Re: intrauterine ectopic
From: art fougner, md (evsono@pipeline.com)
Tue Aug 27 21:13:45 2002
me neither lol
got some discussion going tho.
art
At Tue, 27 Aug 2002, Terry J DuBose wrote:
>
>Dr. Fougner, I don't think we are disagreeing...
>
>Peace, Terry
>
>----------------
>
>----------------
>On Tue, 27 Aug 2002 14:47:56 -0500 evsono@pipeline.com (art fougner, md)
>----------------
>----------------
>writes:
>----------------
>
>--
>----------------
>> Terry
>----------------
>>
>----------------
>> in the third trimester all bets are off - diff people are diff sizes
>> and
>> size becomes a poor reflection of age the older we get. in the
>> second
>> trimester outliers are problematic - for example the short femur in
>> conjunction with a maternal serum screen suspicious for Down's.
>> including the femur in age assignment may factitiously lower the
>> sonographic age sufficient to alter the screen results. ignoring
>> the
>> femur's contribution may be preferable in this case.
>>
>> art
>>
>> At Tue, 27 Aug 2002, Terry J. DuBose wrote:
>> >
>> >Dr. Fougner, very good point... in fact seeing outliers is the
>> reason I like more measurements... you can "see" the fetal
>> proportionality. Granted, a short femur is not necessarily
>> diagnostically specific, but it is better to have the information
>> than not to have it. And "age range analysis" allows one to compare
>> all the parameters at once without a bunch of graphs that are much
>> more difficult to interpret, which is another reason I like more
>> measurements.
>> >
>> >For example look at this BBII report in the 23rd week with normal
>> proportions and all parameters falling within +/-1SD of the mean
>> (time-series plot across the bottom of the screen).
>> >http://www.io.com/~dubose/BB-REPT.GIF
>> >
>> >Then this case near term (38th week by head parameters), that has
>> short femurs and humeri....
>> >http://www.io.com/~dubose/BB-38-1.GIF
>> >
>> >Granted from this information one can not Dx Downs or other
>> conditions, but I do believe that it is helpful to know that the
>> femur is at a -1.5SD and the humerus is at a -0.7SD below the mean.
>> >
>> >Are you saying we should ignore outliers? That is the same
>> argument that Dr. Sabbagha had with Dr. Hadlock in the 1980's...
>> Sabbagha felt that the average of multiple fetal parameters would
>> "dilute" the accuracy of the "true" or "correct" measurement. The
>> problem was that due to individuation of fetal proportions, some
>> long, some short, some fat, some thin, some brachicephalic, some
>> dolichol, and on and on, it was impossible to determine which
>> parameter in any given case was the "true"
>> >measurement. So we all now use Hadlock's average of multiple fetal
>> parameters' ages for dates. But that is only part of the "picture"…
>> there is also the question of how far from the mean or average of
>> the multiple fetal parameters can a single parameter be without
>> being "too far" out… an outlier? Thus the ARA to view the fetal
>> proportions as a distribution about the mean. Baslically, all
>> parameters' should be within +/-8% of the age... Hadlock & Bowie's
>> distribution... personally I prefer to
>> >use +/-10% of the age because it is easier to calculate, the 2%
>> difference is very small, gives the advantage to the fetus, and is
>> based upon the average of up to 12 parameters' ages rather than
>> Hadlock's 4.
>> >
>> >Of course, we must also realize that I am approaching this from a
>> non-physician sonographer's point of view... my job is to provide
>> the physician with as much accurate information as I can... not
>> nearly so difficult, I realize, as making the final Dx from all of
>> this.
>> >
>> >For more about BBII and Age Range Analysis (ARA) see:
>> >http://www.io.com/~dubose/BB-WEBH.HTM
>> >and http://www.io.com/~dubose/bbii.html
>> >Also, Fetal Sonography, chapter 7, Fetal Size/Age Analysis.
>> >
>> >Peace, Terry J DuBose, M.S., RDMS
>> >Little Rock, Arkansas USA
>> >
>> >----------------------------------------------------------
>> >
>> >----------------------------------------------------------
>> >----------------------------------------------------------
>> >----------------------------------------------------------
>> >ultrasound@obgyn.net writes:
>> >----------------------------------------------------------
>> >----------------------------------------------------------
>> >----------------------------------------------------------
>> >>Terry,
>> >----------------------------------------------------------
>> >----------------------------------------------------------
>> >
>> >----------------------------------------------------------
>> >--
>> >----------------------------------------------------------
>> >>
>> >----------------------------------------------------------
>> >----------------------------------------------------------
>> >>more parameters may smooth datasets but problems arise with
>> >----------------------------------------------------------
>> statistical
>> >----------------------------------------------------------
>> >>outliers. for example, does a short femur suggest down's, short
>> >----------------------------------------------------------
>> stature
>> >>or a younger fetus?
>> >>
>> >>art
>> >>
>> >>At Mon, 26 Aug 2002, Terry J DuBose wrote:
>> >>>
>> >>>Yes, I know you are correct about garbage, but one person's
>> garbage may
>> >>>be another's found treasure.
>> >>>
>> >>>Multiple fetal parameters do provide better data, and the more
>> parameters
>> >>>the higher the statistical power. I really do miss the days
>> before
>> >>>managed care when there was time to take measurements and study
>> the
>> >>>results. Sonography is much more accurate than it is given
>> credit for
>> >>>being, I am sure. There is a lot of sloppy work being done
>> because the
>> >>>reputation is that it is fuzzy and highly variable. However, the
>> normal
>> >>>embryos are quite uniform... it is the operator dependency that
>> is the
>> >>>main variable... and the equipment, knowledge, and skill of some
>> of those
>> >>>operators.
>> >>>
>> >>>Peace, Terry
>> >>>
>> >>>-------------------------------------------------
>> >>>
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>On Mon, 26 Aug 2002 16:59:30 -0500 evsono@pipeline.com (art
>> fougner, md)
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>writes:
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>--
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>> Terry -
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>>
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> >>>> sure as long as the measurements mean something - "measure
>> >>>-------------------------------------------------
>> >>>-------------------------------------------------
>> twice,
>> >>>-------------------------------------------------
>> >>>> cut
>> >>>-------------------------------------------------
>> >>>> once & you'll save a lot of wood" is an old carpenter's
>> >>>-------------------------------------------------
>> expression
>> >>>> that
>> >>>> works. BUT - if your measurements have not been validated for
>> a
>> >>>> particular situation - then garbage in -> garbage out may
>> apply. in
>> >>>> the
>> >>>> end we all subscribe to Hunter's theorem - "works for me!"
>> >>>>
>> >>>> art
>> >>>>
>> >>>> At Sun, 25 Aug 2002, Terry J DuBose wrote:
>> >>>> >
>> >>>> >No argument from me either. Obviously the larger the
>> structure the
>> >>>> more
>> >>>> >accurate the measurement because a few pixels at 1-3 mm will
>> be a
>> >>>> larger
>> >>>> >percent error than those same few pixels at 10 mm or more.
>> For
>> >>>> this
>> >>>> >reason the CRL continues to be more and more accurate until
>> the
>> >>>> >embryo/fetus begins to flex and extend, or gets too large for
>> the
>> >>>> field
>> >>>> >of view. There are CRL tables out to 18-19 weeks, but the
>> accuracy
>> >>>> is
>> >>>> >less than that of the head at that late date. However, I
>> have
>> >>>> found
>> >>>> >that we can measure very early simply by measuring the mass
>> of
>> >>>> cells
>> >>>> >where the cardiac activity is observed.
>> >>>> >
>> >>>> >Often we are called upon to evaluate a pregnancy for early
>> spotting
>> >>>> and
>> >>>> >we don't always have the luxury of choosing the exact date.
>> If it
>> >>>> is at
>> >>>> >5-6 weeks, then I always measure the mean sac as well as the
>> CRL
>> >>>> and EHR
>> >>>> >for age. If all three give a similar age, then that is a
>> "warm
>> >>>> fuzzy",
>> >>>> >but if the EHR trails the CRL age by more than 6 days, then it
>> is
>> >>>> >worrisome. The mean sac is more variable due to shape
>> differences
>> >>>> due to
>> >>>> >the placement in the uterus, degree of bladder pressure,
>> myomas,
>> >>>> etc.
>> >>>> >However, I did not like the sac after 7 weeks because the CRL
>> is
>> >>>> much,
>> >>>> >much better at that time. Even the EHR age is better than the
>> mean
>> >>>> sac
>> >>>> >in normal embryos, but nothing is better than the CRL after
>> the 6th
>> >>>> week.
>> >>>> >
>> >>>> >Granted, in the 5th week we are dealing with some variables
>> we
>> >>>> don't
>> >>>> >completely understand... the implantation date and it's
>> influence
>> >>>> on
>> >>>> >growth... and very small structures with larger percent
>> errors.
>> >>>> >
>> >>>> >Not only was Robinson and Shaw-Dunn's CRL table very good for
>> the
>> >>>> >equipment they used, their EHR was also remarkably accurate.
>> Only
>> >>>> they
>> >>>> >apparently could not see the EHR before about 7 weeks, and
>> only saw
>> >>>> the
>> >>>> >two week acceleration to the early 9th week. Others who
>> measured
>> >>>> the EHR
>> >>>> >later, with better equipment saw the earlier acceleration
>> >>>> (Hertzberg,
>> >>>> >Mahony, Bowie: 1st Trimester Fetal Cardiac Activity; JUM
>> 1988,
>> >>>> >7:573-575), but they completely missed the high peak rate in
>> the
>> >>>> early
>> >>>> >9th week that Robinson & Shaw-Dunn documented. They missed
>> the
>> >>>> peak
>> >>>> >because they did not use M-mode, but tried to visually count
>> the
>> >>>> heart
>> >>>> >rate that reaches 175+ and only found a plateau around
>> 140-160
>> >>>> B/M.
>> >>>> >
>> >>>> >I like all the measurements I can get... the more the better,
>> >>>> whenever it
>> >>>> >is...
>> >>>> >
>> >>>> >Peace, Terry J DuBose, M.S., RDMS
>> >>>> >Little Rock, Arkansas USA
>> >>>> >
>> >>>> >On Sun, 25 Aug 2002 19:07:38 -0500 evsono@pipeline.com (art
>> >>>> fougner, md)
>> >>>> >writes:
>> >>>> >> i agree - anecdotally first tried to date a pregnancy from a
>> 6
>> >>>> wk
>> >>>> >> fetal
>> >>>> >> pole only to find myself wiping the yolk off my face so to
>> speak
>> >>>> at
>> >>>> >> 13
>> >>>> >> wks when i not surprisingly redated the pregnancy. i avoid
>> >>>> >> assigning
>> >>>> >> dates until crl is at least 7 wks size. amazing how hugh
>> >>>> >> robinson's
>> >>>> >> table worked out - even with the old compound b scanner.
>> >>>> >>
>> >>>> >> art
>> >>>> >>
>> >>>> >> At Sun, 25 Aug 2002, Allen Worrall wrote:
>> >>>> >> >
>> >>>> >> >I am of the opinion that measuring the greatest embryonic
>> >>>> length
>> >>>> >> (not
>> >>>> >> >properly called a CRL in a very early embryo) is a
>> somewhat
>> >>>> >> imprecise thing
>> >>>> >> >at 5.5-6 menstrual weeks, because it is difficult to know
>> >>>> exactly
>> >>>> >> where to
>> >>>> >> >put the cursors on a very early fuzzy embryonic pole. And
>> MSD
>> >>>> is
>> >>>> >> not very
>> >>>> >> >precise (but can be measured more precisely than greatest
>> >>>> embryonic
>> >>>> >> length,
>> >>>> >> >since you can be pretty sure where to put the cursors when
>> you
>> >>>> are
>> >>>> >> measuring
>> >>>> >> >the gestational sac). I feel this way despite having a
>> very
>> >>>> good
>> >>>> >> machine,
>> >>>> >> >excellent transvaginal probe, and ability to enlarge the
>> >>>> embryonic
>> >>>> >> pole as
>> >>>> >> >much as needed.
>> >>>> >> >
>> >>>> >> >I have the feeling that gestational age may be more
>> accurate
>> >>>> when
>> >>>> >> measured
>> >>>> >> >at 7-8 weeks, when the embryo is larger and you can see
>> just
>> >>>> where
>> >>>> >> to put
>> >>>> >> >the cursors.
>> >>>> >> >
>> >>>> >> >Anyone have a comment pro or con?
>> >>>> >> >
>> >>>> >> >Allen
>> >>>> >> >
>> >>>> >> >Joseph A Worrall MD RDMS
>> >>>> >> >OB/GYN Ultrasound at the Fairbanks Clinic
>> >>>> >> >Fairbanks, Alaska, USA
>> >>>> >> >jworrall@alaska.net
>> >>>> >> >http://www.obgynsono.com
>> >>>> >> >
>> >>>> >
>> >>>
>
>>>> >>>>>> >>> >>----- Original Message -----
>> >>>> >> >From: "Terry J DuBose" <tjdubose@juno.com>
>> >>>> >> >To: "Multiple recipients of list ULTRASOUND"
>> >>>> >> ><ultrasound@mail.medispecialty.com>
>> >>>> >> >Sent: Sunday, August 25, 2002 9:52 AM
>> >>>> >> >Subject: Re: intrauterine ectopic
>> >>>> >> >
>> >>>> >> >> Dr. Fougner, I agree... I have also seen EHRs at 1 mm...
>> >>>> >> correlates to
>> >>>> >> >> about 5.0 weeks after LMP and a mean EHR of of 94 B/M
>> (my
>> >>>> table
>> >>>> >> 7-5,
>> >>>> >> >> Fetal Sonography, 1996. The heart rate will usually
>> >>>> accelerate
>> >>>> >> at a rate
>> >>>> >> >> of 3.3 beats per minute per day from when it is first
>> >>>> detected
>> >>>> >> until a
>> >>>> >> >> CRL of 2.6-2.8 mm or 9.2 weeks before beginning a
>> >>>> deceleration
>> >>>> >> from a
>> >>>> >> >> peak of about 189 B/M at 9.2 weeks (+/-1 to 2 days). The
>> EHR
>> >>>> >> time series
>> >>>> >> >> curve has the shape of a classic damping feed-back
>> curve.
>> >>>> >> >>
>> >>>> >> >> Dr. Ronald Shats, Amsterdam 1991, TV Sonography in Early
>> >>>> Human
>> >>>> >> Preg. said
>> >>>> >> >> that if you see cardiac activity you are seeing the
>> embryonic
>> >>>> >> pole. He
>> >>>> >> >> also indicated that one of the problems in getting an
>> exact
>> >>>> age
>> >>>> >> is there
>> >>>> >> >> appears to be a variation in time of first heart beating
>> due
>> >>>> to
>> >>>> >> >> variations in implantation times. On page 39 of his
>> >>>> dissertation
>> >>>> >> that
>> >>>> >> >> "References to days are given only as guidelines and thus
>> are
>> >>>> >> >> approximations of the truth because early stages of
>> >>>> implantation
>> >>>> >> of the
>> >>>> >> >> human blastocyst have not been observed. Most
>> knowledge
>> >>>> about
>> >>>> >> early
>> >> >> >> implantation is based on studies of the Rhesus monkey, but
>> >>>> the
>> >>>> >> process is
>> >>>> >> >> thought to be essentially similar to man."
>> >>>> >> >>
>> >>>> >> >> Sonography has given us a very early window on embryonic
>> >>>> >> development.
>> >>>> >> >> The correlation of the CRL, EHR, and hCG have not been
>> >>>> thoroughly
>> >>>> >> studied
>> >>>> >> >> and are not well understood. We have gotten to within
>> about 3
>> >>>> >> days of a
>> >>>> >> >> "true" date, but can't seem to resolve it more than
>> that.
>> >>>> >> >>
>> >>>> >> >> One of the most interesting questions in human
>> development,
>> >>>> >> IMHO.
>> >>>> >> >>
>> >>>> >> >> Peace, Terry J DuBose, M.S., RDMS
>> >>>> >> >> Little Rock, Arkasas USA
>> >>>> >> >>
>> >>>> >> >> On Sun, 25 Aug 2002 11:08:06 -0500 evsono@pipeline.com
>> (art
>> >>>> >> fougner, md)
>> >>>> >> >> writes:
>> >>>> >> >> > Martin -
>> >>>> >> >> >
>> >>>> >> >> > have seen as Terry so fondly calls it - embryonic
>> cardiac
>> >>>> >> activity
>> >>>> >> >> > with
>> >>>> >> >> > 1 mm fetal poles using 7 - 8 Mhz frequency vaginal
>> >>>> >> transducers.
>> >>>> >> >> >
>> >>>> >> >> > Sharon -
>> >>>> >> >> >
>> >>>> >> >> > have seen for want of a better term - intra-amniotic
>> yolk
>> >>>> sacs
>> >>>> >> twice
>> >>>> >> >> > -
>> >>>> >> >> > both pregnancies ended in spontaneous Ab. wonder if
>> your
>> >>>> >> findings
>> >>>> >> >> > could
>> >>>> >> >> > represent the early appearance of the extrachorial
>> >>>> gestation?
>> >>>> >> do
>> >>>> >> >> > you
>> >>>> >> >> > have images? i sense a case report.
>> >>>> >> >> >
>> >>>> >> >> > art
>> >>>> >> >> >
>> >>>> >> >> > At Sat, 24 Aug 2002, Sharon Brown wrote:
>> >>>> >> >> > >
>> >>>> >> >> > >At Sat, 24 Aug 2002, Martin Necas wrote:
>> >>>> >> >> > >>
>> >>>> >> >> > >>Dear Sharon,
>> >>>> >> >> > >>
>> >>>> >> >> > >>I don't think it is possible to get fetal heart tones
>> at
>> >>>> 6-7
>> >>>> >> weeks
>> >>>> >> >> > GA.
>> >>>> >> >> > >>That's just way too early.
>> >>>> >> >> > >>
>> >>>> >> >> > >>>From your description, are you saying that the
>> embryo is
>> >>>> >> outside
>> >>>> >> >> > the
>> >>>> >> >> > >>gestational sac and outside the endometrium... so
>> that
>> >>>> seems
>> >>>> >> to
>> >>>> >> >> > imply
>> >>>> >> >> > >>that the embryo is within the myometrium?
>> >>>> >> >> > >>
>> >>>> >> >> > >>A couple things that I thought of with your
>> desciption
>> >>>> was
>> >>>> >> for
>> >>>> >> >> > example
>> >>>> >> >> > >>small focal subchorionic clot pulsating with
>> maternal
>> >>>> heart
>> >>>> >> beat.
>> >>>> >> >> > >>
>> >>>> >> >> > >>Usually when I see something really strange on a
>> first
>> >>>> >> trimester
>> >>>> >> >> > scan, I
>> >>>> >> >> > >>would ask myself:
>> >>>> >> >> > >>1) does bHCG correlate with the ultrasound findings?
>> >>>> >> >> > >>2) does LMP correlate with the ultrasound findings?
>> >>>> >> >> > >>3) does FH Rate correlate with CRL
>> >>>> >> >> > >>
>> >>>> >> >> > >>If I think I'm seeing a heartbeat, but I'm not
>> entirely
>> >>>> sure
>> >>>> >> if it
>> >>>> >> >> > may
>> >>>> >> >> > >>be from maternal pulsation or embryonic in origin, a
>> neat
>> >>>> >> trick is
>> >>>> >> >> > to
>> >>>> >> >> > >>grab the patient's wrist and see if the embryonic
>> >>>> heartbeat
>> >>>> >> is
>> >>>> >> >> > different
>> >>>> >> >> > >>rate. If not, it's probably transmitted pulsation
>> from
>> >>>> the
>> >>>> >> >> > mother.
>> >>>> >> >> > >>
>> >>>> >> >> > >>I hope this helps. A set of images would be great.
>> >>>> >> >> > >>
>> >>>> >> >> > >>Yours,
>> >>>> >> >> > >>
>> >>>> >> >> > >>--
>> >>>> >> >> > >>Martin Necas
>> >>>> >> >> > >>RDMS, RVT
>> >>>> >> >> > >>
>> >>>> >> >> > >>At Fri, 23 Aug 2002, Sharon Brown wrote:
>> >>>> >> >> > >>>
>> >>>> >> >> > >>>I need info if posible. Last week I was sent a
>> patient
>> >>>> from
>> >>>> >> the
>> >>>> >> >> > ER, in
>> >>>> >> >> > >>>which the doc told the woman that he found fetal
>> heart
>> >>>> >> tones. I
>> >>>> >> >> > did a
>> >>>> >> >> > >>>transvag and found a gestational sac with a yolk
>> sac
>> >>>> >> within.
>> >>>> >> >> > However,
>> >>>> >> >> > >>>hard as I looked I couldn't find a fetal pole. As I
>> was
>> >>>> >> scanning
>> >>>> >> >> > the
>> >>>> >> >> > >>>uterus I found what the doc was talking about. The
>> >>>> problem
>> >>>> >> is
>> >>>> >> >> > that the
>> >>>> >> >> > >>>fetal pole that I found was outside of the
>> gestational
>> >>>> sac
>> >>>> >> and it
>> >>>> >> >> > did
>> >>>> >> >> > >>>have heart motion, it was also hyperechoic. I am
>> >>>> >> completely
>> >>>> >> >> > baffeled by
>> >>>> >> >> > >>>this, and the Rad that I showed the images and
>> talked
>> >>>> with
>> >>>> >> >> > couldn't
>> >>>> >> >> > >>>quite figure it out either. How is it possible that
>> a
>> >>>> fetus
>> >>>> >> can
>> >>>> >> >> > reach
>> >>>> >> >> > >>>the 6-7 week stage outside of the gestational sac,
>> and
>> >>>> what
>> >>>> >> would
>> >>>> >> >> > cause
>> >>>> >> >> > >>>it to implant outside of the endometrious, yet
>> still
>> >>>> within
>> >>>> >> the
>> >>>> >> >> > uterus.
>> >>>> >> >> > >>>It was in the area where one would normally find a
>> sub
>> >>>> >> chorionic
>> >>>> >> >> > bleed.
>> >>>> >> >> > >>>The fetal pole and the yolk sac both measured 4 mm.
>> Any
>> >>>> >> help
>> >>>> >> >> > would be
>> >>>> >> >> > >>>appreciated. Thanks Sharon
>> >>>> >> >> > >>
>> >>>> >> >> > >--
>> >>>> >> >> > >Thanks for your input. Hopefully I will be able to
>> speak
>> >>>> with
>> >>>> >> the
>> >>>> >> >> > radiologist
>> >>>> >> >> > >that read the scan. He wanted to do some research
>> and
>> >>>> said
>> >>>> >> he
>> >>>> >> >> > would let me
>> >>>> >> >> > >know what he found out. The motion was too fast to be
>> that
>> >>>> of
>> >>>> >> the
>> >>>> >> >> > mother. The
>> >>>> >> >> > >heart motion was discovered by the ER doc before
>> referring
>> >>>> >> the
>> >>>> >> >> > patient to me.
>> >>>> >> >> > >At first I thought he was mistaken because of the
>> empty
>> >>>> sac,
>> >>>> >> >> > however when I did
>> >>>> >> >> > >find what he was referring to I did my own testing
>> and
>> >>>> found
>> >>>> >> heart
>> >>>> >> >> > motion a
>> >>>> >> >> > >posibility in the absence of anyother logical
>> conclusion.
>> >>>> I
>> >>>> >> am not
>> >>>> >> >> > an expert
>> >>>> >> >> > >in ob and so far what I have seen has been pretty
>> straight
>> >>>> >> forward.
>> >>>> >> >> > I was unprepared
>> >>>> >> >> > >for this finding. I will certainly let all know what
>> it
>> >>>> turns
>> >>>> >> out
>> >>>> >> >> > to be if possible.
>> >>>> >> >> > >again thanks for your response. Sharon
>> >>>> >> >> > >
>> >>>> >> >> > >I will try to get permission to upload a couple of
>> images.
>> >>>> At
>> >>>> >> this
>> >>>> >> >> > point I
>> >>>> >> >> > >don't know what to think.
>> >>>> >> >> > >
>> >>>> >> >> >
>> >>>> >> >> > --
>> >>>> >> >> > art fougner, md
>> >>>> >> >> > ich bin ein New Yorker
>> >>>> >> >> >
>> >>>> >> >>
>> >>>> >>
>> >>>> >> --
>> >>>> >> art fougner, md
>> >>>> >> ich bin ein New Yorker
>> >>>> >>
>> >>>>
>> >>>> --
>> >>>> art fougner, md
>> >>>> ich bin ein New Yorker
>> >>>>
>> >>--
>> >>art fougner, md
>> >>ich bin ein New Yorker
>> >>
>> >Peace, Terry J. DuBose, M.S., RDMS
>> >Assistant Professor & Director, Diagnostic Medical Sonography
>> Program
>> >University of Arkansas for Medical Sciences, CHRP
>> >4301 West Markham St. Mail Slot #563
>> >Little Rock, Arkansas, 72205 USA
>> >501-686-6510
>> >DuBoseTerryJ@UAMS.edu
>> >http://www.io.com/~dubose/
>> >http://www.uams.edu/CHRP/dmshome.htm
>> >http://www.obgyn.net/us/panel/panel.htm
>> >
>>
>> --
>> art fougner, md
>> ich bin ein New Yorker
>>
--
art fougner, md
ich bin ein New Yorker
