is particularly useful for endorectal ultrasound. For evaluation of endorectal tumours, 3D-data sets were recorded prior to computation of the axial layer. Preliminary experience with this technique has been reported, however, until today no systematic studies were published. The same is true for evaluation of the sphincter apparatus and perirectal fistulas by sono-elastography. The latter displays sclerosing fistulas as homogenous blue (harder) tissue structures, whereas acute inflammation with perifocal oedema is displayed as green/yellow (soft tissue).

Comparison of PNUS and ERUS ▼▼

ERUS often fails to demonstrate perianal fistula that run diagonally from the sphincter apparatus. PNUS permits acquisition of those lesions by using variable section planes. However, as PNUS cannot demonstrate the complete sphincter, it is recommended to use PNUS in conjunction with conventional ERUS. Table 1 Indications of PNUS Indications Perianal complaints

For staging of perirectal tumours, PNUS can be used complimentary to conventional ERUS. A valuable extension of the diagnostic application of PNUS is its supportive role during invasive interventions, such as drainage of fluids or targeted puncture of tissue lesions. PNUS is particularly useful if clinical examination, ERUS or MRI (with endorectal coil) cannot be performed (e.g., due to severe pain when introducing the probe into the anus, particularly in children). Indications of PNUS are summarized in Table 1. The complete evaluation of the sphincter for diagnosis of incontinence remains the domain of ERUS, however, PNUS can add additional information on extra-sphincteric complications (e.g., fistula, abscesses). The classification of anorectal malformations is also possible. For complex overview of the pelvis and the perineum, MRI is still the imaging technique of choice. However, when diagnosis of acute inflammatory processes of the anorectal region has to be made, MRI is often not readily available, time-consuming and cost-intensive, and might be supplemented by PNUS with better detail resolution compared to CT and MRI. Fistula and abscesses The most frequent causes for perianal and pararectal fistula as well as abscesses are crypto-glandular inflammations that expand into the sphincteric region, as well as chronic inflammatory bowl diseases (e.g., Crohn‘s disease). In addition, venereal and HIV-associated inflammatory and neoplastic diseases can also cause fistula and abscesses. Rare diseases (e.g., the Langerhans cell histiozytosis) must also be considered, particularly as they can be

Explanations Detection of perianal fistula and abscesses, especially in patients with inflammatory bowel disease (IBD) and veneral infections

Characterisation of perianal fistula and abscesses Staging of anal carcinoma

Including lymph node status, sphincter infiltration, follow-up after surgery

Staging of distal rectal carcinoma

Including lymph node status, sphincter infiltration, follow-up after surgery

Anal incontinence

Complementary sphincter evaluation

Gynaecology

Descensus uteri, intususception, cervix insufficiency, incontinence

Urology

Evaluation of urethra, prostate, (following rectum amputation), urinary incontinence

Pediatrics

Diagnosis of anal atresia and other malformations

Ultraschall in Med 2010; 31

EFSUMB Newsletter mistaken sonographically and radiologically as anal carcinomas. Complex fistulas that involve the M. sphincter ani externus, M. levator ani and/ or M. obturatorius cannot be assessed by native PNUS. However, discrimination of the fistula by PNUS can be enhanced by instillation of contrast agents (SonoVue) over the external ostium of the fistula. Hydrogen peroxide or sparkling mineral water can be also used as an economical ultrasound contrast agent.

Diagnostic of anal incontinence ▼▼

The work-up of anal incontinence requires the exact knowledge of individual anatomical and functional defects of the sphincter apparatus and the surrounding structures. The M. sphincter ani internus can be displayed sonographically as circular, low-echogenic structure with a crosssectional diameter between 2–4 mm. The M. sphincter ani externus presents as stronger echogenic structure with a thickness between 4–6 mm. The sono-morphological diagnosis of incontinence remains a domain of ERUS, which allows a right-angled and orthogonal inspection of both sphincters. The assessment of the sphincters by non-invasive PNUS can give some complimentary information, particularly in women, but is limited by diagonal angle of inspection. Combined results from ERUS, PNUS and rectal perfusion manometry allow us to distinguish four ma-

jor forms of anal incontinence: A purely sensory form, a predominantly muscular form, a combination of both as well as a malfunction of the rectal reservoir function. This is important, since each form of incontinence requires a distinct therapeutic approach. In several patients that were formerly diagnosed with “idiopathic incontinence“, sonographic evaluation now reveals a lesion of the sphincter apparatus as morphological correlate. The most frequent causes of sphincter lesions in women are delivery traumas (e.g. forceps delivery). Resulting scars are typically located between the ventral edge of the anus and the vagina. Within the echo-rich external sphincter muscle, the scar usually presents as echopoor tissue. In contrast, within the echopoor M. internus, the scar presents as a comparative echorich structure. Sonographic evidence of disruptions of the external anal sphincter correlates with faecal incontinence, particularly in women.

Diagnostic of descensus uteri and other pelvic diseases ▼▼

PNUS can also give complimentary information for the diagnosis of descensus uteri and other pelvic disease. The ultrasound transducer is placed above the external aperture of the urethra, which allows imaging of the urethra and the posterior wall of the urinary bladder. The degree of descensus uteri can be estimated from the delta of the angel between both structures

Table 2 TNM-Classification of anal rim and anal canal carcinoma TNM-Classification Anal canal carcinoma Tx

No evaluation of the primary tumour

No indication for primary tumour

Tis

Carcinoma in situ

Tumour < 2 cm

Tumour > 2 und < 5 cm

Tumour > 5 cm

Tumour infiltrates neighbouring organs*

Regional lymph nodes not evaluable

Regional lymph nodes not affected

Perirectal lymph nodes affected

Inguinal and/or iliacal lymph nodes affected on one side

Both sides and/or perirectal and inguinal lymph nodes of one side affected

Distant metastases not evaluable

No evidence of distant metastases

Distant metastases

Anal rim carcinoma

Tumour infiltrates extradermal structures (cartilage, muscle)

Ipsilateral inguinal lymph nodes affected

*Vagina, urinary bladder, prostate, sphincteric infiltration is not considered as T4, Differences were marked in italic

Ultraschall in Med 2010; 31

at rest and during Valsalva maneuver. For details, we refer the reader to the specialized literature (e.g., published by Hans Peter Dietz).

Diagnosis of anal and rectal tumours ▼▼

Early anal carcinomas typically presents as superficially located echo-poor infiltration. According to the valid UICC classification, anal carcinomas are subdivided according to their size. For further staging and design of an individual therapeutic strategy, imaging procedures have to be used, in order to determine the extension and the exact position of the tumour in relation to neighbouring structures. In respect to lymph node metastases, two different localisations have to be differentiated: the anal rim carcinoma, which metastasises primarily inguinal; and the carcinoma of the anal canal, which spreads primarily perirectal (Table 2). The conventional pre-therapeutic staging of anal carcinomas relied on clinical investigation, such as palpation and proctoscopy, as well as imaging techniques like computed tomography or magnet resonance tomography. PNUS (in conjunction with ERUS) examination allows a detail resolution of < 1 mm, which greatly improve estimation of the depth of tumour infiltration. Due to the improved detail resolution by ultrasound imaging, several groups have now suggested a revision of the UICC classification for anal carcinoma. Instead, a new classification that considers the infiltration of the different portions of the sphincter muscle was proposed. The accepted first-line treatment for anal carcinomas is currently radio-chemotherapy. Surgical intervention is usually limited to small anal rim carcinomas or cases of extended disease and associated complications (e.g., bleeding or ileus). In some cases of distal located carcinomas of the rectum, PNUS examination can provide useful additional information; however, conventional ERUS remains the diagnostic method of choice. For rectal carcinomas that are situated more proximal (> 4–6 cm) PNUS is much less reliable. However, after surgical amputation of the rectum, PNUS and ERUS can supplement radiological imaging, thereby improving quality of follow-up examinations.

EFSUMB Newsletter Diagnostic and therapeutic interventions ▼▼

Fig. 1a

A valuable extension of the diagnostic application of PNUS is its supportive role during invasive interventions, such as drainage of liquids (e.g., inflammatory, postoperative) or the targeted puncture of suspected lesions (e.g., infectious, neoplastic). For this purpose, specialized transducers with a build in needle holder/applicator are available. However, conventional curved array probes can be used for free hand punctures, particularly if the lesion of interest is close to the surface and large

enough in size. A condition sine qua non for interventions in the very sensitive perineal region is the appropriate use of local anaesthesia or analgo-sedation.