ISSN 1441-6891

Volume 7 Number 2 May 2004 Australasian Society for in Medicine ULTRASOUND BULLETIN

Registration details for ASUM Meetings in this issue: ASUM NZ Branch Scientific Meeting 25–27 June ANZSVS/ASUM vascular meeting 4–8 September ASUM Annual Scientific Meeting 23–26 September Kuala Lumpur 2004 Asia-Link Meeting 5–6 November

Carotid ultrasonography Acute cholecystitis Cystic adventitial disease Morton’s neuroma Lactating adenoma Draft worksheets Toshiba realise that performing ultrasound examinations shouldn’t be painful.

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TOSHIBA MEDICAL SYSTEMS www.toshiba.com U L T R A S O U N D BU L L E T I N President Dr Glenn McNally President Elect ASUM Ultrasound Bulletin May 2004 7: 2 Dr David Rogers Honorary Secretary Mrs Roslyn Savage Honorary Treasurer Dr Dave Carpenter Chief Executive Officer Dr Caroline Hong Notes from the Editor ULTRASOUND BULLETIN Official publication of the Australasian Society for Ultrasound in Medicine Welcome to the May issue of the greatly exceed our expectations, and Published quarterly Bulletin. This must be our biggest ever the facilities just coped. One paper ISSN 1441-6891 posting. We try to avoid too many from that meeting on Morton’s neuro- ma appears in this issue. Indexed by the Sociedad Iberoamericana inserts with the Bulletin but this time de Informacion Cientifien (SIIC) Databases everything has happened at once. I This issue again features a variety Editor assure you that this is not a new trend, of technical papers covering aspects of Dr Roger Davies simply an aberration. The inserts cardiac, vascular, breast and general Women’s and Children’s Hospital, SA include a complimentary educational ultrasound. We continue our series of Co-Editor CD-ROM from Philips, and registra- draft worksheets. Consideration is Mr Keith Henderson ASUM Education Manager tion information for a set of excellent being given to formalising these into a Assistant Editors ASUM ultrasound meetings. Not all of single official volume. Please let us Ms Kaye Griffiths AM the meetings are on inserts. In addition know if you are using them. Criticism Royal Prince Alfred Hospital, NSW check out the ASUM New Zealand is invited, indeed wanted. Please Ms Louise Lee respond to [email protected] Gold Coast Hospital, Qld Scientific Meeting on the inside back cover. Registration for all of ASUM’s The balance of this issue reflects Editorial contributions Original research, case reports, quiz cases, meetings can be obtained online at the wide range of educational projects short articles, meeting reports and calendar http://www.asum.com.au that your Society is involved in. Read information are invited and should be March 2004 saw a very successful and enjoy. addressed to The Editor and sent to ASUM at the address below Multidisciplinary Workshop. A raft of Roger Davies Membership and general enquiries late registrations saw the numbers Editor should be directed to ASUM at the address below Published on behalf of ASUM by Minnis Communications Mr Bill Minnis, Director THE EXECUTIVE The gallbladder wall: acute cholecystitis versus circumferential gallbladder 4/ 16 Maple Grove President’s message 2 Toorak Melbourne Victoria 3142 Australia oedema 15 tel +61 3 9824 5241 fax +61 3 9824 5247 CEO’s desk 6 Isolated occlusion due to cystic adven- email [email protected] titial disease of the popliteal artery – Disclaimer EDUCATION ultrasound diagnosis 17 Unless specifically indicated, opinions Book reviews 30 expressed should not be taken as those of Ultrasound diagnosis of Morton’s the Australasian Society for Ultrasound in Fetal measurements requirements 32 neuroma 21 Medicine or of Minnis Communications DMU examination dates and venues 34 Lactating adenoma – a case study 26 DDU exam dates and fees 34 AUSTRALASIAN SOCIETY FOR Giulia Franco Teaching Fellowships 35 ULTRASOUND IN MEDICINE DRAFT WORKSHEETS 2/181 High Street ASUM invites scientific papers for Willoughby Sydney NSW 2068 Australia ASM 2004 36 Neonatal hip ultrasound 28 tel +61 2 9958 7655 fax +61 2 9958 8002 Adjudication of prizes and awards Scapho-lunate 29 email [email protected] website:http //www.asum.com.au ASUM ASM 36 ABN 64 001 679 161 Chris Kohlenberg Teaching THE SOCIETY Fellowships 39 DDU/DMU preparation course 40 NZ Ultrasound Video Library 35 2004 Multidisciplinary Workshop 41 ASUM Society groups and ISO 9001: 2000 branches 2004 44 Certified RESEARCH AND TECHNICAL ASUM new members 45 Quality Management Carotid ultrasonography Corporate members 2004 46 Systems – How do I do it? 11 Ultrasound Calendar 47

ASUM Ultrasound Bulletin 2004 May 7: 2 1 THE EXECUTIVE

the current status of education and President’s message accreditation of diagnostic ultrasound in Indonesia. Council has agreed to grant a $5000 scholarship from the ASUM Asia Link budget to an ISUM member Glenn McNally for placement in Australia or New Zealand for one to three months. Council has also agreed to explore the was largely due to the change of hosting of a joint meeting with ISUM requirements of the Secretariat in the in the next two years. years since the original purchase over 15 years ago. Council has determined DMU (Asia) that a more functional space is The DMU (Asia) continues to make required and there is likely to be better progress. The course is currently being capital growth with an office reloca- assessed in Malaysia by the National tion. Accreditation Board, Ministry of The sale was recently completed, Higher Learning Malaysia, with with a good price having been regard to becoming a recognised qual- realised. A three-year lease back ification. Such recognition will be a arrangement has been put in place. significant achievement for the Council will commence the search Society as we work to help to develop for new premises in the near future to the discipline of diagnostic medical Much has happened since the last ensure a smooth transition to sonography in Asia. Ultrasound Bulletin with Council hav- improved premises in the next one to Marketing has commenced within ing been very active in a number of three years. the region and the first intake is antic- areas important to the functioning and ipated for September 2004. future of the Society. ISO 9001:2000 accreditation The school is currently seeking an Everybody will be greatly relieved The Society recently achieved ISO experienced diagnostic medical sono- to see that there are very few pictures 9001:2000 quality management sys- grapher from Australia or New of me in this issue. I think there was tem accreditation. This was a major Zealand and details of this position are widespread consensus that the undertaking, which required the coop- to be found elsewhere in this issue. Bulletin would be more enjoyable eration of all the ASUM staff in ensur- The concept of sonographer train- without the pictures of yours truly, and ing that quality documentation and ing is still relatively new in Asia and in with this issue the Bulletin has procedures within the Secretariat were Malaysia there is only a handful of returned as an upmarket publication. able to be audited. This was a volun- accredited sonographers. tary process. Asia Link Program Council believes it is important Multidisciplinary Workshop The Asia Link Program continues to that all of our processes are continual- The recent Multidisciplinary take shape. Recently, the CEO ly reviewed and improved. We believe Workshop held at Conrad Jupiters on travelled to Hong Kong following an that this assists in promoting confi- the Gold Coast was a tremendous suc- invitation and sponsorship from the dence in the Society as a quality cess. Over 400 people attended and Hong Kong Government. Caroline organisation where a permanent focus the feedback has generally been most Hong, CEO, attended several business exists on quality improvement and favourable. meetings on behalf of ASUM in Hong Special thanks go to Roslyn transparent processes. Savage who acted as a Convenor and Congratulations go to our CEO Dr Daniel Makes, President of ISUM to the local organising committee. Caroline Hong, Keith Henderson, addressing the ASUM Council March 2004 Congratulations are also due to the James Hamilton, Marie Cawood and ASUM CEO, the ASUM Education Iris Hui. Manager and all the support staff Indonesian Society for involved in the organisation of the Ultrasound in Medicine Workshop. More details are contained At the recent Multidisciplinary elsewhere in this issue. Workshop on the Gold Coast, Dr Daniel Makes, the President of the Sale of ASUM office Indonesian Society for Ultrasound in The sale of the ASUM office in Medicine (ISUM), was a guest of Willoughby (a suburb on the North ASUM Council. Dr Makes was most Shore of Sydney) has been on the interested in the concept of the Council agenda for some time. Multidisciplinary Workshop and Council resolved at its last meeting in attended many of the sessions. He also November 2003 to sell the office. This made a presentation to Council about

2 ASUM Ultrasound Bulletin 2004 May 7: 2 ASUM Meetings 2004 Australasian Society for Ultrasound in Medicine 2/181 High Street Willoughby Sydney NSW 2068, Australia tel: +61 2 9958 7655 fax: +61 2 9958 8002 email [email protected] website: www.asum.com.au

ASUM NZ 2004 Christchurch, NZ 25Ð27 June 2004 See the ASUM website: www.asum.com.au Contact Rex De Ryke: email [email protected]

ASUM Ð ANZSVS 2004 Rotorua NZ 4Ð8 September 2004 See the ASUM website: www.asum.com.au Contact David Ferrar email [email protected]

ASUM Ultrasound Bulletin 2004 May 7: 2 3 THE EXECUTIVE

Kong and met with Dr Gregory Program. ASUM Council will adopt I participated in a panel discussion Antonio and Prof Anil Ahuja who guidelines, which are currently being concerning the future role of sonogra- have both agreed to be the local con- developed, to enable an ASUM sonog- phers, about which there will be much venors for the proposed Asia Link rapher member to spend some time in future discussion. meeting to be held in Hong Kong and the United Kingdom for a short-term Mr Chris Sheedy, the Secretary of Shanghai in November 2006. research project. This will be funded the Diagnostic Imaging Branch, The CEO has established many from the ASUM Research and Grants Department of Health and Ageing, useful business contacts in Asia and Fund. spoke at this meeting and has agreed will continue to work with the Asian Research and Grant Policy to speak at the ASUM 2004 Meeting Convention Bureau and government A Research and Grant Policy has now in Sydney and will address the topic of bodies for support for our Society in been approved and will soon be placed ‘Sonography practice – changing roles the region. on the ASUM web site. If you need a and responsibilities’. Queensland sonographer copy, please email Caroline Hong and I will be meet- registration [email protected]. Members will ing with Mr Sheedy in the near future Recently ASUM has communicated soon be able to apply for funding in Canberra to advise him of the role with the Medical Radiation grants for research. It is the aim of the that ASUM may have to play in pro- Technologists Board (MRT) in Society to build the funding to at least moting high standards of practice and Queensland expressing our concern $A1 million for the fund to be sustain- quality improvement in diagnostic and reservation about a proposal able in the long term to support ongo- ultrasound. We will also be seeking requiring sonographers to register with ing, significant research. some support for the quality improve- ment activities of the Society through the MRT. There are several issues Giulia Franco Teaching within the proposal that concerned the assisting funding for the Research and Fellowship Grants Committee. Council, including the fact that many The Giulia Franco Teaching sonographers have not trained as radi- Fellowship, which is sponsored by WFUMB sponsored workshop ographers and that many of those who Toshiba, will travel to Western I participated in a WFUMB-sponsored have, no longer practice . Australia in 2004. Registration under the one umbrel- workshop in the Philippines in la, we believe, does not adequately Christopher Kohlenberg January. Several WFUMB Councillors serve the interests of diagnostic med- Teaching Fellowship conducted a ‘Train the Trainer’ work- ical sonography. It has been suggested There are two Christopher Kohlenberg shop in Manila and participated in the that ASAR could take on the role of Teaching Fellowships sponsored by 2nd Convention of the Philippines the national registration body for GE, the first will be travelling to New Society for Ultrasound in Clinical sonographers. I think that it is yet Zealand and the second to the ACT, Medicine. This was a most interesting another illustration of the continuing both in 2004. More information is experience for me and certainly put problem with government and bureau- available from Keith Henderson, into some perspective the great diffi- cratic bodies that exist regarding the ASUM Education Manager. Email culties faced by many practitioners of recognition of the unique discipline of [email protected] diagnostic ultrasound in the develop- diagnostic medical sonography. ing world. Online education ASUM will continue to promote Draft work sheets proper recognition of diagnostic med- Members are encouraged to log on to the Online Education Section of the The Bulletin again contains three work ical sonography by government, state sheets. The inclusion of the work ASUM web site. The Online and territory health departments. sheets is designed to promote further Education Handbook is functioning discussion and we would greatly Corporate member liaison and we are looking for both feedback appreciate feedback from members. Council has determined that ASUM and content. Feedback should be We are looking to develop a series of should continue liaison with trade cor- directed to Keith Henderson. work sheets to be reviewed and hope- porate members by agreeing to meet fully adopted by the Standards of regularly with a corporate member Business of Ultrasound meeting Practice Committee. representative. Initial meetings will be I attended, along with Caroline Hong, Obviously there will not be unanimous with the ASUM Executive and a key CEO, on behalf of the Society a short agreement about the content of such liaison person will be appointed by meeting held in Canberra on 28 and 29 work sheets, however, Council feels that it is appropriate to try and develop Council for ongoing liaison with the February 2004. The meeting entitled some work sheets as a basic aid to sup- ‘The Business of Ultrasound’ and was corporate members, who are key part- port high standards of practice. ners with ASUM in supporting its hosted by Mr Rob McGregor of Roger Davies and Keith work in Australia, New Zealand and SonoEd and sponsored by Toshiba. Henderson have again produced an beyond. The meeting was an interesting excellent Ultrasound Bulletin and our mix of sonographers, medical practi- thanks go to both of them. UK/Australia sonographer tioners, corporate and government exchange interests. It provided a productive Best wishes The British exchange of views regarding many Glenn McNally Society (BMUS) and ASUM have aspects of the future of diagnostic President ASUM established a Sonographer Exchange ultrasound practice. Email: [email protected]

4 ASUM Ultrasound Bulletin 2004 May 7: 2 ASUM Ultrasound Bulletin 2004 May 7: 2 5 THE EXECUTIVE How ASUM communicates COUNCIL 2003–2004 with members of the Society EXECUTIVE President Caroline Hong Glen McNally NSW Medical Councillor even if they have already provided their email addresses for other purpose President Elect eg. membership record. Please feel David Rogers NZ free to direct your enquiries or any Medical Councillor requests for information to [email protected] Honorary Secretary Congratulations to the President Roslyn Savage Qld – AICD Diploma Sonographer Councillor Congratulations go to Dr Glenn McNally who passed the Diploma Honorary Treasurer course of the Australian Institute of Company Directors. Dave Carpenter NSW ASUM now has two graduates of the Scientific Councillor We are often asked about how we AICD Diploma, namely, the President communicate with our members. The and the CEO. Dr David Rogers and MEMBERS ASUM Council meets four times each Stephen Bird will be the next two year. News and updates of ASUM Councillors to enrol for the AICD Medical Councillors activities, ASUM meetings and course. This is part of Council's ongo- Matthew Andrews Vic Council decisions are reported to ing commitment to maintain high standards in corporate governance in Roger Davies SA members via various means. News and update reports are published four the Society. times a year in the ASUM Ultrasound Sonographer Councillors Bulletin which now has a circulation Ultrasound Imaging 1976: Stephen Bird SA of about 3000 copies in Australia, New Australian Innovations stamp series Margaret Condon Vic Zealand, Asia and other overseas countries. ASUM news and all infor- Members are alerted to the release of a Kaye Griffiths NSW mation about meetings, workshops, set of five stamps which is scheduled Janine Horton WA DDU, DMU, membership and for release in May 2004 by Australia MOSIPP are regularly updated on the Post. One of the set of stamps in the ASUM website noticeboard. ASUM Australian Innovation series is about ASUM Head Office also sends out email broadcasts to ‘Ultrasound Imaging 1976’. Members members from time to time. For are encouraged to spread the news instance, members would have been about this special Australia Post stamp Chief Executive Officer kept up to date with the ASUM release, and to promote actively the Caroline Hong Bookshop advising them of the latest advances that ultrasound has made to in ultrasound books and publications. society since that time. More informa- Education Manager ASUM also sends out information tion is available from your local post office. Keith Henderson about upcoming meetings, scholar- ships and education resources by email broadcasts. Members are Multidisciplinary Workshop and All correspondence should be O and G Symposium – another directed to encouraged to read the Bulletin and log in to the ASUM website to keep success story The Chief Executive Officer abreast of the latest updates, see This meeting attracted about 400, indi- ASUM www.asum.com.au. Members are also cating a growing interest in the work- 2/ 181 High St requested to provide an email address shop style meeting. Our thanks go to Willoughby to our Membership Registrar by Roslyn Savage, members of the organ- NSW 2068 emailing to [email protected] if ising committee and ASUM staff who worked very hard to make the meeting Australia they wish to be included in the ASUM a success. Again, we are grateful to the [email protected] email broadcast list and the ASUM Bookshop email list. Members can sponsors and exhibitors who support- www.asum.com.au have the option of unsubscribing from ed the meeting and provided the our email broadcasts by advising us Ð equipment for the workshops.

6 ASUM Ultrasound Bulletin 2004 May 7: 2 He sees more than ultrasound. He sees a new frontier in clinical diagnosis.

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Professor Lil Valentin, our internation- program with many opportunities for Research and Grants policy al speaker, and all the Australian and combining a holiday pre- or post meet- This policy is now approved. It will be New Zealand speakers received posi- ing. ASUM has negotiated the special placed on the ASUM website. If you tive feedback from attendees. Surplus airfares which start from $A800 to need a copy, please email funds from this meeting will again go Kuala Lumpur return. There is also a [email protected]. Members will into the ASUM Research and Grants special ‘Discover Malaysia’ airfare for soon be able to apply for grants and Fund. The Multidisciplinary $US199 for a maximum of five funding for research. It is the aim of Workshop for 2005 is now planned for domestic stops in Malaysia, including ASUM to build the fund to at least 17Ð19 March 2005 in Melbourne. Sabah, Langkawi Island and Penang $A1m for the fund to be sustainable in Island. This meeting will attract atten- the long term and for ongoing ASUM NZ 24–26 June 2004 dance from Australia, NZ, Singapore, research. Christchurch Thailand, Indonesia, Malaysia and Rex de Ryke, Convenor of the ASUM other parts of the Asia. NZ meeting to be held at Rydges Keynote speakers include the lead- ASUM AGM Saturday 25 Hotel in Christchurch, invites all ing radiologists of Malaysia, Dr P September 2004 members of ASUM to register early Sathyamorthy, Dr Sulaiman This year the AGM will be held at Star for this conference. An interesting pro- Tamanang, and well renowned obste- City Sydney on 25 September 2004 gram has been organised and many tricians/gynaecologists Dr Raman during the ASUM 2004 Annual thanks go to Rex and his dedicated Subramaniam and Dr Patrick Chia. Scientific Meeting. The ASUM hard working organising committee. The Australian and New Zealand Council has approved for Tulloch There are some cheap airfares on the Faculty will consist of Dr Simon Bove and Gauld to again be the finan- internet from Australia. Meagher, Dr David Rogers, Dr Roger cial auditors for the Society. Council The ASUM Council members will Davies, Dr Stan Barnett, Dr Andrew has also approved for a CPI increase in be attending this meeting and will also Ngu and Dr Glenn McNally. If you are 2005Ð2006 membership subscription hold a Council meeting on Saturday planning to attend a meeting in Asia, rates which will be recommended to 26 June. For more information email mark this meeting on your calendar. the AGM for adoption. Rex de Ryke at [email protected] Sonographer exchange with Dr Caroline Hong BMUS Chief Executive Officer ASUM 2004 Annual Scientific BMUS and ASUM have a sonograph- email [email protected] Meeting 23–26 September 2004 er exchange program in place. ASUM Star City Sydney Council will adopt guidelines, which All members would have received the are being developed to create an Call for Abstracts Brochure. The exchange program for an ASUM sono- Join ASUM Registration Brochure will be released grapher to spend some time in the UK soon as the speakers and program are for a short term research project. This being finalised. will be funded from the ASUM The Australasian Society for Ultrasound in We have 12 keynote speakers, Research and Grants Fund. Medicine is a multidisciplinary society from USA, UK, Brazil, France, New whose primary role is to assist in dissemi- Zealand and Australia. They will be nating scientific information, providing edu- supported by a wide array of quality Teaching Fellowships cation and setting standards of practice in this continually developing specialty. local speakers. This meeting will The Giulia Franco Teaching Fellowship, proudly sponsored by remain as ASUM's biggest meeting Our members include medical specialists each year and is the major highlight of Toshiba will travel to WA in 2004. There are two Chris Kohlenberg in almost all disciplines of medicine: med- our calendar. ical doctors, sonographers, scientists, vet- Fellowships, sponsored by GE, the If you are not a resident of Sydney, erinarians and corporations. you may also use this opportunity to first will travel to NZ and the second combine a holiday in Sydney and will go to the ACT, both in 2004. More The society is affiliated with the World regional NSW. There are wonderful information is available from Federation for Ultrasound in Medicine and attractions in Sydney, the Blue Education manager Keith Henderson Biology (WFUMB) and has linkages with Mountains, the Hunter Valley and at email [email protected] ultrasound societies in Asia. many others. For information contact: Education Online now live Membership Registrar ASUM 2004 Asia Link Malaysia Members are encouraged to log on to Australasian Society for Ultrasound 5-6 November 2004 the Online Education section of the in Medicine ASUM has successfully negotiated ASUM website. Branches are asked to 2/ 181 High St Willoughby NSW 2068 with Malaysian Airlines (MAS) for actively promote the website and to tel +61 2 9958 7655 special discounted airfares for forward feedback on the Online fax +61 2 9958 8002 Australian and NZ members to attend Education Handbook to the Education email [email protected] the meeting in Kuala Lumpur. This Committee by emailing khender- web www.asum.com.au meeting will present another exciting [email protected]

8 ASUM Ultrasound Bulletin 2004 May 7: 2 What’s the difference between Aquasonic® 100 and those other gels? Clarity, reliability, and economy. Aquasonic 100 Ultrasound Transmission Gel The clarity that sonographers have counted on for over 40 years.

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Parker Laboratories, Inc. 286 Eldridge Road, Fairfield, NJ 07004 973.276.9500 • Fax: 973.276.9510 www.parkerlabs.com ISO 13485:1996 Certified lian Owned tra & s Op Au e y ra dl te ou d. Pr a. Ex rali celray Aust ASUM Ultrasound Bulletin 2004 May 7: 2: 11–14 CAROTID ULTRASONOGRAPHY Carotid ultrasonography – How do I do it?

Stella SY Ho

Introduction triplex mode of operation, steerable ultrasound beam angle, Ever since the results of two large randomised trials: North adjustable angle correction, selectable sweep speeds, wall American Symptomatic Carotid Trial filters and spectral display. (NASCET) and the European Carotid Surgery Trial (ECST), published in 1991 showing the benefit of carotid Technique endarterectomy for high-grade internal carotid artery steno- Each vascular laboratory should develop its own scanning sis greater than 70% diameter reduction1,2, carotid ultra- protocol and diagnostic criteria in conformity to the criteria sonography has become an important tool for man- in the randomised trials Ð say the NASCET criteria, with agement and prevention, and is one of the standard investi- proper validation with arteriography. The vascular sonolo- gations for patients suffering from transient ischaemic gists must adhere to the standardised technique in carotid attacks (TIA) and recent acute . examinations so as to ensure the diagnostic accuracy for Hence, the primary role of carotid ultrasonography for documentation of high-grade stenoses of greater than 70% these patients is to look for the presence of carotid diameter reduction. and to document the degree of stenosis in conformity to the criteria in these randomized trials Ð the NASCET criteria Patient preparation are most widely adopted by vascular sonologists. No prior patient preparation is required. During the scan, It is noteworthy that the diagnostic criteria of the two tri- the patient lies supine with the neck rested on a pillow and als are different. In NASCET, the degree of stenosis was slightly extended. The patient’s head turns away from the determined by comparing the diameter of the residual side being examined. lumen to the true diameter of a normal portion of ICA on arteriography, whereas in ECST, comparison was made Imaging protocol between the diameter of the residual lumen and an estimate The scan should cover both common carotid arteries (CCA) of the true diameter in the same segment1,2. and the proximal segments of their branches: the external carotid arteries (ECA) and ICA as well as the extracranial Clinical indications verterbral arteries (VA), utilising gray-scale, colour Doppler Recent TIA and acute strokes are the most common and and spectral Doppler imaging. important clinical indications that we encounter in everyday Gray-scale imaging carotid ultrasound examinations because of the high associ- A quick sweep of the carotid arteries is first performed to ation between recurrent strokes and the presence of an exclude any carotid stenosis. If there is plaque formation, occult carotid stenosis3. Other indications include follow-up the location and severity of luminal narrowing should be of or and follow-up of a documented. If a stenosis is of low-grade ie. less than 50% carotid stenosis greater than 50% diameter reduction. diameter reduction, direct measurement of the stenosis on Equipment the frozen gray-scale image usually gives a good estimation of the severity of the luminal narrowing. Colour/power A high-resolution linear array transducer with frequency Doppler imaging is helpful in depicting the residual lumen range between 10 Ð 5 MHz is preferable. Trapezoidal imag- in moderate and high-grade stenosis. ing is definitely advantageous in providing a wider field of view for assessing the extracranial segment of the internal Colour and spectral Doppler imaging carotid artery (ICA). The ultrasound system should include If direct measurement of a stenosis is inadequate due to all standard features for colour Doppler imaging such as densely calcified plaques or poor visualisation of residual adjustable sample volume size, simultaneous duplex or lumen, spectral Doppler analysis of the flow velocities before, at and after, the stenosis must be carefully per- formed for estimation of the peak systolic velocity (PSV) at Correspondence to the most stenotic segment, since the PSV is an important Stella Ho PhD, RDMS, RVT, PDDR estimate for the degree of stenosis. Department of Diagnostic and Organ Imaging, Colour Doppler imaging is not always necessary in normal Prince of Wales Hospital, cases but is particularly useful in guiding angle correction Shatin, Hong Kong during velocity measurement at the stenosis and aiding in tel 852 2632 2760 the delineation of the residual lumen (Figure 1). fax 852 2645 1520 Estimation of the degree of stenosis by Doppler flow email [email protected] velocities at the stenosis relies heavily on the accuracy of angle correction. A 2¡ error in angle correction at a large ASUM Ultrasound Bulletin 2004 May 7: 2 11 Carotid Ultrasonography – How do I do it?

Figure 1 High-grade ICA stenosis. Accurate angle correction could Documentation of ICA stenosis easily be achieved with the delineation of the residual lumen by Recently, a multidisciplinary expert panel of the Society of colour Doppler imaging. Measured PSV at the stenotic segment was Radiologists in Ultrasound (USA) issued a consensus state- 331.0 cm/s indicative of a ≥70% stenosis ment regarding Doppler ultrasound in the diagnosis of . The panel recommended that the degree of stenosis should be determined from both gray- scale (plaque formation) and Doppler ultrasound (PSV), and classified into the categories: normal, < 50% stenosis, 50% to 69% stenosis, ≥ 70% stenosis to near occlusion, near occlusion and total occlusion. Only when these findings are questionable should the PSV ratio (= PSVstenosis/ PSV ipsilateral normal CCA) and ICA end-diastolic velocity be used7. Diagnostic criteria In our institution, we also utilise the information obtained on gray-scale and Doppler ultrasound for the diagnosis of carotid artery stenosis. However, we adopt the PSV ratio instead of the PSV to estimate the degree of stenosis angle of insonation ≥ 70¡ will incur an unacceptable error in the velocity measurement. To ensure accurate velocity because PSV ratio is physiologically independent, elimi- nates technical variations and is unaffected by tandem or measurement, a small angle of insonation ≤ 60¡ is always applied. For reasons discussed below, the author further rec- contralateral arterial stenosis. Having said that, it cannot be ommends constant insonation angle during ICA flow veloc- applied if the ipsilateral CCA is diseased. ity measurement when feasible. Because of variability in the computation of Doppler Using constant insonation angle in ICA velocity meas- velocity by different ultrasound machines, each laboratory should perform an internal validation for the Doppler crite- urement, we compared the side-to-side difference of ICA 8 flow velocities in 68 Chinese stroke patients who had no, or ria they are using with arteriography . Only when the labo- ratories have not yet gathered enough data for validation, only mild, extracranial carotid stenosis ≤ 50% diameter reduction, and correlated the findings with their MR arteri- should they use published data as a rough guide for diagno- ography of the brain. sis of ICA stenosis. We found that in 42 patients without any significant The diagnostic criteria quoted in the recent consensus stenosis in the middle cerebral arteries, the side-to-side ICA statement by the Society of Radiologists in Ultrasound provide a reasonably reliable reference for application flow velocities were relatively symmetrical, ≤ 15 cm/sec. Of 7 10 patients with asymmetrical flow > 15 cm/sec, all had (table 1) . severe unilateral middle cerebral artery stenosis. Other useful information Using this cutoff of flow asymmetry, the sensitivity and With the advent of ultrasound technology, a carotid ultra- specificity for predicting intracranial stenosis were 53% and sound examination should not only identify the presence or 86% respectively. Despite the relatively low sensitivity, a absence of an operable carotid stenosis, but also acquire discrepancy of ICA flow velocities > 15 cm/s is a very use- useful data such as intima-media thickness (IMT) of the ful parameter for excluding intracranial stenosis. This infor- carotid artery, plaque morphology and arterial blood flow mation is especially relevant in our population because volume for the prediction of risk and prognosis of stroke intracranial stenosis is more prevalent in the Chinese popu- patients. lation4. The vertebral arteries are not as extensively investigated Intima-media thickness as the carotid arteries, partly because of lower clinical rele- Intima media thickness (IMT) is defined as the distance vance compared with the carotid arteries and partly due to between the leading edges of the lumen-intima interface and the fact that vertebral angioplasty is infrequently performed the media-adventitia interface of the far wall (figure 2). by the interventional radiologists in our institution. To Recent studies have shown that IMT is a strong predictor of locate the vertebral artery, the transducer is tilted 2Ð3 cm incident stroke and the risk increases at higher IMT val- laterally from the ipsilateral CCA. The vessel lumen is usu- ues9,10. ally visualised between the acoustic shadows cast by the bony foramina of the cervical vertebrae. Table 1 Doppler Criteria for Diagnosis of ICA Stenosis Doppler imaging is used to check for artery patency and flow direction. Retrograde flow in the vertebral artery is Degree of Stenosis(%) ICA PSV (cm/sec) PSV ratio diagnostic of subclavian steal syndrome5. Normal vertebral Normal < 125 < 2.0 arteries are usually symmetrical in size (about 3.8 mm) in < 50 < 125 < 2.0 diameter and flow but hypoplasia in either artery is common 50–69 125–230 2.0 – 4.0 and may result in flow asymmetry6. ≥ 70– less than near occlusion > 230 > 4.0 Measuring the vessel diameter may give us a clue to the near occlusion High/Low /Undetectable Variable flow asymmetry encountered and exclude any underlying Total occlusion Undetectable Not applicable significant arterial occlusive disease.

12 ASUM Ultrasound Bulletin 2004 May 7: 2 Stella SY Ho

Figure 2 Intima-media Thickness. IMT is the distance (x – x) between Arterial blood flow volume two bright interfaces in the far wall of distal 1 cm CCA just proximal Arterial blood flow volume is a valuable clinical parameter to flow divider and normally less than 1.0 mm and previous studies have been reported on its clinical sig- nificance in proximal ICA stenosis/occlusion with respect to altered cerebral haemodynamics15,16. As estimation of arterial blood flow volume by Doppler technique has inherent technical errors17, colour velocity imaging quantification utilising time domain processing has been advocated as an accurate technique for blood flow vol- ume measurement (figure 3)18. Using this technique, the author demonstrated that in 40 patients with carotid occlusive disease, a blood flow volume of ≥ 370 mL/min in the CCA or ≥ 120 mL/min in the verte- bral artery was indicative of the presence of intracranial col- laterals19. This information is important because intracranial collateralisation is found to be associated with a reduction in hemispheric cerebrovascular events20. Therefore, with the availability of the equipment, arterial blood flow volume should be incorporated into routine carotid ultrasound examination for an additional five to ten minutes in proce- Though measurement of IMT in the literature is variable dure time. with regard to the site of investigation and the number of measurements; in a practical sense, measuring IMT at the Conclusion distal CCA 1 cm segment just proximal to the bifurcation is Carotid ultrasound examinations are indispensible in cur- recommended as measurements in this segment are more rent management and prevention of strokes. Its primary role reproducible. An IMT ≥ 1.0 mm is considered as definitely is to look for carotid arterial occlusive disease and docu- 11 abnormal . ment the degree of stenosis based on standardised, validat- ed diagnostic criteria in accordance with those of ran- Plaque morphology domised trials. Both gray-scale imaging and Doppler crite- The importance of plaque morphology is emphasised when ria should be used in diagnosis. it has been demonstrated to be associated with cerebrovas- With the advance of ultrasound technology, more clini- cular events. Although the degree of stenosis is still an inde- cally relevant information such as IMT, plaque morphology pendent strong predictor of ischaemic stroke, hetero- and arterial blood flow volume can be obtained in a carotid genecity and surface irregularity of the plaque have also ultrasound examination and it is invaluable in helping the been found to be positively correlated with an increased risk neurologists in the prediction of stroke risk and prognosis of 12Ð14 of strokes . Therefore, differentiating the echopattern of stroke. a plaque into ‘homogeneous’ and ‘heterogeneous’, and characterizing the plaque surface into ‘smooth’ and ‘irregu- lar’ are recommended in a routine carotid ultrasound exam- References ination. 1 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991. 325: 445 Ð 453. Figure 3 Colour Velocity Imaging Quantification. CCA flow was 2 European Carotid Surgery Trialists Collaborative Group. MRC European carotid surgery trial: interim results for symptomatic patients equal to 385 mL/min. Noted that CVIQ was more superior than with severe (70Ð99%) or with mild (0Ð29%) carotid stenosis. Lancet Doppler technique in arterial blood flow volume estimation because 1991. 337: 1235 Ð 1243. in CVIQ blood flow volume was computed as a function of simulta- 3 Whisnant JP, Matsumoto N, Elveback LR (1973). The effect of antico- neous vessel diameter and flow velocity over several cardiac cycles agulant therapy on the prognosis of patients with transient cerebral ischemic attacks in a community: Rochester, Minnesota, 1955 through 1969. Mayo Clin Proc,vol. 48, no. 12, pp. 844 Ð 848. 4 Leung SY, Ng TH, Yuen ST, Lauder IJ, Ho FC. Pattern of cerebral ath- erosclerosis in Hong Kong Chinese. Severity in intracranial and extracra- nial vessels. Stroke. 1993 Jun; 24 (6): 779 Ð 786. 5 Reivich M, Holling HE, Roberts B, Toole JF. Reversal of blood flow through the vertebral artery and its effect on cerebral circulation. N Engl J Med. 1961 Nov 2; 265: 878 Ð 885. 6 Bartels E, Fuchs HH, Flugel KA. Duplex ultrasonography of vertebral arteries: examination, technique, normal values, and clinical applications. Angiology. 1992 Mar; 43 (3 Pt 1): 169 Ð 180. 7 Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, Carroll BA, Eliasziw M, Gocke J, Hertzberg BS, Katanick S, Needleman L, Pellerito J, Polak JF, Rholl KS, Wooster DL, Zierler RE. Carotid artery stenosis: gray-scale and Doppler US diagnosis-Society of Radiologists in Ultrasound consensus conference. Radiology. 2003 Nov; 229 (2): 340 Ð 346.

ASUM Ultrasound Bulletin 2004 May 7: 2 13 Carotid Ultrasonography – How do I do it?

8 Kuntz KM, Polak JF, Whittemore AD, Skillman JJ, Kent KC. Duplex ultrasound criteria for the identification of carotid stenosis should be lab- oratory specific. Stroke. 1997 Mar; 28 (3): 597 Ð 602. 9 Chambless LE, Folsom AR, Clegg LX, Sharrett AR, Shahar E, Nieto FJ, Rosamond WD, Evans G. Carotid wall thickness is predictive of inci- dent clinical stroke: the Risk in Communities (ARIC) study. Am J Epidemiol. 2000 Mar 1;151 (5): 478 Ð 487. 10 Hollander M, Hak AE, Koudstaal PJ, Bots ML, Grobbee DE, Hofman A, Witteman JC, Breteler MM. Comparison between measures of athero- sclerosis and risk of stroke: the Rotterdam Study. Stroke. 2003 Oct; 34 (10): 2367 Ð 2372. 11 Sidhu PS, Allan PL. The extended role of carotid artery ultrasound. Review I. Clinical Radiology. 1997. 52: 643 Ð 653. 12 Rothwell PM, Gibson R, Warlow CP. Interrelation between plaque surface morphology and degree of stenosis on carotid angiograms and the risk of ischemic stroke in patients with symptomatic carotid stenosis. On behalf of the European Carotid Surgery Trialists' Collaborative Group. Stroke. 2000 Mar; 31 (3): 615 Ð 621. 13 AbuRahma AF, Wulu JT Jr, Crotty B. Carotid plaque ultrasonic het- erogeneity and severity of stenosis. Stroke. 2002 Jul; 33 (7): 1772 Ð 1775. 14 Carra G, Visona A, Bonanome A, Lusiani L, Pesavento R, Bortolon M, Pagnan A.Carotid plaque morphology and cerebrovascular events. Int Angiol. 2003 Sep; 22 (3): 284 Ð 289. 15 Nicolau C, Gilabert R, Garcia A, Blasco J, Chamorro A, Bru C. Effect of internal carotid artery occlusion on vertebral artery blood flow: a duplex ultrasonographic evaluation. Ultrasound Med. 2001 Feb; 20 (2): 105 Ð 111. 16 Tan TY, Schminke U, Lien LM, Eicke BM, Tegeler CH. Extracranial internal carotid artery occlusion: the role of common carotid artery vol- ume flow. J Neuroimaging. 2002 Apr; 12 (2): 144 Ð 147. 17 Gill RW. Measurement of blood flow by ultrasound: accuracy and sources of error. Ultrasound Med Biol. 1985 JulÐAug; 11 (4): 6256 Ð 6241. 18 Ho SS, Metreweli C. Preferred technique for blood flow volume meas- urement in cerebrovascular disease. Stroke. 2000 Jun;31 (6): 1342Ð1354. 19 Ho SS, Metreweli C, Yu CH. Color velocity imaging quantification in the detection of intracranial collateral flow. Stroke. 2002 Jul; 33 (7): 1795 Ð 1798. 20 Henderson RD, Eliasziw M, Fox AJ, Rothwell PM, Barnett HJ. Angiographically defined collateral circulation and risk of stroke in patients with severe carotid artery stenosis. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. Stroke. 2000 Jan; 31 (1): 128 Ð 132.

14 ASUM Ultrasound Bulletin 2004 May 7: 2 ASUM Ultrasound Bulletin 2004 May 7: 2: 15–16 THE GALLBLADDER WALL The gallbladder wall: acute cholecystitis versus circumferential gallbladder oedema

Jacqueline F Spurway, Bradley J Simmons and Roger P Davies

Introduction Figure 1 Acute cholecystitis with the gallbladder wall thick- The ultrasound criterion for a normal gallbladder wall is less ened to 2.3 cm. A calculus is noted in the fundus and depend- than or equal to 3 mm. Increased thickness of the gallblad- ent sludge is present der wall is frequently described as a sign of acute inflam- matory involvement of the gallbladder. Several non-biliary conditions can lead to a similar sonographic appearance and this article will summarise the differences on ultrasound examination between acute cholecystitis and global gall- bladder wall thickening without intrinsic gallbladder dis- ease. Acute cholecystitis Acute cholecystitis commonly occurs in the 5Ð6th decade of life, and three-quarters of cases occur in females1. A major- ity of cases (96%) occur secondary to cystic duct obstruc- tion, while the remainder arise from the reflux of pancreat- ic enzymes2. Less than 10% of acute cholecystitis cases occur in the Figure 2 Hyperaemic vascularisation of the gallbladder wall absence of gallstones. Acalculous acute cholecystitis fre- quently occurs in the elderly and the critically ill and may be due to depressed motility or starvation eg. trauma, nar- cotics, total parenteral nutrition; diminished perfusion through the cystic artery eg. arteriosclerosis, diabetes, shock; extrinsic compression of the cystic duct eg. lym- phadenopathy; and infections including salmonella and cholera3. Ultrasound criteria for the diagnosis of acute cholecysti- tis depend on the presence of several of the following char- acteristics: ¥ Gallbladder wall thickness exceeding 3 mm. This fea ture is only present in 50Ð75% of patients4 (Figure 1); ¥ Positive sonographic ‘Murphy’s sign’. The ‘Murphy’s sign’ is defined as tenderness elicited by direct trans ¥ The presence of pericholecystic fluid; and ducer pressure over the inflamed gallbladder;5 ¥ Hyperaemic vascularisation on colour Doppler6 ¥ ‘Halo sign’ with the wall appearing as three layers (Figure 2). with an anechoic/ hyperechoic middle layer; ¥ Gallbladder hydrops defined as the AP diameter meas Circumferential gallbladder wall oedema uring greater than 50 mm; Predisposing factors in gallbladder wall thickening, unrelat- ed to intrinsic gallbladder pathology, include reduced plas- Correspondence to ma osmotic pressure, increased portal venous pressure and/ Jacqueline Spurway or increased extravascular fluid volume4. These factors may Department of be present in any of the following conditions; Orange Base Hospital hypoproteinemia; elevated portal venous pressure; conges- PO Box 319 tive ; multiple myeloma; acute viral hepatitis; Orange, NSW 2800 Australia hypoalbuminemia; haemorrhagic fever with renal syndrome tel +61 2 6393 3566 (hantaviruses)7; falciparum malaria; amoebic and pyogenic fax +61 2 6393 3577 liver abscesses; cirrhosis; infectious mononucleosis8; email [email protected] dengue haemorrhagic fever9; septicaemia; ascites; and AIDS. Jacqueline Spurway AMS Ultrasound criteria for the diagnoses of circumferential Bradley Simmons AMS gallbladder wall thickening depend on the presence of sev- Roger Davies MBBS FRACR MoHSM MoHLaw eral of the following characteristics:

ASUM Ultrasound Bulletin 2004 May 7: 2 15 The gallbladder wall: acute cholecystitis versus circumferential gallbladder oedema

Figure 3 Normal vascularity of thickened gallbladder wall Figure 6 Generalised oedema around the intrahepatic portal triad

Figure 4a Hypoechoic, striated collection surrounding a normal ¥ Gallbladder wall thickening to greater than 3 mm; gallbladder wall ¥ Negative sonographic ‘Murphy’s sign’; ¥ Normal vascularity of the thickened wall (Figure 3); ¥ The gallbladder wall may be seen as a distinct nor- mal wall surrounded by a hypoechoic, striated collec- tion (Figure 4); the striated thickening around the gall bladder wall often contains anechoic material consis- tent with oedema (Figure 5). ¥ Free fluid in other peritoneal recesses ¥ Hypoechoic borders of the intrahepatic portal triad consistent with generalised oedema (Figure 6); and in acute disease states the gallbladder wall thickening resolves with the course of the disease and without antibiotic therapy. Conclusion Gallbladder wall thickening can be due to inflammatory reaction in the case of acute cholecystitis or as a conse- Figure 4b Hypoechoic, striated collection surrounding a normal quence of non-biliary conditions. The distinguishing char- gallbladder wall acteristics of acute cholecystitis over non-biliary gallbladder wall thickening are a positive sonographic ‘Murphy’s sign’, hyperaemic response in the wall and lack of striations. In acute cholecystitis the entire wall is involved in the inflam- matory process whereas a delineated wall with associated oedema is seen in the non-biliary response. Specific interro- gation of these secondary signs should be routine in patients at increased risk of non-inflammatory gallbladder wall thickening to avoid an erroneous diagnosis of acute chole- cystitis. References 1 Hahn YH, Diffuse gallbladder wall thickening Ð Chorus, Collaborative Hypertext of Radiology, 2001. Web site available at: http://chorus.rad.mcw.edu/doc/00997.html. Accessed on 19 February 2004. 2 Grainger RG, Allison D, Adams A, Dixon A, Carty H, Sorigg A. Diagnostic Radiology, A textbook of Medical Imaging (4th Ed). London: Churchill Livingstone, 2001. Page 1295. 3 Dahnert W, Radiology Review Manual (1st Ed). Baltimore: Williams and Figure 5 Striated gallbladder wall Wilkins, 1991. Page 334. 4 Pickering Sharyl, University Hospitals of Cleveland, Department of Cleveland, Body Imaging Teaching Files, Case 117 Ð Gallbladder Wall Edema Related to Acute Hepatitis. Web site available at: http://www.uhrad.com/ctarc/ct117.htm. Accessed on 19 February 2004. 5 James Michael A, Personal communication, 2004. 6 Schiller VL, Turner RR, Sarti DA. Colour Doppler imaging of the gallblad- der wall in acute cholecystitis: sonographic-pathologic correlation. Abdominal Imaging 1996 MayÐJune; 21 (3): 233 -Ð 237. 7 Kim YO, Chun KA, Choi JY,Yoon SA,Yang CW, Kim KT and Bang BK. Sonographic evaluation of gallbladder wall thickening in hemorrhagic fever with renal syndrome; prediction of disease severity. Journal of Clinical Ultrasound 2001 June; 29: (5) 286 Ð 289. 8 O’Donavan N, Fitzgerald E., 1996. Gallbladder wall thickening in Infectious Mononucleosis: an ominous sign. Postgraduate Medical Journal 1996; 72: (847) 299 Ð 300. 9 Setiawan MW, Samsi TK, Pool TN, Sugianto D and Wulur H, 1995. Gallbladder wall thickening in dengue hemorrhagic fever; an ultrasonograph- ic study. Journal of Clinical Ultrasound 1995 Jul-Aug; 23: (6) 357 Ð 362. ¥ 16 ASUM Ultrasound Bulletin 2004 May 7: 2 ASUM Ultrasound Bulletin 2004 May 7: 2: 17–20 DIAGNOSTIC ULTRASOUND Isolated occlusion due to cystic adventitial disease of the popliteal artery – ultrasound diagnosis Allison C Newey, Dhanabalan Thiruchelvam, Roger P Davies

Abstract 100 metres. Other symptoms included episodic right foot Cystic adventitial disease (CAD) of the popliteal artery is a sweating and non-positional sensations of hyper- and hypo- relatively rare cause of occlusion compared to the more thermia. prevalent atherosclerosis and occurs most commonly in The past history included hypercholesterolemia treated younger male patients. A case of cystic adventitial disease with Simvastatin and a brief period of smoking as a teenag- of the popliteal artery identified preoperatively based on the er. There was no history of diabetes mellitus nor was there arterial ultrasound appearances is presented. The imaging of a family history of coronary or peripheral vascular disease. cystic adventitial disease is discussed and the importance of A ruptured cruciate ligament of the right knee 20 years recognising this condition is emphasised. Treatment options before was not repaired. do not include percutaneous angioplasty that might other- On examination, the right foot appeared slightly pale wise be a first choice in a patient with isolated occlusive and was cooler that the left. In the right leg there was a arterial disease. strong femoral pulse. No popliteal pulse was palpable. Right foot pulses were present but diminished when com- Key Words pared to the left. On right knee flexion the right foot pulses Cystic adventitial disease; popliteal artery; . were absent. No bruit was heard in the popliteal fossa. No neurological deficits were noted. There were no other stig- Introduction mata of peripheral vascular disease. Peripheral pulses were Cystic adventitial disease is one of the more rare non-ather- normal in the left leg. osclerotic causes of isolated occlusive peripheral arterial disease. Atkins and Key first reported this condition in the Figure 1 Digital subtraction angiogram of the popliteal artery show- 1 ing abrupt tapering to near occlusion of the proximal popliteal artery external iliac artery in 1947 . It most commonly affects the on the right over a distance of approximately 2.5 cm. Distal to this popliteal artery and is characterised by a mucinous cyst in there is a tapered reconstitution of a faintly opacified vessel at the the tunica adventitia layer of a blood vessel wall. This cys- level of the superior patella border and distal to this the popliteal tic structure can eventually cause a localised narrowing in artery is normal in calibre the vessel lumen and may lead to intermittent claudication. Diagnosis is based on history, examination, and imaging. Characteristic ultrasound appearances may lead to prospec- tive identification. Case report A 53-year-old man presented with a sudden onset of inter- mittent claudication of the right calf. Previously he was able to walk extended distances including steep inclines. In 8 weeks before presentation, there was a rapid deterioration with claudication at 700 metres progressing to symptoms at

Correspondence to Dr R Davies Department of Medical Imaging Orange Base Hospital PO Box 319 Orange, NSW, 2800 tel (02) 6393 3566 fax (02) 6393 3577 email [email protected]

Allison C Newey MBBS Dhanabalan Thiruchelvam MBBS Roger P Davies MBBS FRACR MoHSM MoHLaw

ASUM Ultrasound Bulletin 2004 May 7: 2 17 Allison C Newey, Dhanabalan Thiruchelvam, Roger P Davies

An arterial ultrasound of the right leg was performed Below the level of the occlusion, the artery returned to elsewhere. Pre-exercise pressures were measured with an normal calibre and damped low velocity flow was demon- ankle-brachial index (ABI) of 1.0 in the right leg and 1.08 strated in the distal popliteal artery. The anechoic material on the left side. The ABI dropped to 0.5 and 0.6 after 1 and filling the lumen of the proximal popliteal artery raised the 2 minutes of exercise but returned to 1.0 after 5 minutes. possibility of cystic adventitial disease as a cause for the Grey-scale imaging demonstrated 80% narrowing of the occlusion. right popliteal artery 4Ð5cm above the knee crease. There Open excision of the cystic lesion and interposition was no evidence of plaque nor calcification reported in this graft was performed. Pathological examination of the region. Distal to this, arteries showed low velocity excised segment confirmed precisely the diagnosis and mor- monophasic waveforms. phology of the lesion as predicted by preoperative imaging. The patient then proceeded to aorto-bi-femoral arteri- ogram with a view to angioplasty of the suspected athero- Discussion sclerotic popliteal plaque. The aorta was normal in calibre Cystic adventitial disease (CAD) is a rare condition most and the iliac system showed minor tortuosity. There was no widely reported affecting the popliteal artery. There is a cys- evidence of calibre change to indicate the presence of ather- tic abnormality of the adventitia and this may occasionally osclerotic disease. The iliac system was otherwise normal. cause occlusion of the lumen of the artery causing symp- Distally on the right, the common femoral artery was nor- toms of intermittent claudication. It has been described in mal in calibre. The profunda femoris and superficial the popliteal artery, external iliac artery, axillary artery, and femoral system were both uniform and normal in calibre, distal brachial, radial, and ulnar arteries as well as in the again with no evidence of atherosclerotic disease. The only saphenous, iliac, and common femoral . There are abnormality seen was just beyond the right adductor hiatus around 300 reported cases2. The ultrasound appearances and where there was an abrupt tapering near occlusion of the preoperative recognition by ultrasound are not widely proximal popliteal artery on the right over a distance of reported. approximately 2.5 cm (Figure 1). CAD most commonly affects males in the fourth to fifth There was a tapered reconstitution of the vessel at the decades of life. The intermittent unilateral claudication may level of the superior patella border and distal to this the be severe and of rapid onset. Patients may often be lacking popliteal artery was normal in calibre. There was three-ves- in typical risk factors for atherosclerosis, and there is usual- sel run-off and the posterior and anterior tibial vessels ly no history of preceding trauma. On examination all puls- crossed the ankle joint. es in lower extremities can usually be palpated. Pedal puls- The abrupt tapered occlusion of the proximal popliteal es may sometimes disappear on knee flexion3. There may be artery in the absence of any other evidence of atherosclerot- a bruit auscultated in the popliteal fossa4. Right and left legs ic disease was thought atypical for atherosclerotic disease. are equally affected5. A further ultrasound examination was therefore performed The aetiology of CAD is not clear. One proposed mech- to determine whether there was an extrinsic cause of com- anism is that microtrauma due to movement of the popliteal pressive occlusion of the popliteal artery. artery during knee flexion leads to adventitial trauma and Ultrasound of the right popliteal artery demonstrated a cyst formation6. This theory does not entirely explain why normal calibre vessel with laminar flow proximally. There there is not a higher incidence in athletes and labourers, nor was ectasia of the artery through the obstructed segment why the disease is more frequent in younger patients. An with mural anechoic material compressing the lumen alternate explanation is the formation of a ganglion-like col- (dimensions: 14 mm x 13 mm) Figure 2. Peripheral flow lection either from pluri-potent connective tissue cells in the was seen around the occluded central lumen corresponding wall of the artery or vein or as a result of cell migration, pos- to the appearance at angiography. sibly supported by the fact that adventitial cysts may be

Figure 2 Axial ultrasound section through the occluded segment. Figure 3 Longitudinal ultrasound image shows eccentric colour flow Anechoic mural material measuring 1.4 by 1.3 cm is seen com- closely matching the angiographic appearance. The expanded ves- pressing the lumen. Colour flow is seen in a small adjacent collater- sel with the large eccentric anechoic concentric lesion is again al vessel demonstrated

18 ASUM Ultrasound Bulletin 2004 May 7: 2 Isolated occlusion due to cystic adventitial disease of the popliteal artery – ultrasound diagnosis

biochemically and histologically similar to synovial gan- narrowed11. Initial evaluation of the popliteal fossa should glia7. It has been proposed that the cysts may arise from be by non-invasive means with (colour Doppler) US, CT, or synovial structures and track along vascular branches to the MR imaging11. adventitia of the adjacent major vessels. Connections CT with angiographic contrast may have the advantage between the joint capsule and adventitial cyst seem to sup- of not only outlining the vessel lumen but also displaying port this theory8. The alternative developmental theory sug- the tissue characteristics of the perivascular lesion (eg. fluid gests mucin-secreting cells derived from the mesenchyme density, toft tissue density or mixed)17. For this reason some of adjacent joints are misplaced into the adventitial layer of reports suggest that CT is superior to arteriography in the nearby arteries or veins during development9. These cells assessment of suspected popliteal vascular disease18. In may become stimulated in adult life to actively secrete CAD, a low attenuation lesion (values between water and mucoid material resulting in the acute onset of compressive muscular tissue) is present. There should be no calcification symptoms. in the cyst wall19. Axial images can demonstrate the rela- CAD is always localised in vessels adjacent to a joint, tionship between the cyst and the artery and the severity of and may communicate with the joint. At gross examination the lumen reduction can be measured. CT may be useful for there is usually a unilocular or multilocular cyst (averaging distinguishing CAD from popliteal artery entrapment and 1Ð8 cm) situated in the adventitia containing gelatinous popliteal artery aneurysm. material that usually appears clear. It does not communicate MR imaging has been used for evaluation of CAD. Like with the vascular lumen, and the cyst itself does not charac- CT it can directly detect the cyst and show the cyst wall. teristically have a lining. It is histologically similar to a gan- There appears to be little evidence that MRI is superior to glion cyst with the contents rich in hylauronic acid10. other forms of imaging for the diagnosis and planning ther- CAD may be difficult to diagnose. In young patients apy for CAD20. presenting with claudication, a non-atherosclerotic cause of The differential diagnosis of stenosis of the popliteal popliteal disease, such as CAD, popliteal entrapment, artery includes popliteal aneurysm, Baker’s cyst, fibromus- popliteal aneurysm, compression by a Baker’s cyst, cular dysplasia, atherosclerotic stenosis, popliteal artery embolism, or false aneurysm should be considered11. entrapment syndrome, and false aneurysm. True aneurysms Duplex ultrasound, computed (CT) or magnet- are a dilatation of all three layers of the vessel wall, where- ic resonance (MR) imaging can demonstrate the cystic as CAD affects only the adventitia, leaving the intimal layer lesion. Arteriography may demonstrate a segmental steno- uninterrupted. A fine echogenic line can be seen on ultra- sis, which is most often scimitar shaped. It can also have the sound separating the cyst from the intimal layer.21. False appearance of a smooth ‘hourglass’ shape, demonstrate a aneurysms lie completely outside the vessel and typically triangular filling defect, have the shape of a flute connect to the lumen by a neck. Blood flow is usually seen embouchure, or be M-shaped. Less commonly there is seg- within a false aneurysm and is never present in the cyst of mental occlusion12. CAD. In fibromuscular dysplasia of the popliteal artery the The remainder of the vascular system is otherwise unre- typical angiographic findings are alternate dilatation and markable with normal calibre of the artery proximal and stenosis of short segments of the artery giving a classic distal to the affected segment. The normal course of the beaded appearance or string of pearls13. In this condition, popliteal artery in the popliteal fossa helps to differentiate simple stenosis, aneurysmal dilatation or occlusion may be CAD from popliteal entrapment syndrome12,13. present. However it can be differentiated from CAD as there Ultrasound may be valuable in detecting and character- is no cyst within the vessel wall. Finally, with a Baker’s ising CAD. It is more specific than angiography in demon- cyst, the cyst is not connected or adjacent to the popliteal strating the contents of the extra-luminal mass or pseudo- artery and instead lies more medial and closer to the knee occlusions14. Ultrasound can visualise the cystic lesion in joint. the artery wall, which is anechoic, or has hypoecho con- Due to the rarity of CAD there still remains no stan- tents. The wall typically shows less echogenicity than the dardised method of surgical intervention. Although sponta- wall of a popliteal artery aneurysm where there is laminat- neous resolution22,23 and spontaneous rupture24 have been ed thrombus and atherosclerotic or calcified and thickened reported, therapy is aimed at cyst removal and maintaining intima. The isolated eccentric nature of the lesion, the char- the patency of the popliteal artery. Surgical resection of the acteristic echo-characteristics and the patient’s age should cyst is performed via a posterior popliteal approach. suggest the diagnosis of CAD15. Sometimes the cyst can be enucleated, but the affected seg- In this case the appearance of the angiogram aroused ment of the artery often requires resection and repair with an suspicion, leading to the ultrasound confirming the diagno- interposition vein graft13. This technique has shown long sis. term durability in one small series. Using this approach, Colour shows a typical picture Flannigan et al. report a success rate of 94%25.Percutaneous of stenosis with increased systolic and diastolic velocities, trans-luminal angioplasty (PTA) has not been shown to be poststenotic turbulence and distal flow reduction. successful26. Because the intima is not affected in CAD, (IVUS) has been reported as being ballooning the area does not change the pressure on the ves- a helpful diagnostic modality but is restricted due to cost sel lumen due to the cyst. The applicability of an endovas- and the invasive nature of the procedure16. With IVUS, cular for CAD of the popliteal artery has yet to be CAD appears as a sharply bordered, hypoechoic cyst locat- shown27. Percutaneous cyst aspiration under ultrasound or ed within the adventitia of the arterial wall. The cyst can CT guidance can be performed and has been shown to effec- displace the media centrally, and the arterial lumen is tively relieve the obstruction; however there has been a high

ASUM Ultrasound Bulletin 2004 May 7: 2 19 Allison C Newey, Dhanabalan Thiruchelvam, Roger P Davies

incidence of recurrence reported10,13. 12 Manke D. Regional Angiography of the Aorta In: Diagnostic Angiography, 1st edition.WB Saunders Company, Philadelphia, 1986; In conclusion, CAD is a relatively rare cause of non-ath- 299. erosclerotic peripheral occlusive disease. Prospective diag- 13 Beard JD, Gaines PA. Treatment of Chronic Lower Limb Ischaemia. nosis is important for treatment selection. In: Vascular and Endovascular Surgery 2nd edn. Harcourt Publishers, London, 2001; 56Ð58. Sonographers, radiologists, surgeons and other practi- 14 Dai-Do D, Braunscgweig M, Baumgartner I et al. Adventitial cystic tioners should be aware of this condition so that the appro- disease of the popliteal artery; Percutaneous US-guided aspiration. priate investigations and management can be arranged. In Radiology 1997; 203: 743Ð746. 15 Wolf KJ, Fobbe F. Colour Duplex Sonography, Georg Thieme Verlag, the investigation of a young patient, non-invasive investiga- 1995; 82Ð83. tions should be performed first. In the older patient who 16 Benenati JF. Intravascular ultrasound: the role in diagnostic and thera- often proceeds to angiography, as was the case in this report, peutic procedures. Radiol Clin North Am 1995; 33: 31Ð350. 17 Miller A, Salenius J, Sacks B et al. Non-invasive vascular imaging it is important to recognise the characteristic appearance of diagnosis and treatment of adventitial cystic disease of the popliteal CAD and consider US, CT or MRI to clarify the diagnosis. artery. J Vasc Surg 1997; 26: 715Ð720. 18 Beregi, Jean Paul MD, Louvegny et al. Spiral CT in the Assessment of References Suspected Popliteal Vascular Disease. J of Vascular and Interventional 1 Atkins HJB, Key JA. A case of myxomatous tumour arising in the Radiology 1998; 9(2): 204Ð205. adventitia of the left external iliac artery. Br J Surg 1947; 34: 426Ð427. 19 Wilbur AC, Woelful GF, Meyer JP et al. Adventitial Cystic disease of 2 Eric A, Elster MD. Adventitial Disease of the Axillary Artery. Annals of the popliteal artery. Radiology 1985; 155: 63Ð65. 2002. 20 Rutherford RB. Vascular Surgery, 5th edn., WB Saunders, 3 Ishikawa K, Mishima Y, Kobayashi S. Cystic adventitial disease of Philadelphia, 2000: 10. popliteal artery. Angiology 1961; 12: 357Ð366. 21 Stapff M, Zoller WG, Spenge FA. Image-directed Doppler ultrasound 4 Eastcott HHG. Cystic myxomatous degeneration of the popliteal artery findings in adventitial cystic disease of the popliteal artery. J Clin (Letter). Br Med J 1963; 2: 1270. Ultrasound 1989; 17: 689. 5 Manke D. Regional Angiography of the Aorta In: Diagnostic 22 Owen ERTC, Speechly-Dick EM, Kour NW et al. Cystic adventitial Angiography, 1st edition.WB Saunders Company, Philadelphia, 1986; disease of the popliteal artery Ð a case of spontaneous resolution. Eur J 299. Vasc Surg 1990; 4: 319Ð322. 6 Shute K, Rothnie NG. The aetiology of cystic adventitial disease. Br J 23 Furunaga A, Zempo N, Akiyama N, et al. Cystic disease of the right Surg 1973; 60; 397Ð400. popliteal artery with spontaneous resolution. Journal of Japan Surgical 7 Di MArzo L, Rocca CD, D’ AMati G et al. Cystic Adventitial Society 1992; 93 (12): 1501Ð1503. Degeneration of the popliteal artery: lectin- histochemical study. Eur J 24 Lossef SV, Rajan S, Calcagno D et al. Spontaneous rupture of an Vasc Surg 1994; 8: 16Ð19. adventitial cyst of the popliteal artery: confirmation with MR imaging. 8 Campbell WB, Millar AW. Cystic adventitial disease of common JVIR 1992; 3: 95. femoral artery communicating with the hip joint. Br J Surg 1985; 72: 537 25 Flannigan DP, Burnham SJ, Goodreau JJ, Bergan JJ. Summary of 9 Levien LJ, Benn C. Adventitial cystic disease: A Unifying Hypothesis. cases of adventitial cystic disease of the popliteal artery. Ann Surg 1979; J Vasc Surg 28: 193Ð205. 189: 165Ð175. 10 Di MArzo L, Peetz DJ Jr, Bewtra C et al. Cystic Adventitial degenera- 26 Fox RL, Kahn M, Allder J, et al. Adventitial cystic disease of the tion of the femoral artery: is evacuation and cyst excision worthwhile as a popliteal artery: Failure of percutaneous trans-luminal angioplasty as a definitive therapy? Surgery 1987 May; 101 (5): 587Ð593. therapeutic modality. J Vasc Surg 1985; 2: 464Ð467. 11 Vos, Louwerens D.MD, Tielbeek et al. Cystic Adventitial Disease of 27 Saeed M, Wolff YG, Dilley RB. Adventitial cystic disease of the the Popliteal Artery Demonstrated with Intravascular Ultrasound. J popliteal artery mistaken for an endoluminal lesion. JVIR 1993; 4: Vascular and 1996; 7 (4): 583Ð586. 815Ð818.

20 ASUM Ultrasound Bulletin 2004 May 7: 2 ASUM Ultrasound Bulletin 2004 May 7: 2: 21–25 DIAGNOSTIC ULTRASOUND Ultrasound diagnosis of Morton’s neuroma Presented at the ASUM Multidisciplinary Workshop 2004

Peter Murphy

Introduction Anatomy: Nerve location metatarsal tunnel Ultrasound is an important adjunct to the accurate diagnosis of Morton’s neuroma in people presenting with a painful forefoot. Figure 2 Morton’s neuroma is a non neoplastic enlargement of a digital branch of the medial or lateral plantar nerve. It is not a true neuroma being characterised by perineural fibrosis, vascular proliferation, edema of the endometrium and axon- al dgeneration. People most commonly affected are females between 18Ð85 years and atheletes. The condition was named after Thomas Morton in 1876 who described the affected patient as “in walking paroximal pain that goes to the heart and provokes unbearable sensa- tions with cold sweats and finally prevents the individual to direct his spirit and will to any other subject but to this unbearable pain.”

Etiology Many require a physical change to the metatarsal tunnel. Figure 3 High heeled narrow toe shoes place excess bodyweight onto the metatarsal (MT) heads and compress the neurovascular bundle (NVB). Crouching can mimic the same effect as wearing heeled shoes (Figures 1Ð4). The condition can result from trauma such as repetitive impacts due to sporting activities like running and tennis or may be due to injuries like fractures, sprains or dislocations. Rheumatoid inflammation and biomechanical abnor- mailities (such as unstable pronation of the foot, stretches the plantar nerve against the deep metatarsal ligament (DML)). Another cause is degenerative changes in the metatarsal tunnel because of diabetes. As NVB passes through the MT tunnel near its termina- tion, local nerve ischemia can easily result from compres- sion.

Figure 1 Figure 4

ASUM Ultrasound Bulletin 2004 May 7: 2 21 Peter Murphy

Metatarsal tunnel Morton’s neuroma The plantar aspect of the tunnel is the superficial transverse metatarsal ligament. The dorsal surface of the tunnel is the deep transverse MT ligament. Lateral and medial walls are the tendons of the flexor and interossei. The tunnel contains Figure 8 the NVB and lumbrical muscle (Figures 5Ð7).

Figure 5

Figure 9

Figure 6

Neuroma

Figure 10

Figure 7

Figure 11

Neuroma Hypoechoic, non compressible, located at the plantar side of the DMT ligament within the web space with positive Mulder’s and Tinel’s sign (Figures 8Ð13). Figure 11 demonstrates the location of this neuroma distal and plantar from the metatarsalphalangeal (MTP) joint.

22 ASUM Ultrasound Bulletin 2004 May 7: 2 Morton’s neuroma

Figure 12 Mulder’s test Compression of the MT heads against each other provokes an increase in pain and sometimes a ‘click’ is felt (Figure 16).

Figure 16

Figure 13

Mulder’s test with compression Applying compression onto the MTP web space will push the bursa towards the plantar aspect of the foot and with compression of the MTs provokes an increase in pain (Figure 17). Neuroma Figure 14 Figure 17

Figure 15 Tinel’s sign The Tinel-Hoffman sign results from tapping over a nerve trunk which causes a sensation of tingling and pins in its distribution. Differential diagnosis In 1980 Bossley and Carney conducted a study on the inter- metatarsophalangeal bursa which was published in the Journal of Bone and Joint Surgery volume 62-B No 22 May 1980 p 184.The bursa is visualised at the level of the 1/2, 2/3, 3/4, 4/5 MT heads on the dorsal aspect of the DML. Moving distally past the MT heads the bursa is still present between the 2/3 and 3/4 MTP webspace beyond the DML.

ASUM Ultrasound Bulletin 2004 May 7: 2 23 Peter Murphy

Note that the bursa at the level of the MT heads is pres- By applying dorsal pressure this bursa is displaced ent. towards the NVB.

Figure 18 Figure 21

Distally pass the MT heads the bursa is still present between the 2/3 and 3/4 webspace beyond the DML Mulder’s test with compression Applying dorsal compression onto the MTP web space will Figure 19 push the bursa towards the plantar aspect of the foot and with compression of the MTs provokes an increase in pain. Tissues from the web space of patients with classical neuro- ma symptoms oftem show lymphocytic infiltration, with additional fibrinoid necrosis of the bursal wall.

Figure 22

In the saggital diagram below you can appreciate how close- ly applied this bursa is to the neurovascular bundle. By applying dorsal pressure this bursa is displaced towards the NVB (Figures 18Ð21).

Pathology Figure 20 Neuroma 1 Hypoechoic mass 2/3 3/4 web space. 2 Non compressible. 3 Plantar distal DML 4 Positive Mulder’s and Tinel’s sign. 5 Pain appears cutting and electrical sensation. Bursa 1 Hpoechoic 2 Compressible 3 Dorsal aspect DML 4 Positive Mulder’s sign.

Bursa Applying dorsal pressure you can compress the bursa (Figures 22Ð24).

24 ASUM Ultrasound Bulletin 2004 May 7: 2 Morton’s neuroma

Figure 23 Figure 27

Figure 28

Figure 24

Bursa Figure 25 Figure 29

Neuroma Neuroma Apply dorsal pressure and you may distort the mass and Figure 30 also produce a sharp electrical pain (26Ð28).

Important Clinical correlation with the history and physical examina- tion is extremely important to prevent aver diagnosis.

Figure 26

Conclusion If you demonstrate a mass between the MT heads it would most likely be a bursa, look more distally towards the web space you can visualise the neuroma and plantar nerve. The most important thing to remember is that the nerve is located on the plantar surface of the MTP joint not between the MTP joints (Figures 6,7,8).

ASUM Ultrasound Bulletin 2004 May 7: 2 25 CASE STUDY ASUM Ultrasound Bulletin 2004 May 7:2: 26–27 Lactating adenoma – a case study

Deborah Moir

Presentation Figure 2 Palpable lesion 2 A 23-year-old woman presented to our department with a palpable lump in her left breast. The woman was pregnant at the time and had only noticed the lump since pregnancy. Ultrasound examination findings As the woman was young and pregnant a mammogram was not performed. The lump was easily palpable, and both breasts were examined using an ATL 5000 and a 12Ð10MHz linear probe. The right breast was considered to be normal. On scanning the left breast the palpable lump, which was situated medial to the left nipple, was found to be a solid well-circumscribed lesion measuring 2 x 1.7 x 1 cm. There were also three other lesions found within the left breast. Two, which measured 19 mm and 9 mm in maxi- mum diameter and were situated inferior and medial to the left nipple, were also solid and well circumscribed. These diameter, was found to be solid with ill-defined margins. lesions, at the time of the examination, were all felt to rep- The aetiology of this lesion was uncertain. The differential resent fibroadenomata due to their sonographic characteris- diagnoses considered were; tics. However the fourth lesion, which was situated just 1 An inflammatory lesion. superior to the left nipple and measuring 9 mm in maximum 2 An ill-defined fibroadenoma Figure 1 Palpable lesion 1 3 Carcinoma of the breast The radiologist discussed these findings with the patient at the time of the examination and it was decided a fine nee- dle aspiration should be performed of the fourth lesion. Fine needle aspiration technique The procedure was explained to the patient, who was placed in the right posterior oblique position with a sponge pad underneath her left shoulder. Using a sterile technique and under ultrasound guidance a 22 gauge needle was passed into the lesion and aspiration performed. Two separate nee- dle passes were performed, with aspiration, and the result- ing slides were sent for cytology evaluation. Cytology findings Specimen Ð FNA left breast Decription Ð 2 wet fixed slides, 2 air-dried slides, 6mL of HMS Correspondence to Microscopic Ð this is a highly cellular specimen containing Deborah Moir clusters of malignant glandular epithelial cells consistent Queensland X-Ray with carcinoma of the breast. PO Box 1473 We received this report and following our protocol, the Sunny Bank Hills Plaza radiologist contacted the referring doctor to ensure the Sunny Bank Hills results had been received. The patient was referred to a Qld 4109 breast surgeon. Deborah Moir DCR, DMU Patient follow-up Second-In-Charge sonographer Seven months later the patient re-presented at our centre for Queensland X-Ray a routine follow-up scan. She was now post-partum and post

26 ASUM Ultrasound Bulletin 2004 May 7: 2 Deborah Moir

surgery. A bilateral was again performed. Figure 3 Fine needle aspiration The ultrasound was deemed to be normal and no lesions were found in either breast. On examining the patient, she was found to have a small scar above the left nipple, and on questioning the patient, she informed us she was counselled postoperatively that the lesion was actually benign. Pathology discussion The laboratory was contacted and the patient's surgical pathology report was obtained. A frozen section of two areas of the left breast, which had been surgically removed, had been performed. One area was the suspicious lesion superior to the nipple and the other was the palpable lesion medial to the nipple. The sections are described macroscopically to contain tan coloured, firm nodules consistent with a lactating breast. Microscopically the areas are said to both be consistent bromocriptine to shrink the lesion followed by surgery. with lactating adenomas. The one above the nipple did not Bromocriptine is a dopamine agonist and reduces prolactin have a capsule, whereas the palpable lesion was partially secretion by its effects on the anterior pituitary. encapsulated. Bromocriptine reduces the size of the tumour and may even cause it to disappear. This drug does, however, suppress lac- Lactating adenoma tation and the patient must be made aware of this fact prior This is a tumour of usually young females who are either to treatment as she may refuse the drug if she wishes to con- pregnant or breast-feeding. It is a variation of a fibroadeno- tinue breast-feeding. ma. A fibroadenoma consists of delicate fibroconnective tis- Acknowledgement sue stroma with glandular structures within. The glandular Thanks to Dr Ann Finney pathologist, Mater health servic- lining consists of a single or multiple layers of epithelial es, and Dr Peter Lush Queensland X-Ray. cells. When the entire tumour consists of glands with very little intervening stroma, this is termed a tubular adenoma. References Lactating adenomas are similar to tubular adenomas, but 1. Hasson J,Pope CH Mammary infarcts associated with pregnancy pre- occur in the pregnant or lactating breast and are often mul- senting as breast tumours. Surgery 1961; 313Ð316. tiple. The lactating adenoma is often encapsulated and lob- 2. Lucey JJ. Spontaneous infarction of the breast. J Clin Path 1975; 28: ular. It demonstrates secretory activity that varies according 937Ð943. 3. Jimenez JF, Ryals R O, Cohen C. Spontaneous breast infarction associ- to length of pregnancy and initiation of lactation. A small ated with pregnancy presenting as a palpable mass. J Surg Oncol 1986; proportion of these adenomas show evidence of infarction. 32(3): 174Ð179. These lesions are considered to be benign, though can occur 4. Anderson T J. Pathological studies of apoptosis in the normal breast. simultaneously with a carcinoma. They are not considered a Endocr Relat Cancer 1999; 6(1): 9Ð12. risk factor for the subsequent development of cancer. 5. Reeves M E, Tabuenca A. Lactating adenoma presenting as a giant breast mass. Surgery 2000; 127:586Ð588. Discussion 6. Correspondence. The initial diagnosis of malignancy from the fine needle biopsy was probably made for two reasons. First, on the pathology request slip, no reference to the patient's pregnant state was made. Second, these tumours grow quite rapidly and can demonstrate very similar features to malignancy such as large nucleoli and active chromatin. There are a variety of theories as to the aetiology of this disease: ¥ There is relative vascular insufficiency caused by the sudden increase in breast tissue proliferation and secretory activity, which may lead to a thrombolytic event, but this has only been seen in a few cases. ¥ Vasculitis or trauma may be the cause, though there is no data to substantiate this. ¥ Apoptosis or programmed cell death occurs in a nor mal breast during the menstrual cycle and is influ enced by pregnancy and lactation due to the high level of cell turn over. The high cell proliferation and apop tosis peak at the first trimester, which could lead to the histological appearance of necrosis. The treatment of these lesions is often administration of

ASUM Ultrasound Bulletin 2004 May 7: 2: 27 WORKSHEETS

Neonatal Hip Ultrasound DRAFT WORKSHEET

NAME MRN CASE No. Date...... /...... /...... DOB...... /...... /......

Roof line

Inclination

α Base line Head of fermur

β

αβFHC % CONCLUSION

Rt HIP

Lt HIP

Graf’sClassification αβConsequences Type 1 > 60 < 55 No Therapy Type 2a 50Ð59 > 55 Physiological immaturity < 3 months old Ð Follow up Type 2b 50Ð59 > 55 > 3 months Ð Treatment Type 2c 43Ð49 < 77 Critical Zone Type 2d 43Ð49 > 77 Subluxed Ð labrum everted Type 3 < 43 > 77 Dislocated Type 4 < 43 > 77 Trapped between femoral head and ilium Ð treatment

FHC Consequences > 50% Normal 49Ð40% Possible dysplasia in newborns 49Ð40% Dysplasia in infants greater than 4 months 39Ð10% Subluxation < 10% Dislocation

SONOGRAPHER Date...... /...... /......

28 ASUM Ultrasound Bulletin 2004 May 7: 2 WORKSHEETS

Scapho-Lunate DRAFT WORKSHEET

NAME MRN CASE No. Date...... /...... /...... DOB...... /...... /......

TECHNICAL QUALITY Poor Good Excellent

Notes: The normal scapho-lunate ligament is a hyperechioc triangular structure between the scaphoid and lunate bones. A liberal amount of transmission gel should be used in place of the standoff pad. The dorsal aspect of the scapho-lunate articulation is imaged in the transverse plane. To identify this articulation, begin the sonographic examination in the transverse plane over the dorsal radial tubercle (Lister’s tubercle), identified as hyper-echoic with posterior acoustic shadowing. The transducer is advanced distally until the proximal pole of the scaphoid bone is visualized distal to the radio-carpal joint space. The transducer is then moved in an ulnar direction to visualize the adjacent hyper-echoic cortex of the lunate bone. The dorsal scapholunate articulation is characterized by triangular space.

Ventral Dorsal

Ventral perspective shows radiocarpal (extrinsic) ligaments Dorsal perspective shows radiocarpal ligament A = radioscaphocapitate ligament F = radioscaphoid portion B = radiolunotriquetral ligament G = radiolunate portion C = radiolunate ligament and intercarpal (intrinsic) ligaments H = radiotriquetral portion D = scapholunate ligament E = lunotriquetral ligament

SONOGRAPHER Date...... /...... /......

ASUM Ultrasound Bulletin 2004 May 7: 2 29 BOOKS Book reviews

Atlas of Chest Sonography however is high Ð high enough to reas- Radiology Illustrated: sure a reviewing radiologist that such Uroradiology Editors G Mathis and KD Lessnau images are unlikely to be obtained Publisher Springer-Verlag Berlin 2003 using a portable device in a pulmo- Author/ Editors WH Bush J Y Cho, Pages 179, with 256 figures and 447 nologist's rooms plugged into an JW Chung et al. illustrations ‘expansion slot’ in a palm pilot (anoth- Publisher Saunders (Elsevier Science) Cost $A178.00 er editorial aspiration). 2003 ISBN 3-540-44262-6 Several uses for ultrasound which Cost $A368.00 approx are probably seen infrequently in This book is intended as a pictorial Australian hospitals are discussed, This book of 938 pages includes atlas aimed mainly at pulmonary including its use in diagnosing rib approximately 3000 illustrations, it is physicians. It is edited by two physi- fractures (for which it is much more designed to be a practical illustrated cians, and chapters have been written sensitive than plain films and which guide to uroradiology. It is very good by German, Austrian or Dutch may prove useful in the settings of Ð even with the $A368.50 price tag. It internists. The stated aim of one of the atypical chest pain and planning for is not exclusively an ultrasound atlas, editors is that ‘the application of surgical fixation of rib fractures) and but includes all imaging modalities in sonography will become democratised in biopsy of mediastinal and peripher- appropriate proportion. and it will be used by many trainees al lung lesions. My only criticism of The book is well set out over 30 and practicing pulmonologists, radiol- the latter is that the literature used to chapters, making it simple to locate ogists and internists’. The same editor promote the real-time advantages of specific topics. Each chapter begins asks the question ‘Why should the US over CT is from the early 1990s with a brief text, which is useful to a sonogram remain exclusively within and takes no account of the ‘CT fluo- point, but by no means comprehen- the Department of Radiology . . .?’ roscopy’ capabilities of modern multi- sive. Lovers of the medical ‘turf battle’, slice scanners. The real value lies in the images. read on. The chapter on endoscopic ultra- Each image has a succinct legend, and Its subject is approached in four sound and biopsy made interesting the images are appropriately labelled broad areas Ð equipment and artifacts reading, as this modality is likely to and arrowed. The cases are generally (three chapters), thoracic regional establish its place as a complementary of a very high quality in terms of sub- imaging (chest wall, pleura, peripheral procedure to mediastinoscopy and CT ject, and are generally very good in lung and mediastinum (four chapters), for the staging of thoracic neoplasms. terms of image quality. interventional chest sonography (one Contentious assertions, such as ultra- Some fantastic examples of com- chapter) and clinical problem-oriented sound as first line imaging in chest mon and uncommon conditions are chest sonography (two chapters). pain or suspected pulmonary embolus included. A minor criticism is that all The writing style varies between are a welcome stimulus to ‘think out- the images are small, and on occasion chapters, some are smooth-flowing side the square’ and are well refer- it is difficult to see the abnormality. and easily readable, others are ham- enced for further reading. Each image is displayed in black and pered by obvious translation prob- Overall, the authors have achieved white, though the same images are lems, the best example being multiple their main aim of illustrating the spec- also displayed in colour in a separate references to the ‘dignity’ of lymph trum of chest disease visible with section (presumably this was done to nodes in Chapter 2. ultrasound. reduce the cost of producing the Similarly, the quality of illustra- This book would be useful as a ref- book). Recent imaging advances are tions varies, with several chapters con- erence text; it is a timely reminder that included, such as MRI, helical CT for taining beautiful images, which are thoracic ultrasound is an underused urothelial tumours and virtual cys- clearly labelled and described, and modality and that there is nothing bet- toscopy. others where mislabelling or lack of ter than a looming turf battle to spur Sections on renal tuberculosis, labelling is obvious. In several areas I radiologists into remedying such a sit- complicated renal cysts and retroperi- felt this to be a major oversight, for uation. toneal tumours are particularly good, example, in the illustrations of chest but no one section is below par. It is wall invasion by tumours, which need hard to find major criticisms, however more meticulous labelling to ade- Dr Stefan Heinze the stone and renal obstruction sec- quately illustrate the subtle sono- Consultant Radiologist tions don’t have too many examples of graphic findings. The overall standard The Royal Melbourne Hospital non-contrast CT and the MRI of the

30 ASUM Ultrasound Bulletin 2004 May 7: 2 BOOKS prostate doesn’t include spectroscopy. Overall I found this to be an excellent PRACTICAL ULTRASOUND TRAINING book covering the whole spectrum of uro- WITH THE AUSTRALIAN INSTITUTE OF radiological imaging. It would be particu- ULTRASOUND larly useful for registrars approaching exams, and as a reference book in a busy The Australian Institute of Ultrasound offers a range of department. proven, ‘hands on’, intensive workshops for the Ultrasound Practitioner. Dr Rick Dowling Consultant Radiologist Coming up in the next quarter are: The Royal Melbourne Hospital * Fasttrack O&G Ð June * Breast Ultrasound Workshop Ð June Case Review: Obstetric and * Fasttrack Vascular Ð July Gynecological Ultrasound. Case * Practical Workshop Ð July Review Series. Pamela Johnson, Alfred B Krutz All of the above workshops are of 3Ð5 days duration and are Mosby 2001 conducted at our purpose designed facility on the Gold Coast ISBN 0323008607 * Advanced Vascular Weekend Ð July This book is one of a series of case review (2 days) volumes available from the publishers, Mosby. It is a soft cover A4 size book of * Check out the Learn On-Line modules available at 194 pages and is well priced at $US 39.95. www.aiu.edu.au It is set out in a similar fashion to the * Free Sample Available Now General and Vascular Ultrasound edition with 127 cases divided by increasing com- To find out more contact: plexity into Opening Round, Fair Game on-line www.aiu.edu.au and Challenge sections. email: [email protected] There are 2Ð3 cases per page with the tel: (07) 55266655 answers and references on the reverse. This has the advantage of not having to continually flip to the end of the book to check the answer. Attention There are usually four questions per image series, and definitive answers are supplied along with a one or two para- Sonographers graph comment on the case, with at least & one (usually more) journal reference. Some of the cases are quite difficult (especially those related to the fetal heart) and are not easy to determine from the Are you thinking of working images supplied. However, the quality of the images is good overall. In the UK ? Each case is an excellent learning tool and the related references are extremely useful. Let us make it easy Overall this book would be a valuable addition to any library and especially use- and our services are free ! ful to students, lecturers and others preparing for exams in the field of obstet- ric and gynaecological ultrasound. TOP RATES OF PAY Alison Lee-Tannock Senior Sonographer SONOGRAPHERS Mater Mothers’ Hospital medical NZ Limited Don’t miss ASUM ASM 2004 Contact: [email protected] 23Ð26 September, Sydney Tel: +64 3 338 6774

ASUM Ultrasound Bulletin 2004 May 7: 2 31 EDUCATION Fetal measurements requirements

The measurements required for a fetus the image. If you can see the kidneys Femur length may seem to be a very basic skill, and then you are too low in the abdomen. The femur must be at 90¼ to the ultra- common knowledge, but it must be Stomach must be visualised, along sound beam, any other angle can lead reinforced to all students attempting with the middle third of the umbilical to inconsistencies in the measurement. DMU Practical exams. vein. The measurement is made at the The proximal femur must be meas- It is vital that all ultrasound fetal outside of the skin edge. ured; this means the femur closest to measurements must be performed pre- the transducer. cisely and meticulously every time Do not measure the distal femur they are done. It is only in this manner Bi parietal diameter and head (the one furthest from the beam), this that dating errors can be minimised. circumference is incorrect. The shaft of the femur An over-measurement of fetal abdom- Bi parietal diameter and head circum- must cast a shadow to prove you are inal circumference and head circum- ference are measured at the same measuring the full length of the bone. ference may be the difference between level. Do not measure the epiphysis. the measurements crossing a centile You must see cavum septum pellu- Do not measure the small side lobe line in a later scan or fetal growth cidum, thalami and falx cerebri in the artifact from the end of the shaft, you remaining within their centile line. image. The falx of the brain must be can visualise where the bone ends All images must be optimised with equidistant from the upper and lower using the shadowing from the shaft, an close attention to depth, focus and skull, with one side of the brain a mir- artifact will not cause this shadow. TGC, sector width, and zoom func- ror image of the other. The measure- tions. ment is taken above the level of the Humerus length All measurements should be done roof of the orbits, and must not include The same principles of measurement at least twice. any posterior fossa. If the posterior of the femur apply to measurements of fossa is showing in the image the head the Humerus. Again Ð the humerus Abdominal circumference circumference is over estimated. must be at 90¼ to the beam. First, the abdominal circumference The measurement is performed at The measurement must be of the must be ROUND. If it is oval the the widest part of the head, from outer proximal humerus, the one closest to measurement is greater than it should table to inner table.(The cavum sep- the transducer. be. If the image is oval then unfreeze tum pellucidum appears as an empty It is only by adhering very strictly the image and try again. box, the thalami resemble a butterfly to the measurement criteria that accu- Kidneys must not be included in and the falx is a straight white line). rate and reproducible measurements

Figure 1 Correct abdominal circumference

Correct outline Incorrect outline

Figure 2 Correct abdominal Figure 3 Ultrasound image correct circum- Figure 4 Ultrasound image of correct head circumference measurement ference measurement image for BPD and HC measurement

32 ASUM Ultrasound Bulletin 2004 May 7: 2 EDUCATION

Figure 5 Correct head placement for Figure 6 Graphic representation of correct Figure 7 Graphic representation of humerus BPD and HC measurement femur visualisation for measurement length measurement

shadow from femur shaft

Distal femur

of the fetus may be obtained. You can- Figure 8 Ultrasound image of correct femur Figure 9 Ultrasound image of correct not use a 'near enough is good enough' length measurement humeral length measurement technique. All ultrasound departments must produce comparable and accurate results. This can only be achieved by each sonographer maintaining the highest standards. Tutor sonographers must insist that all students maintain the same high standards at all times, and a quality assurance program may be helpful.

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ASUM Ultrasound Bulletin 2004 May 7: 2 33 EDUCATION DMU examination dates and venues

Examination dates 2004 candidate enrols in the Part 2 General Ð Saturday 23 October 2004 Part I and II Written Examinations Examination, at a time negotiated Venue Ð Christchurch (NZ candidates) Saturday 31July between the ASUM DMU Board of Venue Ð Perth (WA Candidates) Part II Objective & Standardised Examiners and the Clinical Practice at Venue Ð Sydney (NS, Qld and Vic can- Clinical Examinations (OSCEs) and which the examination will be con- didates) ducted. Oral Examinations: ObstetricÐ Saturday 23 October 2004 Cardiac: Saturday 16 October Notification of the time and place Venue Ð Sydney (ALL candidates) General: Saturday 23 October of examination will be posted to can- Obstetric: Saturday 23 October didates at least 18 working days prior Vascular Saturday 16 October 2004 Ð Vascular: Saturday 16 October to the Practical Examination. Sydney The DMU Board of Examiners The ASUM Board of Examiners Venue Ð Sydney (ALL candidates) will determine the locations for the will not normally accede to requests Part II Practical Examinations: OSCEs and Oral Examinations once from candidates for changes to the Between August to October Ð the final candidate numbers, venue date or time of examination. Conducted at candidates' practices by availability and Examiner require- Managers. ments are known. Venues 2004* *The DMU Board of Examiners Candidates are also reminded that Part I and II Written Examinations - while the dates for the OSCE/Oral Saturday 31 July 2004 determined the final locations for the Examinations are fixed, all modalities Part II Objective & Standardised OSCEs after final candidate numbers, will not necessarily be examined at Clinical Examinations (OSCEs)* and venue availability and Examiner every centre. Oral Examinations requirements were known. Cardiac Ð Saturday 16 October 2004 Candidates are again reminded that Practical Examinations Venue Ð Brisbane (NSW, NT, NZ and while the dates for OSCEs are fixed, Practical Examinations are normally Qld candidates) conducted between 1 April and 31 Venue Ð Melbourne (Vic, SA and WA all modalities are not necessarily October of the year in which the candidates) examined at every centre.

DDU exam dates and fees 2004 WA Branch meetings Part I Examination Fee The Written Examination for Part II will be held on Monday 17 May 2004. June 12/13 Ð Physics Weekend at A$990.00 (includes GST) for ASUM RPH with Roger Gent/Mike Dadd The Oral Examination for Part II will Members A$1,254.00 (includes GST) June 19/20 Ð Part 2 DMU Film for Non members be held on Saturday 19 June 2004 in Reading Weekend at RPH Sydney. June 23 Ð Branch Meeting RPH Ð The Oral Exam for Cardiology candi- Part II Examination Fee Dr E Lee ‘Ultrasound in First dates will be in Melbourne on Trimester’ $A1,760.00 (includes GST) for Thursday 17 June 2004. August 15 Ð Travelling Fellow ASUM Members $A2,024.00 Workshop in Bunbury Ð Venue (includes GST) for Non members Results TBA Examination results will be mailed to August 17 Ð Travelling Fellow Part II Casebook Fee candidates early July following the Workshop in Kalgoorlie Ð KRH $A330.00 (includes GST) DDU Board of Examiners meeting. August 18 Ð Branch Meeting Ð The ASUM Bulletin publishes infor- Travelling Fellow at RPH – ‘DVT mation relating to changes in fees, Research Topic’ Application forms may be down- August 19 Ð Travelling Fellow at loaded from the ASUM website at examination dates, regulations, etc. Members are kept up to date with this RPH Ð Tutorial for Part 2 www.asum.com.au Candidates and other related information by auto- Fees quoted above are from July 1 August 21 Ð Travelling Fellow 2002 and may be subject to change. matically receiving the Bulletin. Workshop in Broome Ð Venue TBA Submissions are invited for November 22 Ð Xmas Branch Information pertaining to the the ASUM Annual Meeting at Lamonts (East Perth) Ð Dr R Hart – ‘Ultrasound In Space’ next examinations Scientific Meeting For further information contact 2004 Part I The Part I Examinations contact ASUM on Elvie Haluszkiewicz or Marilyn for 2004 will be held on Monday 17 +61 2 9958 7655 Zelesco tel +61 8 9224 7076 May 2004.

34 ASUM Ultrasound Bulletin 2004 May 7: 2 EDUCATION Giulia Franco Teaching Fellowships extends education for rural sonographers

In 2004 the Education Committee has career with Toshiba. Its first award is Three Teaching Fellowships are appointed Shaun O’Regan as the in 2004. awarded each year. Giulia Franco Teaching Fellow to Shaun O’Regan will conduct Branches wishing to propose pro- Western Australia. teaching clinics and/or lectures at grams for the 2005 Teaching The Giulia Franco Teaching these venues: Fellowships should, in the first Fellowship was established by ASUM August 15 Ð Bunbury instance, contact Keith Henderson tel in association with Toshiba Medical to August 17 Ð Kalgoorlie Ð KRH +61 2 9958 6200 fax +61 2 9958 8002 provide educational opportunities for August 18 Ð Perth Ð Branch email [email protected] sonographers in all parts of Australia Meeting at RPH – ‘DVT Research Nominations and proposals should and New Zealand. Topic’ The fellowships increase the August 19 Ð Perth Ð RPH - Tutorial be addressed to: opportunity for members outside the for Part 2 Candidates The Education Manager main centres to have access to quality August 21 Ð Broome ASUM 2/181 High St educational opportunities. The organiser contact in Western Willoughby NSW 2068 It is named to commemorate Australia is Marilyn Zelesco (mari- Giulia Franco whose passion for ultra- Australia [email protected]). sound education took her to all parts of and should be received before 22 Australia and New Zealand, and con- Further details will be posted on the tinued as she moved into a business ASUM website www.asum.com.au November 2004.

Chris Kohlenberg Teaching NZ Ultrasound Video Library Fellowships 2004 Due to the lack of a corporate spon- sor, the NZ ASUM Branch In 2004 the Education Committee has Invercargill and Dunedin in November Committee is now operating the appointed Peter Murphy as Chris 2004. Further details will be published Ultrasound Video Library. To cover the cost of mailing the Kohlenberg Teaching Fellow to New in the August Ultrasound Bulletin. The videos, we will be introducing a Zealand, and Dr Gary Sholler as Chris local organiser is Jillian Muirhead charge for ASUM members of $10 Kohlenberg Teaching Fellow to the ([email protected]). for up to three videos for a two- ACT. Gary Sholler will conduct foetal week period. Further details of these programs echocardiography teaching sessions at This charge includes return will be published on the ASUM web- various venues in the ACT 28Ð30 postage. For non-ASUM members site: www.asum.com.au October. The local organiser is Sue the charge will be $NZ20. Please The Chris Kohlenberg Teaching Caitcheon ([email protected]). make cheques payable to NZ Fellowship was established by ASUM Further details will be published in ASUM. in association with GE Medical the August Ultrasound Bulletin and on We will be offering an amnesty Systems Ultrasound to increase the the ASUM website until 1 June 2004 on any videos that are currently outstanding. We opportunity for members outside the www.asum.com.au. would appreciate their return, no main centres to have access to quality Branches wishing to propose pro- questions asked, so other sonogra- educational opportunities. grams for the 2005 Teaching phers may benefit from them. In The Fellowship has been awarded Fellowships should, in the first future any borrowers who do not annually since 1998 to provide educa- instance, contact Keith Henderson tel return videos will receive an tional opportunities for members in +61 2 9958 6200 fax +61 2 9958 8002 account for the replacement cost. New Zealand, Queensland and New email [email protected] We wish to thank Schering for South Wales, Northern Territory, Nominations and proposals should their generous support of the library Western Australia, South Australia and be addressed to: over the past five years. Please email Tasmania. The Education Manager your video requests to: It is named to commemorate Dr ASUM Jo McCann [email protected]. Chris Kohlenberg, who died while 2/181 High St Willoughby NSW 2068 Australia The NZ video library may be travelling to educate sonographers. viewed at http://www.asum.com.au Peter Murphy will conduct teach- and should be received before 22 ing clinics and meetings in Nelson, November 2004.

ASUM Ultrasound Bulletin 2004 May 7: 2 35 EDUCATION ASUM invites scientific papers and posters for ASUM 2004

You are invited to submit abstracts for posters allow delegates to consider the Accepted abstracts will be presented consideration by the Organising material in their own time and are free in either oral or poster sessions and Committee for presentation at ASUM to discuss any point informally with authors will be notified of abstract 2004. The program will include both the presenter. acceptance and the form of presenta- scientific papers and posters. The tion six weeks after submission clo- Organising Committee encourages Abstracts sure. registrants to submit either or both. Abstracts must be submitted no later Scientific papers will be of 15 min- than Friday 4 June 2004 and must fol- Prizes utes duration including 5 minutes dis- low the guidelines for abstract submis- Papers submitted by registrants are cussion time. sions as set out on the Meeting web- generally eligible for a range of gener- Poster presentations are an site. On-line submission is the meet- ous prizes offered by our corporate extremely effective way to present ing’s only method for receipt of sponsors information at a scientific meeting. It abstracts. Please visit the meeting is an ideal way to present research website www.icms.com.au/asum2O04 Registration rebate papers and case studies and has proved for instructions on how to submit. Delegates who have a paper or poster to be a popular alternative to an oral Abstracts will be reviewed by the accepted will receive a rebate of $110 presentation. The advantages are that Meeting Scientific Committee. off their full registration.

Adjudication of prizes and awards at the ASUM Annual Scientific Meeting

Due to the generosity of ASUM The stated purpose of the prize or technique or a literature based review Corporate Members a range of prizes award is a major factor in determining of a particular topic. and awards are offered for proffered the eligibilty of contributions for a presentations at the Annual Scientific particular prize or award. 4 Poster presentation of original Meeting. Prizes and awards are for For the purpose of prizes and research specifically designated purposes as awards, contributions to the scientific This type of presentation will typical- described on the published list of program are broadly categorised into 4 ly describe the methodology, results prizes and awards. groups: and conclusions of scientifically con- Adjudication of the prizes and ducted, original research. awards is undertaken by an Eligibility for particular prizes and 1 Oral presentation of a awards is based on the nature of the Adjudication Panel, under the aus- descriptive clinical or literature pices of the ASUM Education presentation, professional category of review type the presenter and other criteria as Committee. The Adjudication Panel is These may include a case study described in the relevant prize or normally chaired by the Chairman of description, the description of a new award description. In submitting a the Education Committee and has, as technique or a literature based review presentation for consideration for its members, persons selected by the of a particular topic. Chairman, in consultation with others prizes and awards, contributors are advised to read the list of prizes and as required. Selection of panel mem- 2 Oral presentation of original bers is based on considerations includ- awards, and their descriptors, deter- research mining the eligibilty of contributions ing professional expertise, geographi- This type of presentation will typical- for a particular carefully cal location to ensure a balance of rep- ly describe the methodology, results resentation, a balance of sonologist, and conclusions of scientifically con- Adjudication guidelines sonographer and scientist members, ducted, original research. The following lists the components of and willingness to participate. a presentation that are considered by In order to conduct the adjudica- 3 Poster presentation of a the adjudicators during assessment. tion of prizes and awards in the most descriptive clinical or literature The categories and suggested weight- objective and equitable way guidelines review type ing of each component are guides for adjudication and scoring sheets are These may include a case study only may be modified as appropriate used by the panel. description, the description of a new by the adjudicators.

36 ASUM Ultrasound Bulletin 2004 May 7: 2 EDUCATION Adjudication guidelines

1 Oral presentation of a Relates to, and is supported, by rele- 4 Poster presentation of original descriptive clinical or literature vant literature research review type Conclusion Introduction Introduction Suggested weighting 5% Suggested weighting 5% Suggested weighting 5% Summary of findings Sets scene Ð refers to literature and Acknowledges Chair and audience Outlines any recommendations for work already done in the field Sets the scene, why topic was chosen future work/ action Indicates why topic was chosen Aims/ hypothesis/ purpose clearly Originality/ Value of research States aim/ hypothesis clearly stated Content Suggested weighting 30% Content Suggested weighting 50% Suggested weighting 50% The topic displays an originality of Methods clearly outlined Describes the problem/ issue/ tech- topic/ approach Results clearly presented with appro- nique in detail The research is relevantand beneficial priate and valid use of statistics Discussion relates to, and is supported to the profession Outlines limitations of study method by relevant literature Presentation Original thought/ analysis of results is Literature is appropriate and current Suggested weighting10% evident Comprehensive coverage Clear and audible Discussion relates to, and is supported Relates topic/ issues to local context/ Systematic structure, references cited by, relevant literature conditions appropriately Conclusion Conclusion Slides well sequenced, relate to verbal Suggested weighting 5% Suggested weighting 5% Presents summary of findings text and easily viewed Summary of discussion/ major points Outlines any recommendations for Outlines recommendations for future Well timed future research/ action work Design Presentation 3 Poster presentation of a Suggested weighting 10% Suggested weighting 10% descriptive clinical or literature Logical, easy to follow Clear and audible review type Information presented concisely, ref- Systematic structure, references cited Introduction erences cited appropriately appropriately Suggested weighting 5% Text eye catching and easily viewed Slides well sequenced, relate to verbal Important points well illustrated Sets scene Ð refers to literature and text and easily viewed Originality/ Value of topic work already done in the field Well timed Suggested weighting 30% Originality/ Value of topic Content The topic displays originality of topic/ Suggested weighting 30% Suggested weighting 50% approach The topic shows an originality of Indicates why topic was chosen The research is relevant and beneficial approach States aim clearly to the profession The topic is relevant and beneficial to Describes the problem/ issue/ case in the profession detail 2 Oral presentation of original Approach to problem/ issue/ technique Best sonographers research research is valid presentation award Introduction Discussion relates to, and is supported Value $2000 Suggested weighting 5% by, current literature Sponsored by Philips Medical Acknowledges Chair and audience Original thoughts on topic are evident Systems Sets scene Ð refers to literature and Ð Conclusion To be awarded for the best work already done in the field proffered research paper by a Suggested weighting 5% sonographer Methodology Presents summary of findings Suggested weighting 10% Outlines any recommendations for Best research presentation Describes the materials and methods future research/ action award used Value $1500 Describes study design Design Sponsored by Describes sampling methods Suggested weighting 10% Siemens Logical, easy to follow States any variables To be awarded for the best Results Information presented concisely, ref- erences cited appropriately proffered research paper Suggested weighting 20% Text eye catching and easily viewed Presented clearly and concisely Best clinical presentation Important points well illustrated award Appropriate use of statistics Originality/ Value of topic Results are valid Value $1000 plus a shield Discussion Suggested weighting 30% Sponsored by Siemens To be awarded for the best Suggested weighting 20% The topic displays originality of topic/ approach clinical presentation proffered Outlines limitations of study as a paper or poster Original thought/ analysis of results is The research is relevant and beneficial evident to the profession ASUM Ultrasound Bulletin 2004 May 7: 2 37 EDUCATION

BERESFORD BUTTERY TRAVEL GRANT RANZCOG RESEARCH FOUNDATION The Beresford Buttery Travel Grant for further training in obstetrical and gynaecological ultrasound has been provided from donations to the Beresford Buttery Trust Fund, to commemorate the outstanding contribution of the late Beresford Buttery to the development of obstetrical and gynaecological ultrasound. Conditions of the award The Fellowship shall be in the form of a grant to assist the successful applicant to travel to any country for the purpose of making a particular study of any scientific, research or clinical subject relating to the practice of obstetrical or gynaecological ultrasound. It shall not be awarded for the purpose of assisting the applicant to gain a postgraduate degree. Eligibility The travel grant is open to medical graduates who are committed to a career providing obstetrical and/ or gynaecological ultrasound services in Australia or New Zealand, and who are normally resident in Australia or New Zealand. Tenure There is no requirement as to a period of tenure for the overseas visit. Application Applications are to be submitted using the RANZCOG Research Foundation Application Form. The date for receipt of applications is 30 June 2004. Applications must be accompanied by two written references commenting on the personal, clinical and scientific suitability of the candidate to undertake the proposed visit; and confirmation of the study visit placement from the supervisor for the placement. Applications are assessed by the Scholarship Selection Committee of the RANZCOG Research Foundation, with input from the Australasian Society for Ultrasound in Medicine. Stipend and allowances The grant shall be used towards air travel/ accommodation to and from the place of study to the value of $A3000.00 Report on the Fellowship The successful applicant shall agree to submit a report on his/ her work within three months of his/ her return. The report is to be submitted to the Research Foundation and the Australasian Society for Ultrasound in Medicine. This report will be reviewed by the Board of Directors and the Scholarship Selection Committee of the RANZCOG Research Foundation.The Beresford Buttery Travel Grant provided by the RANZCOG Research Foundation/ ASUM is to be acknowledged in any publication or thesis resulting from work undertaken during the period of study by stat- ing that the author was the recipient of the Beresford Buttery Travel Grant during a particular year. A copy of any published article arising from research carried out under the Beresford Buttery Travel Grant is to be submitted to the RANZCOG Research Foundation and the Australasian Society for Ultrasound in Medicine when available. Details of the Beresford Buttery Travel Grant and the application form are available on the RANZCOG website at: www.ranzcog.edu.au or contact Carmel Walker tel +61 3 9412 2926 or +61 3 9417 1699 fax +61 3 9415 9306 RANZCOG RESEARCH FOUNDATION (incorporating the Arthur Wilson Memorial Foundation) c/o The Royal Australian and New Zealand Collegeof Obstetricians and Gynaecologists 254–260 Albert Street East Melbourne 3002 Australia THIS GRANT IS DISTINCT FROM THE ASUM BERESFORD BUTTERY OVERSEAS TRAVEL GRANT FOR DETAILS SEE BELOW

ASUM Beresford Buttery Overseas Traineeship It is with great pride that ASUM and GE have the opportunity to offer an annual traineeship in the field of obstetric and gynae- cological ultrasound, in memory of Beresford Buttery FRANZCOG, DDU, COGUS who made an inestimable contribution to his profession. Since its foundation GE Medical Systems has constantly been at the forefront of research and technical innovation, with GE today being recognised as a world leader in the supply of diagnostic imaging systems. The award will cover attendance at an appropriate educational program at the Thomas Jefferson Research and Education Institute in Philadelphia and will include tuition fees, economy airfare and accommodation for the duration of the course (usu- ally four days). The award will be made to applicants who: 1 Seek to further develop their skills and experience in obstetric and gynaecological ultrasound. 2 Have as a minimum qualification Part 1 of the DDU or DMU (or equivalent) or have been awarded the DDU or DMU (or equivalent) within the last 10 years (since 31 December 1993). 3 Have been a financial member of ASUM for a minimum of two years prior to the closing date Applications should include: ¥ A curriculum vitae ¥ Details of current and post employment, particularly in the field of obstetrics and gynaecology; ¥ Testimonials from two referees in support of the application including contact address and telephone number; ¥ An outline of professional goals and objectives; and ¥ An indication of benefit from award of the Traineeship. The successful applicant is asked to provide a written report on return from the course. Applications addressing the criteria should be forwarded by Friday 25 June 2004 to: GE Beresford Buttery Overseas Traineeship Australasian Society for Ultrasound in Medicine 2/ 181 High Street Willoughby NSW 2068 Australia

38 ASUM Ultrasound Bulletin 2004 May 7: 2 SOCIETY Chris Kholenberg Teaching New jobs for Hassall and Pemble Commencing Monday 24 May 2004 Fellowship report 2003 Ms Lynette Hassall will be appointed as Lecturer in the School of Physical and Chemical Sciences, Faculty of It was a thrill and honour to be award- little extra vascular information to Science, QUT. ed the Chris Kholenberg Teaching what I found was a good knowledge Lynette's role is as Program Fellowship for 2003. To speak and base to start with. Coordinator and Lecturer in the post- work with sonographers in rural South On a personal note, I would like to graduate Diploma of Medical Australia was an excellent opportunity thank Lyn Muir and staff at Mt. Ultrasound programs run by QUT to experience the daily referral base in Gambier, Leanne Murphy and staff at from the Gardens Point Campus in busy remote hospitals. Whyalla Hospital for their warm hos- Brisbane. Visiting both Mt. Gambier and pitality and to the sonographers who Dr Lucia Pemble who currently holds this position will be Senior Whyalla hospitals gave me a better travelled from outside those areas to Lecturer at Griffith University at appreciation of what sonographers do come to my lectures and workshops. Nathan. Lucia has been appointed on a day to day basis, with at times Thank you also to Stephen Bird, Rosie Program Convenor of the limited information and resources to Franklin and Ian Murphy (GE) for Postgraduate Masters of Science in call upon. their hospitality and organisation Clinical Physiology and The sonographers I had the pleas- while in Adelaide. Undergraduate Convenor for Human ure of working with in both areas have The lectures in Adelaide were well Physiology within the School of a good work ethic and the ability to do attended despite SA school holidays Biomolecular and Biomedical Science. everything from OBGYN, general with a chance to share current vascular Both Lynette and Lucia will con- MSK and vascular. practices with the locals. They know that those patients with tinue clinical sonography and are A special thank you also to GE for involved heavily with ASUM in the positive diagnoses will eventually go their continued support of this award, society’s academic and examination to the bigger tertiary hospitals, howev- activities; Lynette as a Practical to keep the Chris Kholenberg passion er to get the initial diagnosis right is a Examiner and Lucia as Secretary of source of great satisfaction and for education a ‘reality’ and not just a the ASUM DMU Board of Examiners. achievement. My goal was to give a memory. We wish them well.

ASUM Chris Kohlenberg ASUM Giulia Franco Teaching Fellowships 2004 and 2005 Teaching Fellowships 2004 and 2005 Sponsored by Sponsored by Toshiba Ultrasound GE Medical Systems Ultrasound The Giulia Franco Teaching Fellowship was established by In 2004 the Education Committee plans programs in the ASUM in association with Toshiba Medical to provide edu- Western Australian and New Zealand branches for the cational opportunities for sonographers in all parts of Chris Kohlenberg Teaching Fellows. Further details of these Australia and New Zealand. programs will be published in the Ultrasound Bulletin and on the ASUM website: www.asum.com.au The fellowships increase the opportunity for members The Chris Kohlenberg Teaching Fellowship was established outside the main centres to have access to quality educa- by ASUM in association with GE Medical Systems tional opportunities. Ultrasound to increase the opportunity for members out- It is named to commemorate Giulia Franco whose pas- side the main centres to have access to quality educational opportunities. It has been awarded annually since 1998 to sion for ultrasound education took her to all parts of provide educational opportunities for members in New Australia and New Zealand, and continued as she moved Zealand, Queensland, New South Wales, Northern into a business career with Toshiba. Its first award is in Te r ritory,Western Australia, South Australia and Tasmania. 2004. It is named to commemorate Dr Chris Kohlenberg, who Further details are on the ASUM website www.asum.com.au died while travelling to educate sonographers. Branches wishing to propose programs for the 2005 Three Teaching Fellowships are awarded each year. Teaching Fellowships should, in the first instance, contact: Nominations and proposals should be addressed to: Keith Henderson tel +61 2 9958 6200 fax +61 2 9958 8002 email [email protected] The Education Manager Nominations and proposals should be addressed to: ASUM 2/ 181 High St The Education Manager ASUM 2/ 181 High St Willoughby 2068 NSW Willoughby 2068 NSW Australia Australia Submissions should be received Submissions should be received by by 22 November 2004 22 November 2004

ASUM Ultrasound Bulletin : 2004 May 7: 2 39 EDUCATION DDU/DMU Preparation Course 2004 University of New South Wales: 4–8 February

higher for candidates attending the Preparatory Course than those who do not. Cardiac numbers were up this year and Louise Morris, Cardiac Convenor, put together a full and varied program. Special thanks must go to GE Ultrasound who made available their latest cardiac machine for the course duration along with the expert services of Danika Southwell who assisted the cardiac lecturers. The General and Vascular Convenors, in acquiring the assistance of Toshiba, were able to provide a comprehensive and full program for their respective candidates. A special thank you goes to Toshiba who gener- ously provided an Aplio 80 and the Instruction to reading ultrasound images services of Rod Pry for the duration of the Prep Course to assist the general and physics lecturers. The 2004 DDU/DMU Prep Course One experience. Overall, the DDU Cardiac, general and vascular can- was held over five days at the candidates appeared satisfied with the didates were given the opportunity to Matthews Building at the University program as presented and recom- fully explore the physical anatomy and of New South Wales from 4Ð8 mended the course as a necessary part pathological aspects of their respective February. in their examination preparation. syllabi as well as being fully grounded The DDU program was particular- The DMU Preparatory Course, run in the pertinent aspects of physics, ly full, given that this section of the over five days, was also well attended clinical anatomy and learning styles Preparatory Course runs for only three by cardiac and general candidates. A and study skills. days. The increased attendance num- modified Vascular Part I and Part II The services of Danika and Rod bers is encouraging and reflects the program was run but the numbers did were greatly appreciated by all the growing interest in the program. not justify the full round of lectures. candidates. Their professional demon- There was a strong emphasis on There was the usual interest in the strations of their respective machines ultrasound physics. In response to the perennial favourite of physics, but and generously giving of their time to high demand for more Q & A sessions, 2004 will see the introduction of Legal answer candidates’ questions and in extra time was programmed for inter- and Ethical Issues and it was this sec- assisting lecturers with demonstra- active sessions between candidates tion of the program that was most well tions and ‘Knobology’ lectures was and lecturers. The final outcome was a attended. Part II candidates will be greatly appreciated. Without the gen- good mix of theory lectures and tutori- examined in legal and ethical issues as erous support of lecturers, examiners, als and examination preparation Q & part of the Written Examination. All sonographers, participating medicos, A sessions where individual concerns Part II candidates will answer a com- machine manufacturers (such as GE and enquiries were discussed and pulsory legal and ethical section as and Toshiba) and the dedication of the resolved. The course evaluations were part of their first essay question and convenors and ASUM staff, events almost unanimous in recommending those who attended the Preparatory such as the DDU/DMU Preparatory this approach. Course are now in a better position to Course would not be possible. DDU candidates sought more address this new content in their A special thank you must go to the physics content and were extremely examinations. Convenors, Margaret Condon (general appreciative of the extra time that the The DMU Preparatory Course pro- and obstetric), Louise Morris (cardiac) physics lecturers, Roger Gent, Mike vides candidates with a valuable and Lucy Taylor-Turner (vascular), Dadd and Dave Carpenter, were able opportunity to clarify their examina- whose unstinting generosity and atten- to volunteer. Evaluations reflected this tion preparation and foundations upon tion to detail made the 2004 and requested that in future preparato- which to build for further study. The DDU/DMU Preparation Course such a ry courses there be a greater represen- anecdotal evidence suggests that the valuable education experience for tation of DDU Examiners with Part candidate pass rate is significantly preparing candidates.

40 ASUM Ultrasound Bulletin 2004 May 7: 2 EDUCATION 400 attend successful Gold Coast Multidisciplinary Workshop Roslyn Savage

hand, wrist and elbow, groin, and ankle and foot ultrasound. Martin Necas gave several presen- tations, including two interesting talks on managing electronic teaching files and multimedia presentation of ultra- sound images and videos as well as introducing the new ASUM On-line Handbook. We were privileged to have two international guests at the meeting. Dr Daniel Makes, President of the Indonesian Society of Ultrasound in Medicine attended as a guest of ASUM, taking the opportunity to meet with The President and Council to dis- cuss joint initiatives with ASUM. Dr Lilith Valentin attended as an invited speaker. Dr Lilith Valentin The meeting was organised and run by the ASUM staff. I would like to The 2004 Multidisciplinary Workshop thank Caroline Hong, was held in conjunction with the Keith Henderson, Marie Annual Obstetrics and Gynecology Cawood and James Symposium at Conrad Jupiter’s Hotel Hamilton for the consid- on the Gold Coast. The meeting com- erable work that went menced with the Nuchal Translucency into managing the meet- course on Thursday 4 March and was ingprogram, speakers, attended by about 420 delegates. sponsorship, promotion Dr Stephen Sinnot convened the and venue, and who were very interesting and educational Obstetrics and Gynecology ‘on deck’ throughout the Symposium. The keynote speaker Ð meeting ensuring that Prof Lil Valentin from Sweden headed everything ran smoothly. a faculty of excellent local speakers A meeting such as covering a wide variety of subjects this would be possible including . Attendance at presentations was excellent without the sponsors of A workshop such as this cannot be the meeting: Toshiba, together a program of presentations successful without a number of will- Siemens, Phillips and GE Ultrasound. ing patients. We thank Sue and Tony and workshops on a wide variety of vascular topics. Deb Moir coordinated Their support through the contribution Davies and Sally Ashwin from the of equipment and expert staff added a Australian Institute of Ultrasound for the women’s health sessions which significant dimension to the workshop giving their time to coordinate their included two presentations by Dr program. group of patients throughout the meet- Colin Furnival, who gave the sur- ing. They even found a patient with a geon’s perspective on sentinel nodes The 2005 Multidisciplinary Morton’s neuroma for the MSK ses- and treatment of early breast cancer. Workshop will be held in Melbourne sion. The Pediatrics presentations were providing members from the south I would also like to thank the coor- well attended thanks to the excellent with the opportunity to be involved dinators for each of the disciplines. presentations by Allison Holley and either as a presenter or registrant. Bonita Anderson and Cathy West Roger Gent. organised and presented most of the The musculoskeletal sessions were Roslyn Savage Cardiac sessions. Yvonne Butcher put mostly hands-on, covering shoulder, Convenor

ASUM Ultrasound Bulletin 2004 May 7: 2 41 SOCIETY

SOUTH WESTERN SYDNEY AREA HEALTH SERVICE Applicants are to ensure that they satisfy the necessary registration/licensing requirements for appointment to the position. Please ensure that application addresses the essential and desirable criteria of the position and includes the names of three (3) referees. Criminal record checks will be conducted for all positions. Please visit the Area’s webpage at www.swsahs.nsw.gov.au LIVERPOOL HEALTH SERVICE SONOGRAPHER (MRS LEVEL 4) F/T OR P/T Inviting senior sonographer to join Feto-Maternal Unit Team at Liverpool Health Service. Three referees required of which two should be sonography related & less than 2 years old. Undertake provision of tertiary level specialised ultrasound services in High Risk Obstetrics & Gynaecology Unit along with 2 staff specialists, 2 midwives & 1 fellow. Essential: Recognised Diploma or Graduate Certificate in Diagnostic Ultrasound. Post graduate experience in Obstetric Ultrasound. ASAR Accreditation (Sonographer). Demonstrate good communication skills. Desirable: Experience in High Risk Obstetric and Gynaecological Ultrasound. Experience/interest in performing Fetal anomaly ultrasound. Interest in research. Computer literacy Enq: Dr John Smoleniec (02) 9828 5694. Email: [email protected]

Closing Date: Friday, June 04, 2004. Readvertised Ad No: LV.012/1 Applications quoting Ad No. to: Employee Services Manager, Liverpool Health Service, Locked Bag 7103, Liverpool BC NSW 1871. Or email: [email protected]

Editor-in-Chief Ultrasound in Medicine and Biology Breast Imaging Victoria The World Federation of Ultrasound in Medicine and Biology (WFUMB), the world’s largest ultrasound asso- SONOGRAPHER ciation, announces the search for Editor-in-Chief of the journal Ultrasound in Medicine and Biology. (Part-time to full-time) The Editor-in-Chief will provide editorial direction and overall guidance for the Journal, including ensuring We are seeking a sonographer to join our dedicated team quality review of all manuscripts and adherence to an orderly editorial process and schedule, as well as offer- at Breast Imaging Victoria. ing recommendations regarding publishing options, such as translations and electronic delivery. Hours are negotiable and attractive terms and conditions A doctoral degree, experience in ultrasound or acoustics, and experience serving on the editorial board are offered. of a peer-reviewed scientific journal are desired. Candidates must have demonstrable leadership ability, a record of academic excellence, superb editorial judg- Previous experience in breast imaging is necessary. ment, and a high degree of integrity. The new Editor will officially assume the position in July 2006 and will work with the current Editor during The Unit is dedicated to the diagnosis of breast disease a transitional phase from July 2006 to 1 January 2007. and operates in a pleasant patient focused environment. Applications for this prestigious position are currently being accepted. For confidential consideration, send your curriculum vitae and a letter of interest to: For further details contact Beryl Benacerraf MD Dr Cathy Galbraith Chair Ð Editor Search Committee Diagnostic Ultrasound Associates Clinical Co-ordinator 333 Longwood Avenue tel 03 9419 6766 fax 9419 6416 Boston MA 02115 USA email [email protected] email [email protected] fax +1 617 738 6703

42 ASUM Ultrasound Bulletin 2004 May 7: 2 SOCIETY

DMU (ASIA) SONOGRAPHER LECTURER POSITION BASED in KUALA LUMPUR, MALAYSIA

Vision College invites ASUM DMU qualified sonographers to apply for the position of lecturer on the Teaching Faculty for DMU (Asia). Vision College, the first Asian Centre of Excellence in Ultrasound will be offering the DMU (Asia) qualifica- tion to candidates from Malaysia and Asia, for practice in Asia. The DMU (Asia) is based on the DMU (ASUM) syllabi and curriculum through a licencing agreement approved by the Australasian Society for Ultrasound in Medicine (ASUM). This will be an exciting opportunity to work overseas, enjoy the culture and life in an Asian country and con- tinue to maintain your professional skills while contributing to the introduction of sonography in the region. The Sonographer shall be experienced in general and O & G sonography, provide lectures and clinical supervi- sion to students, broadly based on similar syllabus to the DMU. Expect a life of diversity, interesting challenges and fun. Remuneration is competitive Ð one year contract, up to RM $140,000.00 pa (approximately $A53,000 pa), including condominium accommodation, private healthcare, travelling and other benefits. $A1.00 is approxi- mately equivalent to Ringgit Malaysia RM$2.60. It is anticipated that this position will commence in August 2004.

Expressions of interest and applications are to be addressed in the first instance to: Dr Caroline Hong ASUM CEO email [email protected] tel +61 2 9958 7655 or fax +61 2 9958 8002

Expressions of Interest Ð DMU Practical Examiners

As part of the DMU’s successful ASAR re-accreditation, it is now a requirement for DMU Practical Examiners to be trained and accredited. It is ASUM’s intention to provide a wide cross-section of qualified DMU Practical Examiners who, having undergone a stan- dardised training program, will ensure the consistent, high standards of the Practical Examinations into the future. Consequently, limited opportunities exist for selection as a DMU Practical Examiner in 2004. Expressions of Interest are now being sought from experienced and qualified sonographers for consideration for selection and training as DMU Practical Examiners. Potential Practical Examiners must be respected in the profession, of superior technical and professional ability and prepared to volunteer three years’ commitment to examining. In addition all interested applicants will need to: 1 Be ASAR accredited. 2 Attend ASUM DMU Practical Examiner Training/Accreditation days. 3 Be Financial ASUM members. 4 Be prepared to travel throughout Australia and New Zealand. 5 Commit to examine at least five candidates annually for three years. 6 Provide a full Curriculum Vitae. 7 Provide professional references. Please apply in writing with attachments (noted above) to: Chairperson, DMU Board of Examiners 2/181 High Street WilloughbyNSW 2068 All Practical Examiners from 2002 and 2003 have already been invited and need not reapply. Practical Examiners from previous years and other members are invited to apply.

ASUM Ultrasound Bulletin 2004 May 7: 2 43 SOCIETY ASUM Society groups and branches 2004

Reproduced from the ASUM Society is ex officio its treasurer, but Secretary Constitution and printed for infor- it may, with the approval of the Martin Necas mation to members who have Council, have a separate bank tel +64 7 839 8826 enquired about the functions and account, and the Honorary Treasurer fax +64 7 839 8893 roles of the Society groups and of the Society may, if he or she email [email protected] branches. Clause 102 to 104 refers: deems it necessary, require that it elect an assistant treasurer to assist Queensland 102 The Council has the power to him or her in dealing with its finan- Secretary establish and maintain groups and cial affairs; Roslyn Savage branches of members within the (d) if it fails to hold its Annual tel +61 7 5495 2077 Society for the purpose, directly or General Meeting in any year, it is fax +61 7 3881 2464 indirectly, of furthering the objects of thereupon taken to have been dis- email [email protected] the Society as set forth in this consti- solved; and tution, and to make regulations not (e) its members must in all respects South Australia inconsistent with this constitution as conform with the provisions of this Chairman to the establishment, functions, pow- constitution. Jane Copley ers and privileges, regulation, admin- tel +61 8 8239 0550 istration and dissolution of groups and State Branches fax +61 8 8344 3194 branches and the appointment, The Society's head office is in Sydney email removal, qualification, disqualifica- with Branches in all States of Australia Secretary tion, duties, functions, powers and (except Northern Territory) and a Stephen Bird privileges of the officers and members Branch in New Zealand. The main tel +61 8 8297 0588 of groups and branches. activities of the Branches involve edu- fax +61 8 8297 18022 cation and liaison with state govern- email [email protected] 103 The groups and branches of the ment and education authorities. Tasmania Society consist of: Contacts Chairman (a) the New South Wales Branch; Rob Jones (b) the Victorian Branch; Australian Capital Territory tel +61 3 6233 9333 (c) the Queensland Branch; fax +61 3 6224 1740 (d) the Australian Capital Territory Chairman Iain Duncan email [email protected] Branch; Secretary (e) the Tasmanian Branch; tel 0408 865 966 fax +61 2 6286 7552 Philip Millner (f) the South Australian Branch; tel 0409 274 918 (g) the Western Australian Branch; email [email protected] Secretary fax +61 3 6244 0992 (h) the New Zealand Branch; and email [email protected] (i) such other groups and branches as Ian Dalziel may from time to time be established tel +61 2 6201 6140 Victoria by the Council pursuant to clause fax +61 2 6201 6145 Chairman email [email protected] 1+61 2. Nicole Woodrow tel +61 3 9663 3999 104 Any regulations made by the New South Wales fax +61 3 9663 3555 Council in relation to a group or Hunter Sub Branch email [email protected] branch pursuant to clause 1+61 2 must Chris Abel Secretary specify the members or classes of tel +61 2 4921 3000 Narelle Spinner members of the Society entitled to be fax +61 2 4946 1949 tel +61 3 9663 3999 members of it, and must provide, inter email [email protected] fax +61 3 9663 3555 alia, that: North East Coast Sub Branch email [email protected] (a) it must hold an Annual General Barry Lennon Western Australia Meeting of its members once at least tel +61 2 6622 2288 Chairman in each calendar year, and each mem- fax+61 2 6622 1534 Martin Marshall ber thereof is entitled to receive not email [email protected] less than four weeks written notice of tel +61 8 9224 2124 each Annual General Meeting; fax +61 8 9224 2912 (b) it must at its Annual General New Zealand email Meeting in each year elect a presi- Chairman [email protected] dent and secretary, and their names Yvonne Taylor Secretary Michelle Pedretti must be notified to the Secretary of tel +64 9 520 1003 tel +61 8 9400 9030 the Society forthwith thereafter; fax +64 9 529 1545 fax +61 8 9400 9033 (c) the Honorary Treasurer of the email [email protected] email [email protected]

44 ASUM Ultrasound Bulletin 2004 May 7: 2 SOCIETY

New members January to March 2004

New members January 2004 Kylie Rowse SA New members February 2004 Praneal Sharma NSW Full members Shunil Sharma Qld Full members Sue Simpson Vic Jane Barbary SA Alana Akacich Qld Medha Sule UK Gerard Bensoussan Qld Saeeda Albalooshi NSW Donna Traves Qld Brenda Biggs Qld Timothy Alchin NSW Kim Ung Vic Rebecca Chalmers Vic Lay Hoon Patricia Ang Mark Cohen NSW Brigid Van Der Kroon NZ Mary Atkinson Qld Ramesh Cuganesan NSW Martin Bennie NSW Sylvia Walker NZ Kim Elliot Qld Lucy Boden Qld Angus Watts Qld Sharan Fergie ACT Julie Bowles Qld Gary Williams Qld Margaret Field NSW Annette Brennan Qld Amanda Wright NZ Susan Forden Qld Samantha Brewer NSW Alison Zahra Qld Jillian Gibson Qld Samantha Brooks Qld Associate members Zarah Inwood SA Michael Burke NSW Len Kliman Vic Sean Allwood Qld Timothy Cain SA Jim Lai NSW Andrew Cary Qld Fiaalii Arasi NSW Chhaya Mehrota NZ Chi Wang Chan HK Lucy Berwick NZ Peter Muller SA Trevor Chan NZ Jane Bucholz NZ Chris O'Callaghan Vic Wei Yee Chan WA Carolyn Burley Qld Wendy Parker NZ Kerrie Child NZ Julie Cahill Qld Thierry Somville Qld Mary Collins NZ Ryan Castillo NSW Graham Standen Tas Rizza Deleon Vic Vivaganagie Chetty NZ Kevin Tay NSW Donna Elphick NSW Adam Di Camillo WA Kate Tod NSW Alison Fawcett NSW Priscilla Gaffur NZ Andrea Walker NSW Robert Federer Qld Louisa Hale NZ Sharon Watson NSW Martha Finn NT Len Yared Qld Glenn Hastings Vic Maha George-Haddad NZ Tanya Glynn NSW Levona Hay NZ Associate members Robyn Grant SA Tanya Hennessy Vic Richard Allwood Qld Janet Gray Qld Minh-Thu Ho SA Arong Saemi Bae WA Marion Hails NSW Nilesh Kumar NZ Erin Baumgartel WA Jacqueline Harding Qld Bridget Lawson NZ Susan Berman WA Barbara Hochstein NZ Xuesen Liu NZ Michael Cartmill Qld Peter Holt Qld Katherine McGlynn UK Faith Casley-Porter Vic Lesa Hollier NSW Thomas Curnow Vic Joanne Mewes NZ Laura Horton NZ Stacey Day NZ Kristine Hunot NSW Ross Meyer NSW Louise Deshon WA Jennifer Jepson Qld Sarah Milne NZ Warren Forgus WA Kelly Johnson Qld Chau Nguyen NSW Jennifer Gillespie WA Fiona Jones Qld Marilyn Noye NZ Justin Hanrahan Vic Susan Heath NSW Yvonne Lake NZ Gabrielle O'Grady NZ Marion Lane NZ Mark Higgins Qld Louisa Siu Fong Lau NSW Shawn O'Leary NZ Samantha Hunt WA Bonita Le Fevre WA Dipti Patel NZ Graham McRae NZ Sheree Lloyd NZ Leanne Purdy NSW Yukari Newman Vic Jackie Mann Qld Dorothy Santos Vic Marnie Peacock WA Elizabeth Marshall NZ Sarah Shortus NSW Hanh Phan NSW Tanya McCahon Tas Adrian Poulton Vic Paul Stoodley NSW Barry Mennim NZ David Scicluna Vic Stephanie Miller Qld Barbara Symes NZ Natalie Smith ACT Anne Mysko WA Jeneen Tattersall NSW Ariana Sorensen NZ Darren Paff Qld Kirsty Thys NSW Craig Thomson Qld Brynley Parry Tas Daniel Traves Qld Antoinette Van Rensburg WA Melanie Wagner NSW Christine Paxton SA Lucienne Velvin NZ Michelle Perkovic SA Andrew Yeadon NZ Janelle Podlich Qld Claire Walker Vic Fleur Rakuns NSW Mark Ready Qld Trainee members Trainee members David Robinson Vic Allison Newey NSW Faraz Shakibaie NSW Peter Ross Qld Katrina Timmins Vic Thodur Vasudevan NZ

ASUM Ultrasound Bulletin 2004 May 7: 2 45 SOCIETY

tel +61 3 9879 6200 Corporate Members 2004 [email protected] Peninsular Vascular Diagnostics Vascular Ultrasound Education Claire Johnston Agfa-Gevaert Ltd tel +61 1300 722 632 mob 0407 069 307 tel +61 3 9781 5001 Scopix, Matrix Images, Digital Memories email [email protected] email [email protected] David Chambers Philips Medical Systems Australasia Elsevier Australia Pty Ltd tel +61 3 9264 7711 Health Science Publisher email [email protected] Incorporating formerly ATL, HP, Agilent Effie Papas Shelley Burnside InSight tel +61 2 9517 8953 tel +61 2 9947 0100 Aloka/ SonoSite email [email protected] email [email protected] John Walstab GE Medical Systems Ultrasound tel +61 1800 228 118 Trisha Cornwell Queensland X-Ray email [email protected] tel +61 2 9846 4658 Radiology Australian Medical Couches email Lynne Salmon +61 7 3343 9466 Couch Manufacturer [email protected] [email protected] Marcus Egli Rentworks Ltd I-Med Limited Medical Leasing Equipment tel +61 3 9589 3242 National Network of Radiology Practices email [email protected] Don Hardman Gabrielle Curtin tel +61 2 9937 1074 Bambach Saddle Seat Pty Ltd [email protected] email [email protected] Sue Johnston Mayne Health Schering Pty Ltd tel +61 2 9939 8325 Comprehensive Health email [email protected] Ethical Pharmaceuticals Darryl Lambert John Peace Bristol-Myers Squibb Medical Imaging tel +61 0412 547 021 tel +61 2 9317 8666 Ultrasound Contrast and Nuclear Imaging email [email protected] email [email protected] Agents Medfin Aust Pty Ltd Wayne Melville Siemens Ultrasound Leasing Finance for Medical Practitioners Nick Kapsumallis tel +61 2 9701 9108 mob 0409 985 011 Barry Lanesman email [email protected] tel +61 2 9491 5863 tel +61 2 9906 2551 email [email protected] email [email protected] Central Data Networks Pty Ltd Toshiba (Aust) Pty Ltd Medical CDN. Affordable PACS and Medical Meditron Pty Ltd Division Imaging Networks Acoustic Imaging, Dornier, Kontron David Rigby Robert Zanier Michael Fehrman tel +61 2 9887 8026

CORPORATE NEWS Philips launches iU22 system Philips Medical Systems Australia has allows for more complete patient where many women can avoid surgical unveiled the Philips iU22 system, information, reporting and trending. procedures for investigation of sus- designed to reduce workplace injuries The result is a ‘smart’ system that pected endometrial pathology.” for sonographers and ensure more delivers revolutionary performance The transducers are lightweight accurate diagnostic results. with the latest breakthroughs in high and ergonomically designed, alleviat- In a survey conducted in 1999, definition imaging and diagnostic ing pressure on the wrist and thus 95.4% of Australian sonographers sur- capability. reducing the incidence of RSI. Its veyed reported muscoskeletal pain and The iU22 is the first premium adjustability and monitor clarity also discomfort since starting scanning ultrasound system to have fully inte- reduce neck, eye and wrist strain. while 80% reported experiencing it grated 2D, 3D and real-time 4D imag- during work duties, 25% of whom ing modes, as well as multiplaner “The advanced ergonomic design reported decreased ability to perform reconstruction (MPR) resolution that is a stand-out feature of the iU22. The work duties as a result of the pain and rivals acquired 2D plane definition. system allows sonographers to manip- discomfort. “Ultrasound is the imaging modal- ulate the system into whatever position The Philips iU22 system addresses ity of choice for obstetric and is most comfortable to them. these challenges with a simpler, easy- women’s pelvic imaging,” said “The control panel is fully to-use interface, hands-free voice Melbourne Obstetrician and adjustable to suit each user and each command, one-button automated opti- Gynaecologist, Dr Andrew Edwards type of scan. The system is smaller, misation controls for quick and con- following the release of the new sistent image acquisition between Philips iU22 in Australia in March. lighter and more mobile than conven- users of varying skill levels, and “Ultrasound assessment of the tional ultrasound machines,” Dr sophisticated data management that endometrium has now reached a level Edwards said. 46 ASUM Ultrasound Bulletin 2004 May 7: 2 ULTRASOUND EVENTS

2004 Thu 19 Aug 2004 Travelling Fellow Tutorial for Contact Elvie Haluszkiewicz or Marilyn Zelesco tel Part II Candidates +61 8 9224 7076 Sat 5 Jun – 4 days XVIth Congress of the RPH, Western Australia European Federation of Societies for Ultrasound Contact Elvie Haluszkiewicz or Marilyn Zelesco Wed 8 Dec – 3 days 36th BMUS Annual Scientific in Medicine and Biology tel+61 8 9224 7076 Meeting and Exhibition Zagreb, Croatia Manchester, UK website www.euroson2004.com Sat 21 Aug 2004 Travelling Fellow Workshop Contact The British Medical Ultrasound Society TBA, Broome, Western Australia tel +44 20 7636 3714, email [email protected] Mon 7 Jun – 5 days Mastering Improved Contact Elvie Haluszkiewicz or Marilyn Zelesco tel Clinician Performance – ARCHI (Vic) Workshops +61 8 9224 7076 2005 presented by Dr Mark O'Brien from the Cognitive Institute Tue 31 Aug 2004 – 4 days 14th World Congress Mon 31 Jan Applications due for ASAR Student Melbourne, Ballarat, Traralgon, Glen Waverley on Ultrasound in Obstetrics and Gynaecology Status Contact ARCHI National office Stockholm, Sweden Contact James Hamilton DMU Coordinator tel +61 2 4985 3165, website www.archi.net.au Contact S Johnson tel +44 20 8725 2505 tel +61 2 9958 0317, fax +61 2 9958 8002, email fax +44 20 8725 0212 email [email protected] [email protected] Sat 12 Jun 2004 – 2 days, Physics Weekend with Wed 8 Sep 2004 WA Branch Meeting Tues 1 Mar DMU Part I and Part II Application Roger Gent/Mike Dadd Deadline RPH, Western Australia Radiology Tutorial Room, Radiology Department, RPH, WA Contact James Hamilton DMU Coordinator Contact Elvie Haluszkiewicz or Marilyn Zelesco tel tel +61 2 9958 0317, fax +61 2 9958 8002, email +61 8 9224 7076 Contact Elvie Haluszkiewicz or Marilyn Zelesco on tel +61 8 9224 7076 [email protected] Thur 17 Jun DDU Part II Oral Examination – Thur 17 Mar Nuchal Translucency Course Cardiology only Sat 11 Sep 2004 – 2 Days Weekend Workshop (Tentative) Melbourne Bruce Hunt Lecture Theatre, RPH, WA Contact ASUM, 2/ 181 High Street, Willoughby, Contact DDU Coordinator Contact Elvie Haluszkiewicz or Marilyn Zelesco tel NSW, 2068 tel +61 2 9958 7655, email [email protected] +61 8 9224 7076 tel +61 2 9958 7655 fax +61 2 9958 8002, email [email protected] Tue 31 Aug – 4 days 14th World Congress on Sat 19 Jun DDU Part II Oral Examination Ultrasound in Obstetrics and Gynecology Sydney Stockholm, Sweden Fri 18 Mar – 2 days ASUM Multidisciplinary Contact DDU Coordinator Contact S Johnson, ISUOG, 3rd Fl, Lanesborough Workshop involving interactive programs in tel +61 2 9958 7655, email [email protected] Wing, St Georges Hospital Medical School, Cranmer Obstetric, Gynaecological, Musculoskeletal, Sat 19 Jun – 4 days American Institute of Terrace, London SW 17 ORE, UK Vascular, Cardiac, Small Parts and Breast Ultrasound in Medicine (AIUM) 2004 Annual tel +44 20 8725 2505, fax +44 20 8725 0212, email Ultrasound. [email protected] Convention Fri 18 Mar – 2 days ASUM Vascular Workshop JW Marriott Desert Ridge Resort & Spa, Phoenix, Sat 4 Sept – 5 days ASUM-ANZSVS 2004 held in conjunction with the ASUM Arizona, USA Rotorua, New Zealand Multidisciplinary Workshop Contact Brenda Kinney, AIUM Contact David Ferrar tel +1 301 498 4100, email [email protected], web- email [email protected], or see ASUM website site www.aium.org www.asum.com.au Fri 18 Mar – 2 days ASUM O&G Workshop held in conjunction with the ASUM Multidisciplinary Sun 20 Jun – 7 days Third World Congress and Thur 23 Sept – 4 days ASUM 2004 34th Annual Workshop Scientific Meeting of the Australasian Society for Contact ASUM, 2/ 181 High Street, Willoughby, the Advanced Course in Fetal Medicine Ultrasound in Medicine Limassol, Cyprus Sydney, NSW 2068, Australia website www.fetalmedicine.com tel +61 2 9958 7655, fax +61 2 9958 8002, email Sat 16 Oct DMU Part II Objective & Standardised [email protected] Clinical Examinations (OSCEs) and Oral Fri 25 Jun – 4 days New Zealand ASUM Branch Examinations – Cardiac Fri 18 Mar – 2 days ASUM Musculoskeletal Meeting, preceded by an OSCE preparation ses- Contact James Hamilton DMU Coordinator Workshop held in conjunction with the ASUM sion on Thur 24 June tel +61 2 9958 0317, fax+61 2 9958 8002, email Multidisciplinary Workshop Rydges Hotel Christchurch, New Zealand [email protected] Contact Rex De Ryke Sun 19 Jun – 3 days 2005 AIUM Annual email [email protected] Sat 16 Oct DMU Part II Objective & Standardised Convention Clinical Examinations (OSCEs) and Oral Walt Disney World, Swan and Dolphin, Orlando, FL Examinations – Vascular Wed 23 Jun 2004 WA Branch Meeting – USA Contact James Hamilton DMU Coordinator Contact Brenda Kinney, AIUM Dr E Lee ‘Ultrasound in First Trimester’ tel +61 2 9958 0317, fax +61 2 9958 8002, email Radiology Tutorial Room, Radiology Department, [email protected] tel +1 301 498 4100, email [email protected], web- RPH, WA site www.aium.org Contact: Elvie Haluszkiewicz or Marilyn Zelesco tel Sat 23 Oct DMU Part II Objective & Standardised Sat 30 Jul DMU Part I and Part II Written +61 8 9224 7076 Clinical Examinations (OSCEs) and Oral Examinations – Provisional Examinations – General Contact James Hamilton DMU Coordinator Contact James Hamilton DMU Coordinator Sat 31 Jul DMU Part I and Part II Written tel +61 2 9958 0317, fax +61 2 9958 8002, email tel +61 2 9958 0317, fax +61 2 9958 8002, email Examinations [email protected] [email protected] Contact James Hamilton DMU Coordinator tel +61 2 9958 0317, fax +61 2 9958 8002, email Sat 23 Oct DMU Part II Objective & Standardised 29 Sept – 4 days ASUM 2005 35th Annual [email protected] Clinical Examinations (OSCEs) and Oral Scientific Meeting of the Australasian Society for Examinations – Obstetric Ultrasound in Medicine Sun 15 Aug 2004 Travelling Fellow Workshop Contact James Hamilton DMU Coordinator Adelaide Convention Centre, Adelaide Bunbury, Western Australia tel +61 2 9958 0317, fax +61 2 9958 8002, email Contact ASUM, 2/ 181 High Street, Willoughby, [email protected] Contact Elvie Haluszkiewicz or Marilyn Zelesco tel Sydney, NSW 2068, Australia +61 8 9224 7076 Fri 5 Nov 2004 – 2 days ASUM Asia Link tel +61 2 9958 7655, fax +61 2 9958 8002, email Program: Joint meeting in Malaysia [email protected] Kuala Lumpur, Malaysia Tue 17 Aug 2004 Travelling Fellow Workshop Registration information available at KRH, Kalgoorlie, Western Australia www.asum.com.au 2009 Contact Elvie Haluszkiewicz or Marilyn Zelesco tel: To register your interest in attending this meeting as +61 8 9224 7076 a delegate or as a sponsor email Thurs 5 Sept – 4 days ASUM hosts WFUMB 2009 [email protected] World Congress in Sydney Wed 18 Aug 2004 WA Branch Meeting Travelling Sydney Convention and Exhibition Centre Fellow ‘DVT Research Topic’ Contact Dr Caroline Hong, ASUM CEO email caro- Mon 22 Nov 2004 WA Xmas Branch Meeting – RPH, Western Australia [email protected] or [email protected] Dr R Hart ‘Ultrasound In Space’ ASUM, 2/ 181 High Street, Willoughby, Sydney, Contact Elvie Haluszkiewicz or Marilyn Zelesco tel: Lamonts, East Perth, Western Australia +61 8 9224 7076 NSW 2068, Australia ASUM Ultrasound Bulletin 2004 May 7: 2 47 GUIDELINES Guidelines for authors

Authors are invited to submit papers Each listing must contain: activity full stop or comma. for publication in the categories title, dates, venue, organising body 2 Journal article Britten J, Golding described below. Final responsibility and contact details including name, RH, Cooperberg PL. Sludge balls for accepting material lies with the address, telephone and facsimile num- to gall stones. J Ultrasound Med Editor, and the right is reserved to bers (where available) and email 1984; 3: 81Ð84. introduce changes necessary to ensure address (where available). Notices will 3 Book: Strunk W Jr, White EB. conformity with the editorial stan- not usually be accepted for courses run The elements of style (3rd ed.). dards of the Ultrasound Bulletin. by commercial organisations. New York: Macmillan, 1979. 4 Book section Kriegshauser JS, Original research Corporate news Carroll BA. The urinary tract. In: Manuscripts will be subject to expert Corporate members are invited to pub- Rumack CM, Wilson SR, referee prior to acceptance for publica- lish news about the company, includ- Charboneau JW, eds. Diagnostic tion. Manuscripts will be accepted on ing structural changes, staff move- Ultrasound. St Louis, 1991: the understanding that they are con- ments and product developments. 209Ð260. tributed solely to the Ultrasound Each corporate member may submit Bulletin. one article of about 200 words annual- ly. Logos, illustrations and tables can- Abstract Quiz cases not be published in this section. Manuscripts for feature articles and A case study presented as a quiz, original research must include an involving no more than three or four Format abstract not exceeding 200 words, images and a paragraph briefly sum- Manuscripts should be submitted in which describes the scope, major find- marising the clinical history as it was triplicate in print and on PC formatted ings and principal conclusions. The known at the time. It will pose two or diskette as MS Word documents. abstract should be meaningful without three questions, and a short explana- Images must be suppled separtely and reference to the main text. tion. not embedded. Powerpoint presenta- tions are not accepted. Images Case reports ¥ Font size: maximum 12 pt, mini- Images may be submitted as hard copy Case reports are more substantial pre- mum 10 pt (in triplicate) or in digital format. sentations resembling short scientific ¥ Double spacing for all pages Images sent must have all personal papers which illustrate new informa- ¥ Each manuscript should have and hospital or practice identifiers tion, or a new or important aspect of the following: removed. Do not embed images in established knowledge. Title page, abstract, text, refer- text. Separate images are required for ences, tables, legends for illustra- publication purposes. Review articles tions. A figure legend must be provided Review articles are original papers, or ¥ Title page should include the: for each image. Hard copy images articles reviewing significant areas in Title of manuscript, the full should be presented as glossy print or ultrasound and will normally be illus- names of the authors listed in order original film. Any labelling should be trated with relevant images and line of their contribution to the work, entered on the front of the glossy print drawings. Unless specifically commis- the department or practice from using removable labels. Send one copy sioned by the Editor, articles will be which the work originated, and of illustrations without labelling as subject to expert referee prior to their position. this can be added electronically prior acceptance for publication. Corresponding author’s name, to publication. On the back of the print contact address, contact telephone include the author’s name, figure num- Forum articles number and facsimile number ber and a directional arrow indicating Members are invited to contribute (where available) for correspon- the top of the print. short articles expressing their observa- dence. Digitised graphics should be sup- tions, opinions and ideas. Forum arti- ¥ Abbreviations may be used after plied as JPG or TIFF files on PC for- cles should not normally exceed 1000 being first written in full with matted 3.5” diskette or CD, which words in length. They will not be ref- abbreviation in parentheses. must be clearly labelled with the ereed but will be subject to editorial ¥ References should be cited using author’s name and the names of the approval. the Vancouver style, numbered image files. according to the sequence of cita- tion in the text, and listed in Copyright Calendar items numerical order in the bibliogra- Authors are required to provide assur- Organisers of meetings and education- phy. Examples of Vancouver style: ance that they own all property rights al events relevant to medical ultra- 1 In-text citation Superscript. If at to submitted manuscripts, and to trans- sound are invited to submit details for the end of of a sentence the num- fer to ASUM the right to freely repro- publication in the Ultrasound Bulletin. ber(s) should be placed after the duce and distribute the manuscript. 48 ASUM Ultrasound Bulletin 2004 May 7: 2 See http://www.asum.com.au Contact Rex de Ryke [[email protected]]