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Re: your opinion appreciated

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  • kevin@msl4u.com
    I thought the discussion on this young man might head this way so here goes! I have been briefly scanning all the athletes at three of the major colleges for
    Message 1 of 27 , Aug 31, 2005
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      I thought the discussion on this young man might head this way so here goes!
      I have been briefly scanning all the athletes at three of the major colleges
      for the last seven years at no charge as a service to my community and as a
      response to three athletes in our immediate area expiring due to obstructive
      hypertrohic cardiomyopathy and one case of Marfans. Through these exams I
      have found 5 interatrial septal defects, 2 aortic stenosis (both of which
      were foreign students) 1 hypertophic cardiomyopathy and one with severe
      pulmonary hypertension apparently primary. It is rare that I scan highschool
      age kids but my son is now one of them so that is where and why I found the
      defect in this young man.

      I have scanned him twice, he was scanned at the pedatric cadrdiologist
      office and again at the hospital I work for by another sonographer. They
      were not able to reproduce the defect at the ped card office but they did
      not exercise him either. The last exam demonstated a late systolic jet
      peaking at 100 mmHg, mean at 32 mmHg. The aortic valve was tricuspid, wall
      thickness 1.0 cm and no obvious structural abnormalities. The obstruction
      was only noted with exercise heart rate 140 bpm and exacerbated with
      valsalva. Patient did not describe chest pain, dizzyness or other symptoms.

      For those of you who disagree with what I have been doing please know that
      it is a labor of love for these kids, I recieve no compensation for it and
      my purpose is simply to make a difference in maybe one young life.

      Thanks so much for the responses, they have been greatly appreciated. kscott
      --
      Kevin G. Scott
      CEO Medical Software Ltd
      www.MSL4U.com home of EIS
    • Gerson Lichtenberg
      A very common presenting symptom for hypertrophic cardiomyopathy is sudden death due to the ventricular arrhythmias many of these patients develop. This is why
      Message 2 of 27 , Aug 31, 2005
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        A very common presenting symptom for hypertrophic
        cardiomyopathy is sudden death due to the ventricular
        arrhythmias many of these patients develop. This is
        why we take warning symptoms like syncope so
        seriously, even though it is often non-cardiac. We see
        many such patients in our lab.

        Gerson Lichtenberg, RDCS, APS
        Echo Lab Coordinator
        Mt. Sinai Hospital
        Chicago, Illinois

        --- hairfree@... wrote:

        > Yes it does. That's one of the reasons these have
        > sort of stuck in my
        > brain. Seems like such a tragedy to have these
        > missed all along the way
        > to their teens.
        >
        > Wouldn't hypertrophic cardiomyopathy have been more
        > symptomatic and
        > therefore more likely detected?
        >
        > Of course starting football in mid August in Texas
        > is somewhat suicidal
        > in my mind. There's a reason why the Cowboys no
        > longer train in Wichita
        > Falls but have moved to Van Nuys, CA.
        >
        > I'm sure there's a heat component in these as well
        > but that doesn't show
        > up as readily on autopsy as a hole in the wall.
        > There have been a few
        > more deaths related to heat stroke on other athletes
        > here in the Dallas
        > metro area. You can't have an obese lineman
        > dissipate heat as
        > effectively as a weight for height running back.
        >
        > I've heard coaches now monitor core temps in the
        > small of the back
        > during practice. Terrific.
        >
        > Thank you so much for the link. That's great.
        >
        > Gotta run -- the local Food Bank is packaging up
        > food stuff to send to
        > the hurricane victims so I'm off to help load
        > trucks. One of those days
        > when it is very important to be a grunt.
        >
        > Judith
        >
        > On Wed, 31 Aug 2005 04:25:03 -0700 (PDT) Gerson
        > Lichtenberg
        > <gersonsl@...> writes:
        > > It seems unusual that so many incidences would be
        > due
        > > to septal defects rather than hypertrophic
        > > cardiomyopathy. That is usually what I think about
        > in
        > > these circumstances.
        > >
        > > For those interested in this topic, you might want
        > to
        > > look at www.aheartforsports.com. This is a very
        > > interested organization dedicated to doing
        > > echocardiography for sports screenings on a
        > minimal
        > > cost basis (I believe.). Please contact them if
        > you
        > > have an interest in doing screenings in your area.
        > > They may have information or support for you.
        > >
        > > Gerson Lichtenberg, RDCS, APS
        > > Echo Lab Coordinator
        > > Mt. Sinai Hospital
        > > Chicago, Illinois
        > >
        > > --- hairfree@... wrote:
        > >
        > > > I think I was trying to answer your original
        > > > question regarding why these
        > > > are becoming more frequent.
        > > >
        > > > "What was the reason for echo? It is not
        > routinely
        > > > done as for
        > > > > > sports
        > > > > > > physical. Was there pathological murmur?
        > or
        > > > abnormal EKG or
        > > > > > symptoms?
        > > >
        > > > The cases that have made the newspapers and
        > > > newscasts around here did not
        > > > present with symptoms. Therefore, there was no
        > > > Official Reason for an
        > > > echo. The first symptom was they dropped dead
        > on
        > > > the football field
        > > > either during practice or post game.
        > > >
        > > > One of them actually made it home and just
        > "didn't
        > > > feel good" (that's the
        > > > one symptom we REALLY encourage people to use as
        > a
        > > > reason to call 911) as
        > > > I remember the details. By the time an
        > ambulance
        > > > was summoned, too late.
        > > >
        > > >
        > > > Several of these were in the Dallas-Ft Worth
        > > > metroplex, one was in
        > > > Houston area, one in Austin area and one in
        > Permian
        > > > Basin --"Friday
        > > > Night" fame.
        > > >
        > > > As I recall, all or almost all were determined
        > to be
        > > > septal defect that
        > > > had not been diagnosed earlier in life as a
        > murmur
        > > > and, since there were
        > > > no symptoms, an EKG was not ordered, etc., etc.,
        > > > etc.
        > > >
        > > > Probably the unclosed hole grew larger as they
        > > > became adolescents and
        > > > perhaps not seen by a ped person any more. So
        > by
        > > > the time they have
        > > > something to really "hear", their single symptom
        > > > precluded advance
        > > > identification and correction.
        > > >
        > > > Yes the heart can hang a little weird in the
        > chest
        > > > for sure. And there
        > > > are lots and lots of measurements that can be
        > done
        > > > and should be done.
        > > > And there are lots and lots of tests that can
        > > > reconfirm what the autopsy
        > > > found -- holes in the septum.
        > > >
        > > > I'm having a problem thinking of a scenario
        > where an
        > > > echo would miss this
        > > > post mortem determined cause of death within the
        > > > first 2-3 minutes given
        > > > the way I was taught to look around the heart
        > PLAX
        > > > view of everyone that
        > > > laid on my table -- old or young.
        > > >
        > > > Let's see, big school district, 4 big sports
        > > > segments of the year --
        > > > football, basketball, baseball, track -- times
        > maybe
        > > > 300 students plus
        > > > intramural sports for maybe 200 more for a total
        > of
        > > > 500 X $1500 each is
        > > > around $750,000 which I would think is a
        > deterrent
        > > > on the basis of $$$$
        > > > alone.
        > > >
        > > > The District could hire PMD and echo
        > cardiographer
        > > > and buy a machine
        > > > (highly portable) and do EVERYONE for
        > significantly
        > > > less than that. And
        > > > less after the equipment purchase is amortized
        > in
        > > > subsequent years.
        > > >
        > > > We have found it to be a really big help to have
        > > > school nurses as a first
        > > > line in the districts, why not do a bit more
        > above
        > > > elementary?
        > > >
        > > > Small school district that uses many of the same
        > > > kids for each sport, not
        > > > such a significant total. But it is STILL a big
        > > > $1500 expenditure that
        > > > the schools may spin the wheel on -- now we have
        > to
        > > > handle the pressures
        > > > of fuel purchases for the busses. It's always
        > > > something.
        > > >
        > > > In closing, the $$$$ is a much bigger
        > consideration
        > > > in my mind than
        > > > yours. That's fine. Not my first difference of
        > > > opinion or my last and
        > > > I'm sure not yours either.
        > > >
        > > > Judith
        > > >
        > > > On Tue, 30 Aug 2005 14:35:06 -0500 "Makram
        > Ebeid"
        > > > <mebeid@...>
        > > > writes:
        > > > > This topic comes up often when an athlete
        > > > unfortunately collapses.
        > > > > The $$ factor is one of many factors. Another
        > > > consideration is the
        > > > > yield of echo in picking up anomalies in the
        > > > origin / course of
        > > > > coronary arteries is small. Thus an echo which
        > is
        > > > reported as normal
        > > > > may miss one of the important reasons of
        > sudden
        > > > death in the young
        > > > > athlete namely anomalous origin of coronary
        > > > arteries especially the
        > > > > left arising form the Rt and coursing between
        > the
        > > > great vessels.
        > > > > Thus in addition to the echo, cath would be
        > > > required as screening
        > > > > too!!!l And if you add the risks of cath and
        > > > selective coronary
        > > > > angiograms the yield will not warrant the
        > risk. A
        > > > lot of us rely on
        > > > > good history, physical EKG to either recommend
        > > > echo or even cath on
        > > > > selected patients. There are no studies to
        > show
        > > > that echo will
        > > > > decrease the incidence of sudden death
        > especially
        > > > that it will miss
        > > > > the anomalous origins or course of the
        > coronaries.
        > > > Even in patients
        > > > > who have echos done to evaluate their hearts
        > > > because of abnormal EKG
        > > > > with evidence of LVH echo may show LVH and you
        > > > wonder wether this is
        > > > > 'athletes heart" or hypertrophic CMO. To make
        > it
        > > > even more
        > > > > challenging occasionally we see abnormal
        > origins
        > > > of the RCA from
        > > > > Left sinus and is found as incidental finding
        > on a
        > > > cath performed
        > > > > for some other reason and you do not always
        > know
        > > > its significance.
        > > > > and if it is repaired is it enough to clear
        > the
        > > > athlete for
        > > > > competitive sports and further even if you
        > have
        > > > cleared that lesion
        > > > > some would restrict competitive contact sports
        > if
        > > > a sternotomy was
        > > > > performed
        > > > > Thus the $$ factor is not the only factor nor
        > is
        > > > it necessary the
        > > > > most important factor
        > > > > Regards
        > > > >
        > > > > Makram R. Ebeid, MD, FAAP, FACC, FSCAI
        > > > > Director, Pediatric Cath Lab
        > > > > University of Mississippi Medical Center
        > > > > 2500 N. State St,. Jackson, MS 39216
        > > > > Tel (601)984-5250
        > > > > Fax (601)984-5283
        > > > > E-mail: mebeid@...
        > > > >
        > > > > >>> hairfree@... 08/30/05 12:41 PM >>>
        > > > > Here in Texas we've had several early in the
        > > > season over the last
        > > > > 2-4
        > > > > years around the state that were the result of
        > > > septal wall defects
        > > > > --
        > > > > very easily PLAX detected by even a rookie
        > > > sonographer, in my
        > > > > opinion.
        > > > >
        > > > > The types of things you're looking for in this
        > > > situation, in my
        > > > > opinion,
        > > > > are quite different from a CHD adult patient
        > or
        > > > even a peds patient
        > > > > with
        > > > > symptoms.
        > > > >
        > > > > I remember one in the Austin, TX, area. A
        > doctor
        > > > was interviewed on
        > > > > TV
        > > > > about it and she basically said it was
        > impractical
        > > > from a $1500 per
        > > > > echocardiogram standpoint to echo the whole
        > team!!
        > > > That may be the
        > > > > real
        > > > > bottleneck.
        > > > >
        > > > > So maybe a different model/protocol for this
        > would
        > > > be important.
        > > > > But I
        > > > > gotta tell you -- when I hear even a hint of
        > > > meetings and committees
        > > > > and
        > > > > interdisciplinary development, I hear the $$$$
        > > > going way up and
        > > > > turf
        > > > > being protected. And that is a real big
        > stumbling
        > > > block, in my
        > > > > opinion.
        > > > >
        > > > > Judith
        > > > >
        > > > > On Tue, 30 Aug 2005 11:06:59 -0500 "GARCIA,
        > > > KATHLEEN (JSC-SK)
        > > > > (WLS)"
        > > > > <kathleen.garcia1@...> writes:
        > > > > > This is an important and interesting topic.
        >
        > > > > > A benchmark of parameters for hemodynamic
        > > > evaluation of an
        > > > > athletic
        > > > > > heart is
        > > > > > useful in light of young folks dying after
        > > > football practice.
        > > > > What
        > > > > > are the
        > > > > > normal hemodynamic parameters? Perhaps a
        > > > combination of sports
        > > > > > medicine and
        > > > > > echocardiogram standardized with help from
        > the
        > > > invasive
        > > > > > disciplines:
        > > > > > gradients under stress? I have not done a
        > > > proper literature
        > > > > search
        > > > > > but I
        > > > > > wonder if there a model out there?
        > > > > > Kathleen
        > > > > >
        > > > > >
        > > > > > -----Original Message-----
        > > > > > From: echocardiography@yahoogroups.com
        > > > > > [mailto:echocardiography@yahoogroups.com] On
        > > > Behalf Of
        > > > > > hairfree@...
        > > > > > Sent: Monday, August 29, 2005 1:17 PM
        > > > > > To: echocardiography@yahoogroups.com
        > > > > > Subject: Re: [echocardiography] your opinion
        > > > appreciated
        > > > > >
        > > > > > Because of young athletes collapsing after
        > > > football practice or a
        > > > >
        > > > > > game and
        > > > > > dying of undetected or diagnosed heart
        > problems,
        > > > a clearance echo
        > > > > is
        > > > > > much
        > > > > > more common now than even 2 years ago.
        > > > > >
        > > > > > I would think it very important to have a
        > > > benchmark echo to which
        > > > >
        > > > > > later
        > > > > > heart problems can be compared.
        > > > > >
        > > > > > Judith
        > > > > >
        > > > > > On Mon, 29 Aug 2005 12:00:54 -0500 "Makram
        > > > Ebeid"
        > > > > > <mebeid@...>
        > > > > > writes:
        > > > > > > What was the reason for echo? It is not
        > > > routinely done as for
        > > > > > sports
        > > > > > > physical. Was there pathological murmur?
        > or
        > > > abnormal EKG or
        > > > > > symptoms?
        > > > > > > Also what was the mean gradient? The peak
        > can
        > > > over estimate the
        > > > >
        > > > > > > gradient lot.
        > > > > > > Having said that was he cleared to
        > participate
        > > > in all physical
        > > > > > sports?
        > > > > > > Based on your findings further evaluation
        > may
        > > > be necessary
        > > > > > >
        > > > > > > Makram R. Ebeid, MD, FAAP, FACC, FSCAI
        > > > Director, Pediatric Cath
        > > > >
        > > > > > Lab
        > > > > > > University of Mississippi Medical Center
        > 2500
        > > > N. State St,.
        > > > > > Jackson,
        > > > > > > MS 39216 Tel (601)984-5250 Fax
        > (601)984-5283
        > > > > > > E-mail: mebeid@...
        > > > > > >
        > > > > > > >>> IamtheLadyK@... 08/26/05 8:10 PM
        > >>>
        > > > > > > If the boy became so hyperdynamic after
        > > > exercise it is possible
        > > > >
        > > > > > that
        > > > > > > you could be picking up some cavity
        > > > obliteration in the LV
        > > > > > >
        > > > > > > Kathy Harrington RDCS
        > > > > > >
        > > > > > > -----Original Message-----
        > > > > > > From: kevin@...
        > > > > > > To: echocardiography@yahoogroups.com
        > > > > > > Sent: Wed, 24 Aug 2005 16:15:35 -0700
        > > > > > > Subject: [echocardiography] your opinion
        > > > appreciated
        > > > > > >
        > > > > > >
        > > > > > > Recently had a 12 yr old young man for a
        > > > sports physical
        > > > > > > echocardiogram.
        > > > > > > After a brief period of exercise I was
        > able to
        > > > produce a peak
        > > > > late
        > > > > >
        > > > > > > systolic gradient across the left
        > ventricular
        > > > outflow tract of
        > > > > 70
        > > > > >
        > > > > > > mmHg. Wall
        > > > > > >
        > > > > > > thickness was normal at 1.0 cm, there was
        > no
        > > > obvious systolic
        > > > > > anterior
        > > > > > > motion of the mitral leaflets nor obvious
        > > > membrane or obvious
        > > > > > source
        > > > > > > for obstruction. The young man is
        > otherwise
        > > > healthy and without
        > > > >
        > > > > > > symptoms. The pediatric cardiologist that
        > > > looked at tape was
        > > > > > > unimpressed. In the absence of obvious
        > HCM,
        > > > IHSS or LVOT
        > > > > membrane
        > > > > >
        > > > > > > where and what else would you suggest I
        > do?
        > > > His blood pressure
        > > > > was
        > > > > >
        > > > > > > 128/84 Thanks so much in advance as my
        > concern
        > > > of course is for
        > > > >
        > > > > > him
        > > > > > > and proper treatment. Kevin
        > > > > > >
        > > > > > >
        > > > > > > --
        > > > > > > Kevin G. Scott
        > > > > > > CEO Medical Software Ltd
        > > > > > > www.MSL4U.com home of EIS
        > > > > > >
        > > > > > >
        > > > > > >
        > > > > > >
        > > > > > > Yahoo! Groups Links
        > > > > > >
        > > > > > >
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        > > > > > >
        > > > > > > Yahoo! Groups Links
        > > > > > >
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        > > > > > Yahoo! Groups Links
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        > > > > > Yahoo! Groups Links
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        > > > > Yahoo! Groups Links
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        > > > > Yahoo! Groups Links
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        > > > >
        > > > >
        > >
        > >
        > > Gerson Lichtenberg, RDCS, APS
        > > Echocardiography Coordinator
        > > Mt. Sinai Hospital
        > > Chicago, Illinois
        > >
        > >
        > >
        > > Yahoo! Groups Links
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        Gerson Lichtenberg, RDCS, APS
        Echocardiography Coordinator
        Mt. Sinai Hospital
        Chicago, Illinois
      • mlouw44@aol.com
        What an interesting project. Were there any sub aortic obstructions? Mary Lou RDCS
        Message 3 of 27 , Sep 1, 2005
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          What an interesting project.  
          Were there any sub aortic obstructions?
          Mary Lou RDCS
        • Rick Duncan
          Hi Kevin, This would be a great case to present online. If you can remove the patient s name you can submit it for everyone to view on Echo-Web. We have some
          Message 4 of 27 , Sep 26, 2005
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            Hi Kevin,

            This would be a great case to present online. If you can remove the
            patient's name you can submit it for everyone to view on Echo-Web. We have
            some really great cases that have been submitted and one in particular that
            presents a spongiform cardiomyopathy that was submitted by Muniza Yousef, a
            regular contributor to the group.

            If anyone is interested in submitting clips or cases, just visit
            www.echo-web.com. We will soon have a HIPAA agreement so we can edit the
            clips for everyone and keep patient info confidential.

            Best regards,

            Rick Duncan


            -----Original Message-----
            From: echocardiography@yahoogroups.com
            [mailto:echocardiography@yahoogroups.com] On Behalf Of kevin@...
            Sent: Wednesday, August 24, 2005 4:16 PM
            To: echocardiography@yahoogroups.com
            Subject: [echocardiography] your opinion appreciated

            Recently had a 12 yr old young man for a sports physical echocardiogram.
            After a brief period of exercise I was able to produce a peak late systolic
            gradient across the left ventricular outflow tract of 70 mmHg. Wall
            thickness was normal at 1.0 cm, there was no obvious systolic anterior
            motion of the mitral leaflets nor obvious membrane or obvious source for
            obstruction. The young man is otherwise healthy and without symptoms. The
            pediatric cardiologist that looked at tape was unimpressed. In the absence
            of obvious HCM, IHSS or LVOT membrane where and what else would you suggest
            I do? His blood pressure was 128/84 Thanks so much in advance as my concern
            of course is for him and proper treatment. Kevin


            --
            Kevin G. Scott
            CEO Medical Software Ltd
            www.MSL4U.com home of EIS




            Yahoo! Groups Links
          • Rick Duncan
            Hi everyone, Lorraine Gattuso from Philips Medical will be our Guest Host on Echo-Web Chat this Thursday, September 29, at 8pm EDT. It s 3D Echo: No Glasses
            Message 5 of 27 , Sep 26, 2005
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              Hi everyone,

              Lorraine Gattuso from Philips Medical will be our Guest Host on Echo-Web
              Chat this Thursday, September 29, at 8pm EDT. It's 3D Echo: No Glasses
              Needed. We invite everyone to attend this informative and fun session and
              to send in questions. 3D Echo is making its way into our toolbox in
              diagnosing cardiac disease. I think you'll be surprised at how useful this
              technology is becoming.

              I hope that everyone will attend.

              Rick Duncan
            • Wayne Moore
              Dear Kevin, exactly what was the pediatric cardiologist unimpressed with? Clearly to obtain a 70mmHg gradient you showed LVOT flow velocity in excess of 4
              Message 6 of 27 , Sep 27, 2005
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                Dear Kevin, exactly what was the pediatric cardiologist unimpressed with?
                Clearly to obtain a 70mmHg gradient you showed LVOT flow velocity in excess
                of 4 meters per second - I would be impressed with that.

                Wayne Moore
                Sonora Medical

                -----Original Message-----
                From: echocardiography@yahoogroups.com
                [mailto:echocardiography@yahoogroups.com]On Behalf Of Rick Duncan
                Sent: Monday, September 26, 2005 5:03 PM
                To: echocardiography@yahoogroups.com
                Subject: RE: [echocardiography] your opinion appreciated


                Hi Kevin,

                This would be a great case to present online. If you can remove the
                patient's name you can submit it for everyone to view on Echo-Web. We have
                some really great cases that have been submitted and one in particular that
                presents a spongiform cardiomyopathy that was submitted by Muniza Yousef, a
                regular contributor to the group.

                If anyone is interested in submitting clips or cases, just visit
                www.echo-web.com. We will soon have a HIPAA agreement so we can edit the
                clips for everyone and keep patient info confidential.

                Best regards,

                Rick Duncan


                -----Original Message-----
                From: echocardiography@yahoogroups.com
                [mailto:echocardiography@yahoogroups.com] On Behalf Of kevin@...
                Sent: Wednesday, August 24, 2005 4:16 PM
                To: echocardiography@yahoogroups.com
                Subject: [echocardiography] your opinion appreciated

                Recently had a 12 yr old young man for a sports physical echocardiogram.
                After a brief period of exercise I was able to produce a peak late systolic
                gradient across the left ventricular outflow tract of 70 mmHg. Wall
                thickness was normal at 1.0 cm, there was no obvious systolic anterior
                motion of the mitral leaflets nor obvious membrane or obvious source for
                obstruction. The young man is otherwise healthy and without symptoms. The
                pediatric cardiologist that looked at tape was unimpressed. In the absence
                of obvious HCM, IHSS or LVOT membrane where and what else would you suggest
                I do? His blood pressure was 128/84 Thanks so much in advance as my concern
                of course is for him and proper treatment. Kevin


                --
                Kevin G. Scott
                CEO Medical Software Ltd
                www.MSL4U.com home of EIS




                Yahoo! Groups Links













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              • muniza yousuf
                How can I ll be able to attend this chat session. Whether I have to register some where? What will be the exact timings acc to Pakistan standard time? From:
                Message 7 of 27 , Sep 27, 2005
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                  How can I'll be able to attend this chat session. Whether I have to register some where? What will be the exact timings acc to Pakistan standard time?


                  From:  "Rick Duncan" <rick@...>
                  Reply-To:  echocardiography@yahoogroups.com
                  To:  <echocardiography@yahoogroups.com>
                  Subject:  [echocardiography] Chat Session on 3D Echocardiography
                  Date:  Mon, 26 Sep 2005 16:09:47 -0700
                  >Hi everyone,
                  >
                  >Lorraine Gattuso from Philips Medical will be our Guest Host on Echo-Web
                  >Chat this Thursday, September 29, at 8pm EDT.   It's 3D Echo: No Glasses
                  >Needed.  We invite everyone to attend this informative and fun session and
                  >to send in questions.  3D Echo is making its way into our toolbox in
                  >diagnosing cardiac disease.  I think you'll be surprised at how useful this
                  >technology is becoming.
                  >
                  >I hope that everyone will attend.
                  >
                  >Rick Duncan
                  >
                  >
                  >
                  >
                  >
                  >
                  >Yahoo! Groups Links
                  >
                  ><*> To visit your group on the web, go to:
                  >     http://groups.yahoo.com/group/echocardiography/
                  >
                  ><*> To unsubscribe from this group, send an email to:
                  >     echocardiography-unsubscribe@yahoogroups.com
                  >
                  ><*> Your use of Yahoo! Groups is subject to:
                  >     http://docs.yahoo.com/info/terms/
                  >
                  >
                  >
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