MEDICAL IMAGING SPECIAL - interhospi.com · ern era of screening for two of the most ... [26 - 27]...

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Managing the kidney dialysis patientCombining disparate IT systems into a single PACS

3D tomosynthesis and mammography

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The MAgAzIne for heAlThCAre DeCISIon MAkerS

Weekly news updates on www.ihe-online.com

real time patient data linked with records

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Defibrillators with capnography and BP

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hospitalinternational

Equipment & solutionsVolume 34 Issue 6

IHE November 2009

MEDICAL IMAGING SPECIAL

Viewing the future: PeT/CT and SPeCT/CTDual-modality probes for molecular imaging

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The recent JAMA paper (Esserman L, et al. Rethink-ing screening for breast cancer and prostate cancer, JAMA 2009 Oct

21; 302: 1685), from three US clini-cians has sparked off a huge contro-versy. After what is now twenty years experience in the United States of what could be described as the mod-ern era of screening for two of the most common and potentially lethal cancers (breast and prostate), the authors looked at the overall epide-miological impact so far of the screen-ing programs. Although the data in this study are restricted to the US, the conclusions are valid for just about every other Western healthcare sys-tem, where similar approaches to early cancer screening programs are taken, even if tighter financial resources limit their implementation. The JAMA authors found that the reported inci-dence of the two types of cancers increased after the introduction of screening and has never returned to the pre-screening levels and that there was an increase in the fraction of all cases that related to early stage can-cers. Such findings are consistent with what would be generally expected from cancer screening programs, based as they are on the apparently reasonable assumption that the early detection of cancers should result in more efficacious, early treatment with a consequent arrest of the develop-ment of the disease to much more dangerous and life-threatening meta-static states. However another finding of the JAMA report shows that, in fact, the incidence of regional cancers (i.e. those identified outside of the original anatomical area) did NOT decrease at a rate commensurate with the higher detection of early-stage cancers. The inference is that screening may be simply increasing the burden of low-risk cancers without reducing the burden of more aggressively grow-ing cancers and so does not have the anticipated reduction in mortality. Understandably, since the publication of the JAMA report a heated debate has arisen, with some extreme com-mentators speculating that this is the proof that all that screening programs

actually do is detect previously unsus-pected cancers that might have spon-taneously regressed anyway. There was even a rumour (since denied) that the normally unflappable American Cancer Society was about to change its recommendations and guidelines on breast and prostate cancer screening. The truth is that current cancer screening programs do bring actual benefits, although these may havebeen

oversold. The problem with the cur-rent debate is that the message reach-ing the general public is likely to be the oversimplified one of “screening is no good”. It would be a tragedy if because of this, all screening programs, imper-fect though they may be, were to be totally abandoned.What is in fact needed is to actually bolster screening programs so that potentially aggressive early cancers

can be distinguished from those that are much less dangerous. The good news is that recently developed genetic tests profiling the expression levels of panels of particular genes can make just such distinctions. The bad news is that, as ever with screening pro-grams, cost issues remain the biggest stumbling block.

A cat among the cancer screening pigeons

Editor’s LEttEr 3


– Issue N°6 – Nov. 2009

ContentsFRONT COVER PRODUCTS[39] 3d tomosynthesis

integrated with mammography

[45] real time patient data linked with records

[46] defibrillators with capnography and BP options

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CoMiNG UP iN dEC 2009Women’s health special

Pulmonary medicine

FEATURES[8 - 16] UROLOGY AND KIDNEY DIALYSIS[8 - 10] Managing the dialysis patient: a review for the hospital physician

[11 - 13] Living kidney donors: current status

[14 - 16] Advances in the surgical management of nephrolithiasis

[18 - 34] MEDICAL IMAGING[18] Scientific literature review: Medical imaging

[20 - 22] PET/CT and SPECT/CT: technology and applications

[24 - 25] Imaging pancreatitis in paediatrics

[26 - 27] MRCP vs ERCP in biliary pathologies

[28 - 30] Mechatronics in MR elastography

[32 - 34] Dual modality probes for molecular imaging

[36 - 38] HEALTHCARE IT transforming disparate systems into enterprise-wide PACs

REGULARS[3] Editor’s letter

[6 - 7] News in brief

[17] scientific literature review — ECG

[39] Product News

[40 - 46] Medica highlights

[46] Calendar of upcoming events

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6 NEWs iN BriEF

Important H1N1 flu advisory for cardiopulmonary transplantation

Each year 3-5 million people world-wide have severe cases of seasonal influenza and 250-500,000 die from complications. This year, the novel H1N1 (nH1N1) influenza, previously called swine flu, has reached pandemic status, bringing particular challenges for cardiopulmonary transplant recipients, as well as for the healthcare workers involved in the transplant process. In an article published recently in the Jour-nal of Heart and Lung Transplantation, physicians representing the Infectious Disease Council of the International Society for Heart & Lung Transplanta-tion (ISHLT) issued an advisory for all programmes in cardiothoracic transplantation.Recognition of the novel 2009 H1N1 influenza virus, aggressive diagnosis and early treatment need to be combined with active preventative measures to stem the impact of infection in the transplant population. This special advisory addresses issues relevant to cardiothoracic trans-plant candidates, selection of donors, recipient management and patients with mechanical circu-latory support devices. Since transplant recipients are treated with anti-rejection drugs, the advisory provides clear directions for specific dosing of antiviral drugs and management of the back-ground immunosuppression. Specific guidelines for evaluation and management of post-surgical transplant patients are also given, as well as rec-ommendations as to how and when to admin-ister vaccines. On the donor side, the advisory provides guidelines for how to evaluate and treat donors so that organs can be safely used and not wasted. Finally, it provides specific guidelines for the healthcare teams managing such patients.www.jhltonline.org

‘Difficult-to-treat asthma’ may be due to poor complianceDifficult-to-treat asthma may often be the result of patient non-compliance rather than inef-fective medication, according to researchers in Northern Ireland. Dr Liam Heaney, of Belfast City Hospital obtained data from patients who were referred to a tertiary referral clinic that specialises in difficult-to-treat asthma. To assess compliance with inhaled corti-costeroid therapy (ICT), the researchers compared

patient prescriptions with the patient’s actual refill usage. They used blood plasma prednisolone and cortisol levels to evaluate oral medication adher-ence. Of the 182 consecutive patients, 35 percent filled fewer than half of their prescribed inhaled combination therapy (ICT), 21 percent filled more than they were prescribed and 45 percent filled between half and all of the medication they were prescribed. Furthermore, in patients who were on a maintenance course of oral prednisolone, blood levels of cortisol and prednisolone showed that nearly half (45 percent) were not taking the medi-cation as prescribed. In follow-up conversations with the researchers, most patients admitted that they were inconsistent in the use of their medica-tions. Of the 23 patients who were non-adherent to their oral prednisolone, 15 — or 65 percent — were also non-adherent in their ICT.Some patient characteristics were more strongly associated with nonadherence than others: women were less likely to be adherent than men. It was also found that patients who filled

fewer than half of their prescribed ICT scored significantly lower on the EuroQol and the Asthma Quality of Life Questionnaire.http://ajrccm.atsjournals.org/

Sensor biochips could aid in cancer diagnosis and treatmentIt is very difficult to predict whether a can-cer drug will be effective in an individual: only around one third of drugs work directly in a given patient. Researchers at the Technische Universität München (TUM), Germany have developed a new test process for cancer drugs. With the help of microchips, it can be established in the labo-ratory whether a patient’s tumour cells will react to a given drug. This chip could enable the rapid identification of the most effective medication for the individual patient. The chips are located in the wells of microtitre plates, kept in condi-tions similar to cells in the body and are covered with patients’ tumour cells. A robot changes the culture fluid in each well containing a chip at intervals of just a few minutes. The microsensors on the chip record, among other things, changes in the acid content of the medium and the cells’ oxygen consumption; photographs of the process are also taken by a microscope fitted underneath the microtitre plate. The electronically collected

data provide an overview of the metabolic activ-ity of the tumour cells and their vitality. After the tumour cells have been able to divide undis-turbed for a few hours, a potential drug is added. If metabolic activity of the cells declines over the next day or two, the drug can be considered to be effective. Using the microchips, twenty-four active substances or combinations of active substances can be tested simultaneously in this way; the patient can then be treated in a timely fashion with the most effective drug available.

http://portal.mytum.de/

New IDF guidelines to improve the treatment of diabetes worldwideNew International Diabetes Federation (IDF) guidelines are focused on meeting the critical global need to provide up-to-date evidence-based information and training for healthcare profes-sionals. This is especially important as, alarmingly, the latest data from the IDF Diabetes Atlas show that over 285 million people worldwide now live with diabetes. Within 20 years, IDF predicts that the figure will jump to 435 million. Healthcare professionals must be equipped with the latest improvements and standards in diabetes care to tackle this spiralling epidemic. The IDF Global Guideline on Pregnancy and Dia-betes aims to set a global standard for the care of gestational diabetes and women with diabe-tes who become pregnant. Gestational diabetes is common and, like obesity and type 2 diabetes, is increasing in frequency throughout the world. The risk of developing diabetes after gestational pregnancy is very high. IDF also released new guidelines on the Self-Monitoring of Blood Glu-cose in Non-Insulin Treated Type 2 Diabetes and Oral Health for People With Diabetes. The IDF Guideline on Oral Health for People With Diabetes recommends a focus on clinical care for

– Issue N°6 – Nov. 2009

The chip is just a few millime-ters in size, but packed with sensors. Here, a ceramic version of the chip is shown.

7

people with diabetes, integrating not only diabetes but oral health profes-sionals. Poor oral health can nega-tively impact the lives of people liv-ing with diabetes and they need to be educated on how to manage their oral health as well as their diabetes. The IDF Guideline on Self-Moni-toring of Blood Glucose (SMBG) in Non-Insulin Treated Type 2 Diabetes provides recommendations for peo-ple with diabetes and their health-care professionals. Type 2 diabetes is responsible for 85-95% of all diabe-tes and this guideline recommends that SMBG should be considered an ongoing part of diabetes self-man-agement education. Another of its key recommendations is that SMBG Protocols (intensity and frequency) should be individualised to address each subject’s specific educational/behavioural/clinical requirements in order to identify/prevent/manage acute hyper- and hypoglycaemia. www.idf.org/clinical-practice-guidelines

Even low alcohol consumption has a negative impact on overall health

Low alcohol consumption is bad for health in general according to Dr Johan Jarl, from Lund University, Sweden, who worked with a team of researchers to determine the effect of low alcohol consumption on health by measuring alcohol-related medi-cal care costs and episodes collected during the Swedish Cost of Alcohol Project in 2002. It was found that, with the exception of people more than 80 years old, men who consumed up to five units a day and women who con-sumed up to 2.5 units a day cost the health service more than those who do not drink alcohol. The finding calls into question the previous assumption that low alcohol consumption is good for health.www.resource-allocation.com/

New emergency medical service system may predict caller’s fateJapanese researchers have developed a computer programme which may

be able tell from an emergency call if the caller is about to die. Research published in the open access journal BMC Emergency Medicine shows that a computer algorithm is able to predict the patient’s risk of dying at the time of the emergency call.Kenji Ohshige and a team of researchers from the Yokohama City University School of Medicine in Japan assessed the new Yoko-hama computer-based triage emer-gency system collecting informa-tion from over 60,000 emergency

calls. For each call, triage informa-tion was entered into the compu-ter system, which then categorised patients according to the severity of their condition. The research-ers then compared the computer-estimated threat of dying at the time of the emergency call with the actual patients’ condition upon arrival at the hospital emergency department. They found that the algorithm was effective in assess-ing the life risk of a patient with over 80% sensitivity.Ambulance response time has risen

rapidly with the increased demand for this service in developed countries. This emphasises the need to prioritise ambulance responses according to the severity of the patient’s condition. www.biomedcentral.com/bmce-mergmed/

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– Issue N°6 – Nov. 2009

8 rENAL MEdiCiNE

Dialysis describes the artificial transfer of sol-utes and water between the patient’s blood and a dedicated solution (dialysate) across a semi-permeable membrane with the aim of restoring the internal milieu of patients with end-stage renal disease. This membrane can be either syn-thetic (as in haemodialysis, HD) or endogenous (as is the peritoneum in peritoneal dialysis, PD). Water movement into dialysate (ultrafiltration, UF) is accomplished by exerting negative trans-membrane pressure in HD and by an osmotic gradient in PD.

HD is achieved by connecting the patient’s cir-culation (through either central venous cathe-ters, CVCs, or an arteriovenous fistula, AVF) to a machine which carries out the procedure. HD patients rely on regular dialysis typically thrice weekly, delivered at a dedicated dialysis unit (in hospital / satellite unit).

PD involves the instillation, dwell time and sub-sequent removal of dialysate into the patient’s abdominal cavity via a permanent, tunnelled, cuffed catheter. In the majority of patients this is carried out by the patients themselves and/or their caregivers at home, and so requires less nursing input.

The physiology of the dialysis patientPatients on dialysis have a glomerular filtration rate below 15mL/min; often less than 8mL/min. This does not mean they are anuric — a pro-portion retain significant residual renal func-tion which is especially important in the PD population. It is important to avoid nephrotox-ins and overdiuresis. The small residual renal clearances seen in dialysis patients are clini-cally relevant. In patients on PD every 1mL/min/1.73m2 of residual function is associated with a nearly 50% reduction of all cause and cardiovascular death. This residual native func-tion (not the achieved peritoneal clearance) correlates with beneficial outcomes in patients

on PD. With increasing time on dialysis (par-ticularly HD), the native urine output dwindles and almost all long-term patients on HD are anuric. Great care with fluid administration is required (the usual recommended daily fluid allowance for patients on dialysis roughly = residual urine output + 500mL).

As the kidneys fail, potassium excretion is impaired leading to hyperkalaemia. A reduc-tion in functioning renal tissue mass causes erythropoietin deficiency and anaemia, impaired vitamin D metabolism with second-ary hypocalcaemia, hyperphosphataemia and hyperparathyroidism.

Advanced kidney failure causes a diffuse pro-atherogenic, pro-inflammatory tendency and widespread vascular disease (characterised by disproportionate vascular calcification)[1]. Uraemia is a catabolic state characterised by a bleeding diathesis and predisposition to gas-trointestinal bleeding [2].

Importance of dietPatients on dialysis require dietetic input to achieve adequate caloric and protein intake while controlling electrolyte load. Dialysis adequacy determines the total body clearance of intracel-lular ions such as phosphate and potassium and a significant proportion of patients on dialysis will require the use of phosphate binders at mealtimes

(e.g. calcium carbonate, sevelamer) to help with phosphate control.

Prescribing in dialysis patientsIn end-stage renal disease (ESRD) the renal route of drug elimination is impaired. In addi-tion, altered drug metabolism, serum protein binding and fluctuations in volume of distribu-tion (especially in HD) occur. Hospital pharma-cists as well as national and local formularies are available to inform prescribing (eg. Renal Drug Handbook) [3].

Common medical emergencies in dialysis patientsThe treatment of intercurrent medical problems in patients on dialysis is broadly the same as for the general population. Patients commonly present to the emergency department with:

* Cardiovascular pathology (cardiac, cerebrov-ascular, peripheral vascular)

* Fluid overload (peripheral ± pulmonary oedema)

* Infection* Diabetic emergencies* Hyperkalaemia* Complications of dialysis access

Cardiovascular diseaseCardiovascular disease accounts for 50% of deaths in patients on dialysis [4]. The relative risk of coronary artery disease is 5-30 times that of the general population [5]. An acute coronary syn-drome (ACS) can be clinically “silent” (uraemic autonomic neuropathy +/- diabetic autonomic neuropathy). Hypertension is treated primarily by reducing circulating blood volume by ultrafil-tration on dialysis and adding combination anti-hypertensive therapy if required. Stroke is 5-10 times more common in patients on dialysis than in the general population with a higher prevalence of haemorrhagic events. Patients with autosomal dominant polycystic kidney disease (ADPKD)

Managing the dialysis patient: a brief review for the hospital physicianAs a relative shortage of organs limits transplantation rates in many countries, the number of patients on dialysis is increasing. Generally nephrologists in specialist centres supervise patient dialysis but, in the context of acute medical emergencies, such patients increasingly present to district general hospitals. this review aims to provide a practical guide to aid the general physicians involved without an in-depth knowledge of nephrology being demanded.

by dr A. Power and dr C. Goodlad

Table 1. Some selected food sources of which to be aware when assessing patients’ diet.

Electrolyte Sources of electrolyte

Potassium Fruit / fruit juice, nuts, chocolate, crisps, coffee

Sodium Added to meals, crisps, ready meals, smoked foods

Phosphate Dairy produce (cheese, milk, yogurt), bony fish (eg. sardines), offal

– Issue N°6 – Nov. 2009

– Issue N°6 – Nov. 20099

have a higher risk of subarachnoid haemorrhage due to the increased prevalence of berry aneurysms.

Treatment of fluid overload in HDDialysis (or haemofiltration in the intensive care unit) is the only defin-itive treatment. Loop diuretics will have minimal impact in oligoanuric HD patients and the delay in starting HD for fluid removal by ultrafiltra-tion should be kept to a minimum.

Treatment of fluid overload in PDDiuresis with high dose fruse-mide can be effective if the patient still passes urine. Rapid exchanges with hypertonic glucose (2.27%) every 1-2 hours will allow maximal UF; there will be substantial glu-cose absorption and blood glucose should be monitored especially in diabetics. Temporary haemofiltra-tion in the ITU may be required in compromised patients.

DiabetesDiabetes is one of the leading causes of ESRD in the developed world. Patients often have a constellation of diabetic organ complications (eg. retinopathy, neuropathy, arterial dis-ease). Metabolic control can be dif-ficult to achieve. Insulin is renally metabolised and not excreted by HD or PD. Accumulation can lead to dangerous hypoglycaemia (espe-cially with soluble insulin in intra-venous infusions – “sliding-scale insulin”).

In diabetic ketoacidosis aggres-sive fluid hydration in oligo-anuric patients can precipitate severe pul-monary oedema and should be avoided. Treatment of insulin defi-ciency, gradual osmotic correction and supplementary correction of acidosis by dialysis is the mainstay of management, as well as enabling a rigorous search for an underlying cause [6].

InfectionESRD is an immunosuppressed state. In addition, patients who have been aggressively treated for immunological disease or trans-plant rejection in the past can remain substantially immunocom-promised for a prolonged period of time. As a result, patients on

dialysis are more prone to severe infection which should be man-aged early and aggressively. The absence of fever or leucocytosis does not per se equate to absence of infection.

The choice of antibiotics is deter-mined by the likely source(s) of infection as well as dialysis unit protocol. “Blind” treatment often includes both Gram positive (including methicillin-resistant Staphylococcus aureus) and Gram negative cover.

HyperkalaemiaSignificant (K+>6.5mmol/L) hyper-kalaemia in patients on dialysis often reflects a need for dialysis. The degree of hyperkalaemia and the presence of electrocardiographic changes dictate the speed at which this is delivered. Ion-exchange resins have no role in this situation. Intravenous calcium can offer temporary cardioprotection and an insulin-dextrose infusion can have a temporary impact on the peak level of potassium (the serum level will rebound) which facilitates timely dialysis [7].

Key points* Cardiovascular disease is com-

mon and can be clinically “silent”* Dialysis is the definitive treat-

ment for fluid overload and hyperkalaemia

* Infection requires rapid and aggressive treatment

Dialysis access-related complicationsHaemodialysis access - AVFThe arteriovenous fistula, AVF is a high-flow, high-pressure structure reserved only for HD. It should

Medical_Fair_Jnr_Pg.indd 1 22/10/09 12:59:18 PM www.ihe-online.com & search 45405

– Issue N°6 – Nov. 2009

not be used for peripheral venous cannulation, blood sampling or blood pressure monitoring as this can cause bleeding and compromise function of the AVF (ultimately resulting in clotting). Preservation of veins is essential to form future AVFs. Repeated venepuncture, phlebitis and haematoma formation will result in veins which are not suitable for surgical use. The cephalic vein at the wrist, the antecubital fossa (and the forearm) are to be avoided.

Haemodialysis access – CVCsCentral venous catheters, CVCs comprise a vari-ety of commercially available tunnelled, cuffed catheters. As they are formed of prosthetic mate-rial, they carry a risk of thrombosis and infection. Access infection requires aggressive management with intravenous antibiotics and consideration of CVC removal in consultation with the patient’s dialysis unit.

Peritoneal dialysis access - peritonitisPeritonitis is the most common reason for emergency admission of patients on PD. The first sign may be cloudiness of the drained dialysis fluid (for which patients check at each exchange) to septicaemia and severe pain. Diar-rhoea, fever, nausea, vomiting and abdomi-nal pain are common. There is often diffuse abdominal tenderness and features of periton-ism may be present. The diagnosis is made by the finding of >100 white blood cells/microlitre

in the dialysate effluent with neutrophil pre-dominance. Treatment is with intra-peritoneal antibiotics (which give better outcomes than oral or intravenous therapy) chosen to cover local patterns of infection. Poor response to first line antibiotics should prompt cross- sectional imaging to exclude bowel pathology and abdominal collections.

Peritoneal dialysis access - mechanical problemsThere are many potential causes of a poorly draining catheter. Frequently it is due to con-stipation and/or catheter position (it should lie in the pelvis) and the degree of bowel load-ing is assessed by plain abdominal film. Treat-ment of constipation often resolves the problem allowing a displaced catheter to migrate back into position. ConclusionsPatients on dialysis have multiple co-morbid-ities and are medically complex. Most patients present to a hospital emergency department with non-nephrological problems. Their management requires an understanding of their physiology and the complications of their dialysis modality as well as discussion with their dialysis team.

References1. Moe SM & Chen NX. Mechanisms of vascular

calcification in chronic kidney disease. J Am Soc

Nephrol 2007; 19(2): 93-101.2. Hedges SJ, Dehoney SB, Hooper JS, Amanzadeh J &

Busti AJ. Evidence-based treatment recommenda-tions for uremic bleeding. Nat Clin Pract Nephrol 2007; 3(3): 138-153.

3. Ashley C & Currie A (Eds). The Renal Drug Handbook. Second Edition. Radcliffe Medical Press, 2004

4. United States Renal Data System – 2007 Report. ht tp : / / w w w. u s rd s . org / 2 0 0 7 / p d f / 0 6 _ h o s p _morte_07.pdf (accessed 14th July 2008)

5. Longenecker JC, Coresh J, Powe NR, Levey AS, Fink NE, Martin A & Klag MJ. Traditional car-diovascular disease risk factors in dialysis patients compared with the general population: The CHOICE Study. J Am Soc Nephrol 2002; 13(7): 1918-1927.

6. Blicker J, Herd AM & Talbot J. Diabetic ketoacidosis in the dialysis-dependent patient: two case reports and recommendations for treatment. CJEM 2004; 6(4): 281-284.

7. Evans K, Reddan DN & Szczech LA. Nondialytic management of hyperkalemia and pulmonary edema among end-stage renal disease patients: an evaluation of the evidence. Semin Dial 2004; 17(1): 22-29.

The authorsDr A. Power* & Dr C. Goodlad Imperial College Kidney and Transplant Institute

*Author for correspondenceDr A. PowerWest London Renal and Transplant CentreImperial College Healthcare NHS Trust Hammersmith HospitalDuCane RoadLondon W12 0HSUnited KindgomTel: +44 20 8383 5256Fax +44 20 8383 5169e-mail: [email protected]

[email protected]

10 rENAL MEdiCiNE

Table 2. Main messages for the hospital physician.

• Dialysis patients are often medically complex – speak to their nephrology team• Always check drug formularies before prescribing new medication• Dialysis access is precious• Dialysis patients are more prone to bleeding – consider before invasive procedures• Cardiovascular events & infection are common – have a low threshold of suspicion

– Issue N°6 – Nov. 2009

Living kidney donation is the best treatment for patients with end stage renal disease (ESRD); survival is significantly higher than in patients receiving cadaver kidneys. However, even though donors are extensively evaluated and carefully selected to ensure that they are healthy there is concern over the long-term consequences of donation. The anticipated changes in donor risk must be balanced with the donor’s willingness to provide benefit to the recipient.

Short-term risks Donor mortalityThe risk of death within 90 days following dona-tion is 0.02-0.04% [1-3]. Twelve-month mortality is 0.08%. Causes of donor death beyond the post-oper-ative period are the same as for the general popula-tion [1, 2]. However even though donors reportedly undergo a thorough evaluation prior to donation, some causes of death a short time after donation (e.g. myocardial infarction, cancer, suicide and

homicide) point to a need for programmes to review donor outcomes in the context of pre-donation medical and psychosocial evaluations. Even within a highly selected population, complications will occur. The question is whether more complications can be prevented.

Short-term post-operative com plications Acute post-operative complications reported to the US United Network for Organ Sharing (UNOS) generally include bleeding, gastrointestinal injury and/or malfunction, venous thromboembolism and re-operation [2]. Analyses of short-term (six weeks post-donation) outcomes for living kidney donors have found that 3.9% of the living kidney donors who donated in 2005 and 2006 had at least one adverse event. The most common post-operative complications were re-operation (0.5% of all living donors), re-admission, blood transfusion and vas-cular complications. The most common reasons for re-operation were bleeding, bowel obstruction and hernia repair. The most common reason for donor readmission was abdominal problems.

Short-term kidney outcomesFollowing donation, the average decrease in overall kidney function is 20-30%. This is at the

Living kidney donors: the current statusover half of kidney transplants worldwide come from living donors, raising the question of the health impact such donations have on the donor. in general, out-comes for donors are no different from those of the general population (although there may be a slight increase in the incidence of end-stage renal disease; the risk of preeclampsia may also be marginally higher in female donors). However with the increase in conditions such as hypertension, proteinuria and obesity, com-plications in living donors may become more frequent. this paper reviews Us data on the risk of death, post-operative complications and Esrd in living donors. Global donor safety standards should be enforced in all countries to include donor evaluation and continued monitoring of all donors. systems should be put in place that allow more complete and continuous follow-up of living kidney donors.

by dr C. davis

11rENAL MEdiCiNE


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expense of hyperfiltration in the remaining kidney. The absolute ability to increase GFR is dependent upon age and obesity. Obese young individuals cannot fully compen-sate for the loss. Older donors do increase single kidney GFR, but the absolute increase is less.

Living donor issuesPregnancy after living donationMany young women consider living donation prior to completing child-bearing. Although classical teaching is that pregnancy is not negatively impacted by a previous unilateral nephrectomy, researchers in Norway linked data from the living donor registry with birth records. It was found that women who donated had

a higher rate of pre-eclampsia fol-lowing donation (5.7%) compared to the rate before donation (2.6%). Randomly chosen controls developed pre-eclampsia in 3.5% of pregnancies [4]. It should be noted however that these data are only relevant for the Caucasian population.

Long-term studies of living donor survivalReported long-term outcomes from single centre studies with largely Cau-casian populations have revealed outcomes equal to or better than the general population [5-7]. The most recent information comes from stud-ies on 3698 Caucasian kidney donors who were followed from 1963 to 2007 for mortality and ESRD development [6]. Mortality was comparable to the

general population. The development of ESRD is discussed below. Renal func-tional studies carried out at a mean of 12.9 ± 9.2 years after donation revealed that 85.5% of the donor population had a GFR > of 60 mL/min/1.73 m2. Hypertension was noted in 32.15% and albuminuria in 12.7% of the pop-ulation. A GFR < 60 mL/min/1.73m2 and hypertension were associated with older age and higher body mass index. Albuminuria was associated with a longer period from time of donation. Most donors had quality of life scores greater than population norms.

Even mild degrees of kidney insuf-ficiency and albuminuria have been associated with increased risks of cardiovascular (CV) disease so rasing concerns of increased CV risk in living donors. However it has been shown that living donors did not have more CV events or a higher mortality over 10 years than the control population, matched for age, gender, income and use of non-physician healthcare [7]. A significant increase in the number of living donors with hypertension was however reported compared to the control group [7].

In addition to “normal” donors who have been carefully selected using medical criteria, it has recently been reported that individuals with certain medical abnormalities are also donat-ing [8,9]. The long-term risks to these donors are not yet well established. Medical problems relevant to kid-ney donation that need further study include renal artery stenosis, hyper-tension, morbid obesity, mild glucose intolerance, nephrolithiasis and thin glomerular basement membranes. ESRD in living donorsRecent research has found that between 0.1 to 1.1% of living donors have developed ESRD [6, 10]. Follow-up on a study of 3698 living donors revealed that 11 (0.29%) developed ESRD 22.5±10.4 years after donation; seven of these donors were women and eight were white [6]. This repre-sents an estimated incidence of ESRD in donors of 180 per million persons per year, compared with the overall adjusted incidence rate of 268 per million persons per year in the white population of the US. Further analyses of the data, however, revealed that 148 living kidney donors were themselves on the kidney waiting list between

1/1/1996 and 3/31/2007 [10-12]. Most of the donors who were later listed for a kidney had donated to a full sibling between the ages of 18 and 34. Of spe-cial concern was the finding that the median time from donation to listing was 21 years for white donors and 16 years for African American donors, implying that short-term follow-up of living donors may not adequately identify or quantify this risk. Also of concern was the finding that 43% of such donors were African Americans, who made up nearly 12% of living kidney donors. These data suggest that the risks of post-donation ESRD are unequal among various ethnic/racial groups and mirror the increased risk of ERSD that these higher-risk groups experience within the general population [10-12].

Current demographics of living donors RelationshipsToday, donors are less likely than in the past to be blood relatives of the recipient and instead are more likely to be partners and friends. There are increased donations by adult offspring to their parents: 9% of liv-ing donors in 1989, 18.7% in 2006 [1, 13]. There is also an increase in donation by unrelated and emotion-ally uninvolved donors. Although the number of such altruistic donors is increasing, they are still a small proportion of all living donors. A hybrid between traditional directed donation and altruistic donation is a relatively new phenomenon known as kidney-paired donation (KPD): two prospective recipients each have a willing living donor with whom they are not compatible, e.g. original donor-recipient ABO incompatibil-ity or positive crossmatch [Figure 1].

Other donor trendsIn general donor age is increasing in concert with recipient age. There is also an increase in the percentage of so-called medically complex donors, with medical complexity defined as the presence of hypertension, an eGFR< 60 mL/min/1.73m2, and in particular obesity.

Other issuesKidney biopsies obtained at time of transplant show that at least half of living donors in the US do not have a completely normal renal histol-ogy, probably reflecting the fact that

12 rENAL MEdiCiNE

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– Issue N°6 – Nov. 2009

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a larger proportion of organ donors than recipients have inadequate health insurance coverage and therefore less access to high quality medical care [14]. Insurance coverage also varied according to the race of the donor. In the US there is no national policy that addresses the length of time that com-plications arising from donation are covered, or the responsibility of the recipient’s insurance plan.

Criteria used to select living donors have changed over time [9], with the most significant changes being the acceptance of living unrelated donors and the elimination of an upper age for donation. Addition-ally, donors with hypertension and a history of kidney stones are more likely to be accepted, as long as certain additional criteria are met. There is considerable variability in testing methods and the criteria used for donor selection in different transplant programmes

Living donation and medical policyThe process surrounding living dona-tion is evolving. Recently several con-ferences have been held to discuss the consent for, evaluation of, and care of living donors [15-17]. Internation-ally, countries have banded together to discourage and, in fact, eradicate paid donation. This follows reports from Pakistan, Iran and the Philip-pines regarding the negative impact of cash payment to donors on their health and the health of recipients.

ConclusionAs the number of living kidney dona-tions has increased so has the number of medically complex donors [8], with nearly a quarter of current US living

kidney donors having some medi-cal problem. Approximately 17% of US living donors don’t have health insurance. Given the low but real risk of medical problems following living donation, particularly ESRD, it is very important to provide medical follow-up for all living donors and to ensure long-term study of their medical and psychological outcomes.

References1. United Network for Organ Sharing, Rich-

mond, VA data as of December 31, 2007.

2. Wainright J et al. Short-term complica-

tions of living donation. Am J Transplant

2008; 8: 282.

3. Matas AJ et al. Morbidity and mortality

after living kidney donation: 1999-2001

survey of United States transplant centers.

Am J Transplant 2003; 3: 830.

4. Reisaeter AV et al. Pregnancy and birth

after kidney donation: the Norwegian

experience. Am J Transplant 2009; 9: 820.

5. Fehrman-Ekholm I et al. Kidney donors

live longer. Transplantation 1997; 64: 976.

6. Ibrahim HN et al. Long-term conse-

quences of kidney donation. N Engl J

Med 2009; 360:459.

7. Garg AX, et al. Cardiovascular disease and

hypertension risk in living kidney donors:

an analysis of health administrative data

in Ontario, Canada. Transplantation

2008; 86: 399.

8. Reese PP et al. Substantial variation in

the acceptance of medically complex live

kidney donors across US renal transplant

centers. Am J Transplant 2008; 8: 206.

9. Mandelbrot DA et al. The medical evalu-

ation of living kidney donors: a survey of

US transplant centers. Am J Transplant

2007; 7: 2333.

10. Gibney EM et al. Living kidney donors

requiring transplantation: focus on Afri-

can Americans. Transplantation 2007;

84: 647.

11. Cherikh WS et al. Prior living kidney

donors who were subsequently placed

on the waiting list: An updated OPTN

Analysis. Annual Meeting of the Ameri-

can Transplant Congress. Toronto, Can-

ada 2008.

12. Cooper M. Follow up of African Ameri-

can Donors. The Transplantation Soci-

ety August 2008 :A868.

13. United Network for Organ Sharing,

Richmond, VA data as of March 30,

2009; http://optn.transplant.hrsa.gov

14. Herring AA et al. Insurance status of US

organ donors and transplant recipients:

the uninsured give, but rarely receive. Int

J Health Serv 2008; 38: 641.

15. Delmonico F, Council of the Transplanta-

tion Society: A Report of the Amsterdam

Forum on the Care of the Live Kidney

Donor: Data and Medical Guidelines.

Transplantation 79(6 Suppl):S53-66,

2005.

16. Barr ML et al. A report of the Vancou-

ver Forum on the care of the live organ

donor: lung, liver, pancreas, and intestine

data and medical guidelines. Transplan-

tation 81:1373-1385, 2006.

17. The Declaration of Istanbul on Organ

Trafficking and Transplant Tourism.

International Summit on Transplant

Tourism and Organ Trafficking. Clin J

Am Soc Nephrol 3:1227-1231, 2008.

The authorConnie L. Davis, M.D.Divisions of Nephrology and TransplantationUniversity of Washington School of Medicine1959 NE Pacific St, Seattle, WA 98040, USATel + 1 206 598 6079. e-mail: [email protected]


Figure 1. Schematic representation of an altruistic donor-initiated living donor chain. Dotted lines indicate intended donor-recipient pairings and solid lines indicate actual donor-recipient pairings. In addition to donor chains, simple donor recipient paired exchanges between a finite number of donors and recipients can occur. The altruis-tic donation of a kidney to the list of donors and recipients who are not compatible

allows for the greatest number of transplants as it is theoretically open-ended.

– Issue N°6 – Nov. 2009

14 rENAL MEdiCiNE

Kidney stone disease is a common medical condition, affecting approximately 10% of the United States and Western European populations. Men are more commonly affected than women, although recent years have seen an increase in the incidence of stone disease among women and children. The primary risk factors for the devel-opment of a kidney stone include obesity, dietary factors, hydration status, and climate [1]. Although most kidney stones pass in an uncomplicated fashion, there are some stones which require sur-gical treatment to be removed. Historically, open surgery was the mainstay of the interventions for stone disease. However, with the introduction of shock wave lithotripsy (SWL) in the mid-1980s, patients who formerly required an open surgi-cal procedure could be treated in a completely non-invasive fashion. Subsequent advances in

endoscopic technology and surgical technique have broadened the minimally invasive treatment options for patients suffering from a symptomatic kidney stone.

Shock wave lithotripsyIn just over two decades following its introduc-tion, SWL has become the most commonly used treatment for patients with upper urinary tract stone disease [2]. It may be performed on an outpatient basis, either with intravenous seda-tion or general anaesthesia, and the duration of treatment is usually less than one hour. Recent advances have been made in the understanding of stone fragmentation and the aetiology of renal injury which have made SWL more effective and safer. Small variations in the technique with which SWL is applied can affect optimal treatment out-comes. For example, a recent literature review and meta-analysis have found that slowing the rate of SWL delivery to 60 shock waves per minute frag-ments stones more effectively than treatment at a rate of 120 shock waves per minute [3]. SWL is known to cause a renal parenchymal lesion. Detailed morphological analyses of por-cine kidneys treated with a clinical dose of shock waves have demonstrated that shock wave energy induces a haemorrhagic lesion, both in the renal parenchyma as well as the renal microvasculature. The volume of the haemorrhagic lesion is dose dependent: it is directly related to the number of shocks delivered and the power settings of the machine [4,5]. There have been several reports describing a phenomenon by which a priming dose of low energy shock waves may reduce the

extent of the haemorrhagic lesion induced by a clinical dose of SWL. During a typical clinical SWL procedure, a protection protocol may be carried out by setting the power to a low level ini-tially, and then ramping up to the standard SWL power setting. This has been reported to result in a significant reduction in lesion size [6]. These findings are clinically meaningful, because they suggest a potential treatment strategy to reduce the adverse effects of SWL.

Lastly, studies have shown that the process by which the patient is coupled to the lithotripter can also affect treatment outcome. Early gen-eration machines employed a water bath, while newer, more compact machines use a dry treat-ment head with ultrasound gel or oil. With this dry coupling, there can be air bubbles at the treatment head which diminish the efficient transfer of shock wave energy. Thus, more shock waves may be needed for fragmentation and lead to increased trauma to the surrounding renal parenchyma [7].

Laser lithotripsyLaser energy can be used to fragment stones in the bladder, ureter or kidney via a laser fiber which is passed through an endoscope [Figure 2]. Typically, a Holmium:YAG laser is used, which operates in the near infra-red area of the electro-magnetic spectrum with a wavelength of approxi-mately 2140 nanometers. The Holmium laser is one of the safest intracorporeal lithotrites avail-able for stone fragmentation. The depth of tissue penetration of the laser light is 0.5 to 1.0 mm, and the laser may be used in patients receiving anti-coagulation medi-cations. Typical fiber diameter sizes for ureteroscopy range from 200-400 microns. The rigidity of the fib-ers can limit the degree of deflec-tion of the flexible ureteroscope, mak-ing the treatment of stones in the lower pole of the kidney especially chal-lenging. The upper limit of stone size that can be effi-ciently treated with laser lithotripsy is

Advances in the surgical management of nephrolithiasisAlthough most kidney stones are passed out via the urinary tract, some cases require surgical removal. With the advent of shock wave lithotripsy (sWL) in the mid-1980s, patients who previously would have required open surgery could be treated completely non-invasively. sWL has now become the most commonly used treatment for patients with upper urinary tract stone disease. this article discusses the technological advances that have been made in the non-invasive treatment of nephrolithiasis leading to safer, more efficient procedures with improved stone-free rates. Better understanding of shock wave mechanics and the effects of shock waves on surrounding tissue has lead to protocols which maximise stone frag-mentation and minimise morbidity. improvements in laser energy and laser fibers have allowed ureteroscopic-based lithotripsy in a wider range of stone locations and sizes. Newer rigid lithotrites provide a variety of energy sources for greater fragmentation capability.

by dr J. r. Berkowitz and dr B. r. Matlaga

Figure 2. Holmium: YAG laser for endoscopic

lithotripsy.

Figure 1 Holmium Laser for Lithotripsy (Both photos courtesy of Boston Scientific)

Figure 2 – Lithoclast Ultra

Figure 1. Intravenous urogram X-ray of renal calculi.

– Issue N°6 – Nov. 2009

– Issue N°6 – Nov. 200915

approximately 1.5cm. Laser lithot-ripsy is usually performed as an out-patient procedure with the patient receiving a general anaesthetic. The operating room time varies based on the stone burden being treated and the surgical approach employed, but typically it lasts one to two hours.

Recent technological advances with the Holmium laser have come from improvement in the laser fibers. Smaller diameter fibers (150 micron and less) are being developed which will allow for more maneuverability of the ureteroscope within the uri-nary tract during laser lithotripsy. Also, newer laser platforms are being developed to provide increased effi-ciency of fragmentation during treatment. For instance, the Thulium laser is available which requires a laser fiber of only 18 microns in diameter. This may be useful for stones in difficult locations in which a large degree of endoscope deflection is needed.

Rigid lithotritesPercutaneous nephrolithotomy (PNL) is a minimally invasive treat-ment alternative to open surgery for patients with large or complex renal calculi. PNL is performed in the operating room using gen-eral anaesthesia, with the patient typically in the prone position, although supine PNL has been described. A rigid nephroscope is placed into the collecting system of the kidney via a small incision in the flank. Intracorporeal lithot-ripsy is then performed by insert-ing a rigid lithotrite through the endoscope and placing it in contact with the stone. Lithotripters using ultrasonic energy are most com-monly utilised during PNL and can efficiently fragment and remove the majority of stone types. Continuous suction irrigation is used to evacu-ate stone fragments quickly and to maintain clear visibility. However, hard calculi such as cystine and cal-cium oxalate monohydrate stones, are less efficiently fragmented and removed with ultrasonic technol-ogy. For these stones, pneumatic lithotripters are often used for frag-mentation, as these devices readily break stones of any composition. The chief disadvantage of pneu-matic lithotripters, however, is their inability to concurrently evacuate

stone debris while fragmenting the stone. Rather, manual frag-ment removal is needed by using stone graspers, which may be a time-consuming process.

New advances on this front have included combined ultrasonic and pneumatic devices, which aim to combine the superior fragmenta-tion ability of the pneumatic com-ponent with the ability of the ultra-sonic modality to evacuate stone fragments simultaneously. The first combination device brought to the

clinical market was the Lithoclast Ultra (Boston Scientific) which relied on a combination handpiece (actually two separate handpieces connected together) to join the ultrasonic and pneumatic compo-nents [Figure 3]. The first portion of the combination handpiece was a traditionally designed pneumatic handle, with a smaller diameter solid probe. The ultrasonic handle, driven by a standard piezoelectric mechanism, was modified to allow the co-axial insertion of the pneu-matic probe. Each modality can be

activated separately or in unison; when operated in unison, the bal-listic fragmentation of the stone is accomplished with the pneu-matic component and the ultra-sonic component then removes the resulting debris. The efficiency of the Lithoclast Ultra combina-tion device has been evaluated in a clinical setting, via a prospective, randomised trial comparing the combination device to standard ultrasonic lithotrites in patients undergoing percutaneous neph-rolithotomy (PNL) [8]. The stone

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– Issue N°6 – Nov. 2009

clearance times were significantly better for the combination device than for the conventional ultrasonic lithotripters.

Another new device on the market, the Cyber-wand (Gyrus ACMI) is an intracorporeal lithot-ripter that relies on a dual ultrasonic probe design which incorporates coaxial high and low frequency probes. The dual probe design cre-ates a synergistic effect, which enables efficient stone fragmentation, while still allowing the suc-tion evacuation of small fragments just as other ultrasonic devices do. The efficacy of this device has been tested in laboratory conditions, and the findings suggest that the stone penetration time for the Cyberwand was almost twice as rapid as it was for the Lithoclast Ultra [9].

ConclusionTechnological advances in the treatment of neph-rolithiasis have led to safer, more efficient pro-cedures with improved stone-free rates. Better understanding of shock wave mechanics and the effects of shock waves on surrounding tissue has lead to protocols which maximise stone fragmen-tation and minimise morbidity. Improvements in laser energy and laser fibers have allowed the urologist to perform ureteroscopic based lithot-ripsy in a wider range of stone locations and sizes. Newer rigid lithotrites provide a variety of energy sources for greater fragmentation capabil-ity. In the coming years, we expect to see a greater understanding of the science of shock waves, as well as an array of new equipment involving high definition imaging and cameras to enhance the urologist’s view during endoscopic proce-dures. With improving technology, we expect the surgical management of stone disease to reach new levels of success with excellent outcomes.

References1. Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters

CA. Campbell-Walsh Urology. 9th ed. Chapter 42.

Urinary Lithiasis: Etiology, Epidemiology, and Patho-genesis. Philadelphia: Saunders Elsevier, 2007.

2. Pearle MS, Calhoun EA, Curhan GC. Urologic dis-eases in America project: urolithiasis. J Urol 2005; 173: 848.

3. Semins MJ, Trock BJ, Matlaga BR. The effect of shock wave rate on the outcome of shock wave lithotripsy: a meta-analysis. J Urol 2008; 179: 194.

4. Willis LR, Evan AP, Connors BA et al. Relationship between kidney size, renal injury, and renal impair-ment induced by shock wave lithotripsy. J Am Soc Nephrol 1999; 10: 1753.

5. Connors BA, Evan AP, Willis LR et al. The effect of discharge voltage on renal injury and impairment caused by lithotripsy in the pig. J Am Soc Nephrol 2000; 11: 310.

6. Willis LR, Evan AP, Connors BA et al. Prevention of lithotripsy-induced renal injury by pretreating kid-neys with low-energy shock waves. J Am Soc Nephrol 2006; 17: 663.

7. Matlaga BR, Lingeman JE. Surgical Management of Stones: New Techology. Adv Chronic Kidney Dis 2009; 16: 60.

8. Pietrow PK, Auge BK, Zhong P et al. Clinical efficacy of a combination pneumatic and ultrasonic lithotrite. J Urol 2003; 169: 1247.

9. Kim SC, Matlaga BR, Tinmouth WW et al. In vitro assessment of a novel dual probe ultrasonic intracor-poreal lithotriptor. J Urol 2007; 177: 1363.

The authorsJared R. Berkowitz, MD, Brian R. Matlaga MD, MPHJames Buchanan Brady Urological InstituteJohns Hopkins Medical InstitutionsBaltimore, Maryland

Corresponding author:Brian R. Matlaga, MD, MPHJames Buchanan Brady Urological InstituteThe Johns Hopkins University School of Medicine600 North Wolfe StreetBaltimore, MD 21287Phone: 410-502-7710Fax: 410 502-7711e-mail: [email protected]

16 rENAL MEdiCiNE

20102010Euroanaesthesia2010Helsinki, Finland

June 12-15The European Anaesthesiology Congress

SymposiaRefresher CoursesWorkshopsIndustrial Symposia & ExhibitionAbstract Presentations

CME AccreditationEACCME - UEMS

Deadline abstracts:December 15th 2009Online submission:

www.euroanesthesia.org

ESA SecretariatPhone +32 (0)2 743 32 90

Fax +32 (0)2 743 32 98E-mail: [email protected]

Adv_PLANGLOBAL_Helsinki.indd 6 02/09/09 09:44


Figure 3. The Lithoclast Ultra combines pneumatic and ultasonic approaches.

Figure 1 Holmium Laser for Lithotripsy (Both photos courtesy of Boston Scientific)

Figure 2 – Lithoclast Ultra

– Issue N°6 – Nov. 2009

– Issue N°6 – Nov. 2009

Exercise-induced ECG changes in Brugada syndromeAmin AS et -al. Circ Arrhythm Electrophysiol 2009; 2(5): 531-9. Ventricular arrhythmia occurrence during exercise is reported in Brugada syndrome (BrS). Experimental studies suggest that BrS-linked SCN5A mutations reduce sodium current more at fast heart rates, but the effects of exercise on the BrS ECG phenotype have not been studied. The study reported in this paper assessed ECG respons-es to exercise in BrS and determined whether these responses were affected by the presence of an SCN5A mutation. ECGs at baseline, at peak exercise and during recovery were analysed in 35 male control subjects, 25 BrS men without a SCN5A mutation and 25 BrS men with a SCN5A mutation. No differences existed in clinical phenotype between the BrS groups. At baseline all BrS patients had lower heart rates, wider QRS, shorter QT(c), and higher peak J-point amplitudes than control subjects; BrS patients with the SCN5A mutation also had longer PR than both control subjects and BrS patients with-out the mutation. Exercise resulted in PR shortening in all groups, more QRS widening in BrS patients with the mutation than those without and control subjects, and less QT shortening in all BrS pa-tients than in control subjects. The increase in peak J-point ampli-tude during exercise was similar in all three groups but resulted in a coved-type pattern only in BrS patients.

Towards noise immune detection of fetal QRS complexes.Kotas M et al.Comput Methods Programs Biomed 2009; Oct 8. Noninvasive foetal electrocardiography is a source of more precise in-formation on foetal heart activity than measurements based on Dop-pler ultrasound signals. However, the clinical diagnostic applications of this technique are limited because of the difficulty of detecting small amplitude foetal QRS complexes. This study investigated the influence of different stages of foetal signal processing on detection performance. The authors suggest that application of normalised matched filtering to foetal QRS complex enhancement and a new approach to the final detection of the complexes would, when compared to classical detec-tors, enable a significant increase in detection performance for signals of very different quality.

Prevalence and characterisation of ECG abnormalities after intracerebral haemorrhage.van Bree MD et al. Neurocrit Care. 2009 Oct 8. Although ECG abnormalities are well known in ischaemic stroke and subarachnoid haemorrhage, these changes have only rarely been in-vestigated systematically in patients with intracerebral haemorrhage (ICH). The prevalence and type of ECG abnormalities were investi-gated in a consecutive series of ICH patients, and their possible as-sociation with pre-defined neurological and radiological parameters studied. Thirty-one consecutive patients with non-traumatic, intra-parenchymal ICH admitted to hospital were included in the study. ECGs obtained within two days of the initial haemorrhage were anal-ysed by one blinded observer. Admission cranial CT scans were re-analysed by two blinded observers. Twenty-five patients (81%) had one or more ECG abnormalities. The most frequently observed ECG abnormality was QTc prolongation (36%), followed by ST-T mor-phological changes (23%), sinus bradycardia (16%), and inverted T wave (16%). No patient was initially misdiagnosed as having myocar-dial ischaemia. QTc prolongation was associated with ICH involve-ment of the insular cortex and presence of intraventricular blood and hydrocephalus on admission CT scan. It would be necessary to investigate a larger cohort of continuously monitored ICH patients to determine whether these ECG abnormalities are associated with poor outcome or death.

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sCiENtiFiC LitErAtUrE rEviEW: ECG 17 – Issue N°6 – Nov. 2009

PEt/Ct and sPECt/Ct: an overview of the technolgies

and applications Page 20 - 22

imaging pancreatitis in paediatrics

Page 24 - 25

MrCP vs ErCP in the evaluation of biliary

pathologiesPage 26 - 27

the case for Mr elastography mechatronics

Page 28 - 30

dual-modality probes for molecular imaging

Page 32 - 34

Imaging Special Selection of peer-reviewed literature on medical imaging

NOVEMBER 2009

Medical Imaging Special

the number of peer-reviewed papers covering the vast field of medical imag-ing is huge, to such an extent that it is frequently difficult for healthcare profes-sionals to keep up with the literature. As a special service to our readers, iHE presents a few key literature abstracts from the clinical and scientific literature chosen by our editorial board as being particularly worthy of attention.

Amyloid imaging in ageing and dementia: testing the amyloid hypothesis in vivo.Rabinovici GD & Jagust WJ. Behav Neurol 2009;21(1):117-28. Amyloid imaging represents a major advance in neuroscience, enabling the detection and quantifica-tion of pathologic protein aggregations in the brain. This article reviews current amyloid imaging tech-niques, focusing on positron emission tomography (PET) with PIB tracer. PIB binds specifically to fibril-lar beta-amyloid (Abeta) deposits, and is a sensitive marker for Abeta pathology in cognitively normal older individuals and patients with mild cognitive impairment (MCI) and Alzheimer’s disease (AD). PIB-PET provides a powerful tool to examine in vivo the relationship between amyloid deposition, clini-cal symptoms and structural and functional brain changes in the continuum between normal ageing and AD. Amyloid imaging studies support a model in which amyloid deposition is an early event on the path to dementia, beginning insidiously in cogni-tively normal individuals, and accompanied by sub-tle cognitive decline and functional and structural brain changes suggestive of incipient AD. As patients progress to dementia, clinical decline and neurode-generation accelerate and proceed independently of amyloid accumulation. In the future, amyloid imaging is likely to supplement clinical evaluation in selecting patients for anti-amyloid therapies, while MRI and FDG-PET may be more appropriate for assessing clinical progression.

The role of magnetic resonance imaging in the diagnosis of acute ischaemic stroke. Sanak D et al. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2009;153(3):181-7. Diffusion- (DWI) and perfusion- (PWI) weighted MRI with MRI angiography are considered to be the most important examinations in the diagno-sis of acute ischaemic stroke prior to reperfusion therapy. The effort to extend the strict therapeutic time window has resulted in the PWI/DWI mis-match concept, established to identify the pres-ence of ischaemic penumbra. However, a lack of standards for methodology and analysis, as well as the existence of alternative interpretations of mismatch still present significant limitations in routine clinical practice. MRI allows accurate diagnosis of the infarct lesion, detection of cer-ebral arterial occlusion or significant stenosis with evaluation of actual collateral flow, and may also display certain reversible ischaemic changes. However, the challenge for MRI is still the rapid and accurate identification of brain tissue at risk for infarction that may be salvaged by safe and effective reperfusion therapy.

The advantages of nanoparticles for PET.Welch MJ, Hawker CJ & Wooley KL. J Nucl Med 2009 Oct 16. Nanoparticles are particularly advantageous for molecular imaging since many functionalities can be added to the surface and interior of the particle. This brief review focuses on the design of nanomaterials that take advantage of PET. An evolutionary approach is presented, leading to the optimisation of the nanoparticle composition and structure to achieve controlled in vivo circulation and tissue-selective targeting. Organic and inor-ganic nanostructures are included. Nanoprobes for use in PET studies of angiogenesis and cancer are highlighted.

Proton magnetic resonance spectroscopy in prostate tuberculosis. Chen Y et al. Urology 2009 Sep 23. Prostate tuberculosis is an uncommon disease of the prostate, which usually involves the upper uri-nary tract. In elderly patients, it may be mistaken for prostate carcinoma, both clinically and by con-ventional radiology. This paper demonstrates that magnetic resonance spectroscopy can provide more information allowing prostate tuberculosis to be differentiated from prostate cancer.


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Nuclear medicine deals with the investigation of physiological or pathophysiological functions and conditions with the help of radioactive tracers, (which are legally classified as pharmaceuticals or radiopharmaceuticals). Radiation detector devices are then used to provide an external, non-invasive visualisation of the distribution of the tracer in the human body. The kinetics of the tracer can also be determined and the relative or absolute concen-trations or turnovers can be established. The radi-otracers are usually tracked with imaging devices of which the most well established is the gamma camera (the Anger camera, named after its inven-tor) which was introduced in 1957 and provides images of gamma ray emitting radiotracers. Typi-cal clinical investigational work that can be car-ried out by gamma cameras includes bone scans, myocardial perfusion studies or thyroid scans.

SPECT and PETAt the end of the 1970s single photon emis-sion tomography (SPECT) was introduced. By rotating the gamma camera around the body

axis and acquiring images at every few degrees of rotation it was possible to reconstruct three dimensional images in a way analogous to the well known X-ray CT systems. In the early 1970s the modality known as positron emission tomography (PET) was invented. As the name suggests, this system images positron emitters, although strictly speaking the technique actu-ally measures the coincidence of the two anni-hilation photons that follow positron decay. From this, a three dimensional image can be directly acquired. Typical applications of PET are in brain scans (e.g. studies of dementia or the search for epileptic foci) and in the deter-mination of myocardial viability. The technique is also indicated in the study of various malig-nancies, including staging, therapy response and follow- up.

All the above-mentioned applications are carried out using radioactive fluorodeoxy-glucose [18F] FDG, but there are also some dozens of other PET-tracers, e.g. 124 Iodine

for differentiated thyroid cancer studies or 68Gallium DOTA- Phe(1)-Tyr(3)-Octreotide (68Ga-DOTATOC) for neuroendocrine tumours.

In contrast to morphology-based modalities such as ultrasound, X-ray and classical MRI, the power of nuclear medicine investigation is mainly deter-mined by the characteristics of the radiotracer. Since the “imaging” is the visualisation of the distribution of the tracer in the body it is not necessary to get “sharp” images. Thus, the spatial resolution of nuclear medicine devices does not need to be high (and, in fact, for several physics-based reasons it isn’t). Since it is the tracer that is imaged and not the actual body, the resulting images can only present anatomical information to the extent determined by the characteristics of the tracer being used. For this reason, it is nec-essary in many situations to compare nuclear medicine images with those generated by mor-phology-based modalities (CT is the most com-mon) in order to attribute a given observation to an organ or to differentiate between physiological and pathophysiological findings.

However, for several reasons reading SPECT or PET images side by side with those from CT is in practice quite difficult. Firstly, the CT data that are available in real life are frequently not in digital form. Secondly the CT investigation may not have been carried out in the anatomi-cal region of the SPECT or PET finding. How-ever, even if all the data were readily available, it should be remembered that each investigation is not carried out under identical positioning or physiological states. For example, the spine could be bent or twisted somewhat differently, the head could be positioned at different angles, and bowel and bladder filling may not be iden-tical. There have been a couple of studies on computer-based retrospective combination of PET and CT images. Unfortunately, apart from the brain, the software solutions showed misalignments of typically 1 cm or more and in some patients the software co-registration (i.e the precise superimposition of two images) failed completely. Software-based co-registra-tion is usually unsuccessful in the whole body (trunk) and is mostly restricted to smaller portions of the body.

SPECT/CT and PET/CTFor the above reasons a combined SPECT/CT was developed and introduced in 1999 and a PET/CT system was introduced into clinical routine in 2001. Whereas the first SPECT/CT was equipped

PEt/Ct and sPECt/Ct – an overview of the technologies and their applicationsProviding both functional and anatomical information that is vital for the accurate diagnosis and subsequent treatment of many pathologies, the techniques of PEt/Ct and sPECt/Ct have advanced dramatically since their development several years ago. this article reviews the underlying principles and describes the current status and the respective applications of these powerful technologies.

by Prof. A. Bockisch and Prof. G. Antoch

Figure 1. The advantage of combining functional and anatomical data. The images above were taken in a patient with metastatic neuroendocrine tumour.

Left: PET investigation using 68Gallium DOTATOC. A somatostatine analogue, DOTATOC enables the visualisation of tumours which overexpress somatostatine receptors. The transaxial slice somewhere through the pelvis shows 4 hot spots (black spots) which can be diagnosed as tumours with somatostatine receptor overexpression. The tumours are

likely to be located in the skeleton.Right: The PET/CT fusion image shows the bone as a white structure and proves that the four metastases are indeed bone metastases. Moreover, the use of the anatomic information enables another previously undetected bone metas-

tasis (arrowed) to be clearly identified.

– Issue N°6 – Nov. 2009

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with a very low dose CT tube that allowed only a crude anatomical orientation, the first PET/CT developed by Townsend and Nutt was equipped with both state-of-the-art PET and CT devices and enabled the carrying out of nearly simultaneous high quality PET and CT investigations.

PET presents functional information so it is very useful to combine it with a modality that presents high quality morphological information in a straightforward and reproducible fashion. CT seems most suited for this purpose. In contrast, the usual practice with SPECT is that a couple of gamma-camera procedures (mostly in planar technique) are first carried out and SPECT is then an individual add-on. Even if SPECT is carried out, in some investigations additional anatomical data are of little value for the interpretation of the nuclear medicine information. This is not the case with PET/CT so that the early stages of the devel-opment of hybrid systems was mainly driven by PET/CT.

In contrast to gamma camera investigations, PET acquires three dimensional data and there-fore co-registration with CT can always be achieved. At least in most oncological inves-tigations, co-registration with anatomical images can be extremely useful so the combi-nation of the two modalities is of high clinical value [Figure 1].

In the early stages of clinical PET/CT applica-tions, there was much discussion over how much the CT was actually really needed. Personally, we have always been in favour of carrying out combined diagnostic PET/CT and in practice we have found that most of our patients have benefitted from the PET and the CT informa-tion. Thus, from the initial idea of merely add-ing some anatomical information to PET the completely new modality of PET/CT was born, providing high end functional and morphologi-cal diagnostics. Only patients with no indication for CT investigation are investigated with PET

together with a low dose CT, used only for rough anatomical orientation.

The history of SPECT/CT is somewhat different from that of PET/CT in several ways. For exam-ple, whereas the that addition of CT to PET meant that the speed of the total procedure could be sig-nificantly increased, this is not the case in SPECT/CT. Likewise, whereas in PET investigations the addition of CT information is mostly helpful, this is not the case in SPECT. Finally, since SPECT systems are much cheaper than PET systems, the addition of CT functionality to SPECT means that, proportionally, the cost of the combined unit is much higher than for the SPECT alone. (The cost of adding CT to an already expensive PET system is proportionally less). This is why SPECT/CT with diagnostic CT capabilities was only intro-duced clinically several years after the success of PET/CT. Today, PET is sold only as a combined PET/CT system, whereas the SPECT market is split almost equally between stand-alone SPECT systems and combined SPECT/CT.

Today the use of diagnostic CT combined with PET or SPECT is well established and combined systems are available with a large range of CT configurations from 2 slices up to at least 128 slices. The combined high end CTs offer all the application of high end CT alone.

Current PET/CT performanceThe success of the combined PET/CT has in turn stimulated the development of the underlying PET method itself. The current highest performance of PET applications is the positional investigation of the body axis 20cm at a time with a spatial resolu-tion of approx 2 mm. Using ultra high speed elec-tronics and leading edge componentry, even time of flight analysis of the coincident annihilation quanta can be performed. By measuring the differ-ent flight times of the quanta arriving at the PET detectors (they are travelling at the speed of light, i.e. one billionth of a second per foot!) the source of the decay can be located. Such developments have

resulted in dramatic improvements in practical performance. Compared to ten years ago, investi-gation time can be reduced by 50% and at the same time only half of the radioactivity is needed to get significantly better image quality.

Applications Although FDG PET is still the most sensitive method both for proving myocardial viabil-ity and for the early detection of Alzheimer’s dementia, the most common use of PET is in oncology. The most frequently used tracer in this application is FDG, since the majority of malignant tumours have an up-regulated glu-cose metabolism and intake. However, some tumours are FDG-negative; in these cases the combination of PET and CT means that the number of false negatives can be reduced since the CT can detect some of the metastases missed by PET. Today PET/CT is the most sensitive modality for the detection of malignant tumour and primary, recurrence, lymph node and dis-tant metastases. In addition since PET charac-terises the tumour biologically it can be used for the early prediction of the likely response to therapy. PET/CT may also be regarded as a necessary prerequisite for high quality external beam radiation therapy.

SPECT/CT is most frequently used in bone scans, where it helps to differentiate between unspe-cific disturbances of bone turn-over and bone metastases. The added value of SPECT/CT com-pared to SPECT alone is highest – as in PET/CT – when there is little anatomical information in the nuclear medicine image and this information is needed and clinically useful. Typical examples are leukocyte imaging or immunoscintigraphy. The CT-generated anatomical landscape underly-ing the SPECT image is of just as great use to the surgeon as it is to the radiotherapist.

ConclusionBoth SPECT/CT and PET/CT have allowed refer-ring physicians to gain a deeper understanding of images generated by nuclear medicine and therefore increased their acceptability. In addi-tion, time and again only the reliable co-reg-istration of anatomical structural information with diagnosed functional abnormalities, such as increased glucose consumption in a tumour, can provide useful information for further treatment such as surgery or external radiotherapy. Today both SPECT/CT and PET/CT have become not only necessary equipment for the practise of high level medicine but also increase the possibility of individualising treatment for the patient.

The authorsProf. Andreas Bockisch, PhD, MD Dept of Nuclear Medicine, & Prof Gerald Antoch, MDDept of Radiology,University Hospital of Essen, Germany

22 MEdiCAL iMAGiNG

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– Issue N°6 – Nov. 2009

24 MEdiCAL iMAGiNG

Pancreatitis in children is associated with clinical findings such as acute abdominal pain in acute pancreatitis and loss of endocrine and exocrine function in chronic pancreatitis. Although not as common as in adults, there is evidence that acute pancreatitis is increasing in children. A significant elevation of serum amylase and lipase are necessary to make the diagnosis, but often there is no such elevation in children with acute pancreatitis. The most common causes of acute pancreatitis are idiopathic, traumatic, structural and multisystem diseases. Chronic pancreatitis is largely due to cystic fibrosis, fibrosing pan-creatitis and hereditary chronic pancreatitis. Partly because of the challenges in making the

diagnosis from clinical symptoms, imaging has an increasingly important role not only for diag-nosis but also for identifying complications of pancreatitis. Because of the anatomical detail they provide and the absence of ionising radia-tion, magnetic resonance imaging (MRI) and Ultrasound (US) are central modalities in the evaluation of pancreatitis

UltrasoundCompared to its use in adults, US is a superior method for the evaluation of a child’s pancreas because of the patient’s small size, the small quan-tity of adipose tissue and prominence of the left hepatic lobe. Ideally the patients should not have had anything to eat or drink for at least four hours prior to the exam (two hours for infants) which corresponds with clinical treatment in suspected pancreatitis or patients with abdominal pain. Water may be given during the US exam to utilise the stomach as an acoustic window [1].

Normally the pancreas is similar or hyperecho-genic to the liver, but a minority are hypoecho-genic. The size of a normal pancreas varies with age, and enlargement of the pancreas is absent in half of the cases of pancreatitis [2]. Pancreatic duct size is the most reliable indicator of acute pancreatitis [Figure 1a] [3].

The most common complication of pancreatitis is a pancreatic pseudocyst, which can be identi-fied with US as an anechoic structure arising from or near the pancreas; pseudocysts are most commonly found in the lesser sac. The pancreatic calcifications or intraductal stones associated with chronic pancreatitis are visible

imaging pancreatitis in paediatricsimaging is central to the diagnosis and treatment of pancreatitis in the paediat-ric population. Ultrasound (Us) is the main modality, but magnetic resonance in the form of Mr cholangiopancreatography (MrCP) is becoming increasingly important. MrCP is replacing endoscopic retrograde cholangiopancreatography (ErCP), which is reserved for interventions. this article reviews the current status of Us, MrCP and ErCP in paediatric pancreatitis.

by dr s. servaes, dr s. Anupindi and dr K. darge

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Figure 1. Seven year old with familial chronic pan-creatitis (a) Dilatation of the pancreatic duct (calipers) demonstrated with ultrasound. (b) There is a stone in

the head of the pancreas (arrow).

Figure 2. Child with a type IV cholededochal cyst and secondary pancreatitis. MIP imaging from MRCP demonstrates dilatation of the pancreatic duct (arrows)

secondary to choledochal cyst (arrowhead).

Figure 3. Pancreas divisum demonstrated with MRCP (arrowhead points to pancreatic duct insertion into duodenum and arrow points to separate common

bile duct).

– Issue N°6 – Nov. 2009

25

as hyperechogenic foci with US [Figure 1b].

In adults there have been several advances made in the US evalua-tion of pancreatitis including the use of intravenous contrast mate-rial, elastography (tissue stiffness measurement), and endoscopic US.

MRCPIn comparison to endoscopic ret-rograde cholangiopancreatogra-phy (ERCP), magnetic resonance cholangiopancreatography MRCP is non-invasive, can be performed in the acute setting, and provides results in the normal, rather than pressurised, physiological state. Comparison between MRCP and ERCP has been carried out in chil-dren with promising results. Ducts as small as 1 mm can be visual-ised with MRCP, but anatomical detail is limited by patient motion. Ingestion of pineapple juice in non-sedated patients results in a negative contrast which decreases the signal from the adjacent bowel (stomach and duodenum). The polypeptide hormone secretin can also be used to improve visu-alisation of the pancreatic ducts by stimulating fluid excretion. An excellent review of MRCP in chil-dren has been written by Chavhan et al [4].

Although CT has often been utilised to evaluate necrotising pancreatitis, MRI with MRCP can also provide this same information as well as bet-ter detail of the ductal anatomy. It should be noted however, that such modality comparisons have so far been made solely in adults. Given the excellent anatomical detail demon-strable in children, and the lack of ionising radiation, MRCP is likely to command a more central role than CT in the evaluation of pancreatitis in children [Figures 2 and 3].

With improved performance through the use of stronger field magnets and new sequence proto-cols, the future is likely to provide many advances in MRCP.

ERCPChallenging to perform in young children, and often requiring gen-eral anaesthesia ERCP is not car-ried out everywhere. With the

improvements in other methods, ERCP is now mainly reserved for cases where interventions such as stent placement, brushings or biopsy are required.

ConclusionIn summary, US and MRI are becoming the modalities of choice for the evaluation of acute and chronic pancreatitis because of their excellent diagnostic anatomi-cal capabilities and lack of radia-tion. ERCP is becoming more of an interventional tool.

References1. Darge K, Anupindi S. Pancreatitis and

the role of US, MRCP and ERCP. Pedi-atr Radiol 2009; 39 Suppl 2:S153-7

2. Siegel MJ, Martin KW, Worthington JL. Normal and abnormal pancreas in children: US studies. Radiology 1987; 165:15-18

3. Chao HC, Lin SJ, Kong MS, Luo CC. Sonographic evaluation of the pancre-atic duct in normal children and chil-dren with pancreatitis. J Ultrasound Med 2000; 19:757-763

4. Chavhan GB, Babyn PS, Man-son D, Vidarsson L. Pediatric MR

cholangiopancreatography: principles, technique, and clinical applications. Radiographics 2008; 28:1951-1962

The authorsSabah Servaes M.D., Sudha Anupindi M.D., Kassa Darge M.D. Department of Radiology, University of PennsylvaniaThe Children’s Hospital of Philadelphia34th & Civic Center Blvd.Philadelphia, PA, USA [email protected]


– Issue N°6 – Nov. 2009

26 MEdiCAL iMAGiNG

MRCP imaging technique and its clinical benefits Magnetic resonance cholangiopan-creatography (MRCP) is an abdom-inal magnetic resonance imaging method that allows non-invasive visualisation of the pancreatobil-iary tree and requires no adminis-tration of contrast agent[1]. MRCP is increasingly being used as a non-invasive alternative to ERCP and a high percentage of the diag-nostic results of MRCP are com-parable with those from ERCP for various hepatobiliary pathologies. Some of the most recent develop-ments include fast, high-spatial-resolution MRCP sequences, such as heavily T2-weighted turbo spin-echo (TSE), single-shot rapid acquisition with relaxation enhancement (RARE), and half-Fourier single-shot TSE (HASTE). Currently investigative software is available worldwide for these new modes of MR sequencing which provide clear projection images that are similar to those obtained during ERCP procedures [2].

For the evaluation of MRCP images, the main signs of biliary tree obstruction are dilatation of extra- or intrahepatic bile ducts. This MR technique provides thin slices that display ductal filling defects as areas of signal void surrounded by bright bile. There is optimal contrast between the hyperintense signal of the bile and the hypointense signal

of the pathology. The secondary imaging signs of biliary pathologies include hypointense signal defects caused by gall-stones, irregular contours or border defects in the biliary tree. A variety of conditions can cause biliary obstruction, but the main ones are stone disease, tumours and bile duct injury result-ing from biliary surgery. Certainly ERCP is the gold standard for diag-nosing biliary obstruction and some authors recommend that MRCP be used only as a secondary tool in cases where ERCP is unsuccessful or contraindicated [3]. However, the new MRCP techniques such as heavily T2-weighted TSE provide high-quality images that allow for very accurate detection of pancrea-tobiliary pathology. Thus we believe that MRCP should be the first choice of diagnostic modality in the major-ity of suspected biliary pathologies.

Biliary stone disease and MRCPWith MRCP, stones are seen as hypointense circular signal voids on axial images. However stones may appear in various forms, such as filling defects or sudden breaks in the intra- or extrahepatic biliary tree with proximal dilatation [4]. The literature indicates that MRCP is a highly sensitive (50% to 100%) and specific (83% to 100%) tool for diagnosing biliary stone disease [5]. One limitation of the MRCP technique in the detection of gall

stones is that the slices are thicker than 5 mm, which requires partial volume averaging. This can lead to false-negative results when a stone is smaller than 5 mm in diameter. There were some false negative cases in our ‘stone disease group’, and we believe that the most likely reason for this was the presence of microcalculi. It is also easy to miss small stones with ERCP, and in some cases such stones are only evident with sphincterotomy and balloon extraction. In addition, MRCP images do not always allow accurate identification, and cases such as pneumobilia, tortuous common bile duct, compression of the hepatic duct by the right hepatic artery and the origin of the cystic duct mimicking common bile duct stones can all be confusing.

Diagnosis of pancreato-biliary malignancies with MRCP Pancreatobiliary malignancy is another fascinating domain in which MRCP has a very important role. Biliary malignancies appear as

filling defects, irregular stenoses, or post-stenotic dilatations in the bil-iary or pancreatic channels. Hyper-intense structures surrounding the biliary or pancreatic ductal systems may also indicate the location and extension of such tumours [6]. MRCP is as accurate as ERCP for diagnosing biliary and pancreatic malignancies. Some authors have suggested that MRCP combined with abdominal MR imaging is bet-ter than any other imaging regime for staging tumours of the pancrea-tobiliary tree. MRCP has a sensitiv-ity of 94% in diagnosing Klatskin tumours. In contrast, ERCP studies yielded a sensitivity of 87% [7].

In another group of rare biliary diseases such as primary sclerosing cholan-gitis, MRCP reveals typical mural irregularities and multifocal stric-tures that alternate with only slightly dilated or normal-appearing bile ducts, producing a beaded or “pruned tree” appearance. In these cases pathological examination of cytol-ogy samples reveals no malignancy and this group of patients can be

Magnetic resonance cholangiopancreatography (MrCP) is the technique that through use of magnetic resonance imaging. visualises the intra- and extrahepatic bile ducts and the pancre-atic duct. First described in 1986, the technique has improved over the years. today, MrCP is almost comparable to endo-scopic retrograde cholangiopancreatography (ErCP) which is the other, invasive, imaging modality for the biliary tree. Compared with ErCP, MrCP has the advantage of adding a 3d imaging and fast multiple imaging planes capability. Morover, MrCP has negligible morbidity and mortality.

by dr K. Hekimoglu

MrCP versus ErCP in the evaluation of biliary pathologies

Figure 1 A) This ERCP image shows a 5 mm sized stone in the common bile duct (black arrows); B) A 3D MIP MRCP image shows choledocholithiasis which was

impacted near the Oddi sphincter (white arrow).

Figure 2 A) This ERCP image shows an apparent sudden break in the common bile duct caused by tumour infiltration (black arrow); B) The 3D MIP MRCP image shows infiltration by a carcinoma in the distal common bile duct (white arrow) and

significant dilatation of intrahepatic bile ducts.

– Issue N°6 – Nov. 2009

27

treate with balloon dilatation and sequential plastic stenting in several ERCP sessions.

Are the advantages of MRCP really significant?ERCP offers the advantage of pro-viding high-quality images of the pancreaticobiliary tract in the majority of patients. However, it is important to underline that ERCP is not entirely safe. It is a time-con-suming, invasive procedure and the morbidity associated with diagnos-tic ERCP is 1% to 2%. The risk of morbidity rises to 10% when ERCP is combined with sphincterotomy of the Oddi sphincter [8]. The poten-tial risks associated with ERCP are haemorrhage, cholangitis, pancrea-titis, duodenal perforation and con-trast allergy. The reported overall mortality connected with ERCP ranges from 0.7% to 0.9% [9]. The success of the procedure is depend-ent on various local factors — con-ditions such as infiltration of the duodenum by malignant tumours, previous surgical procedures or the skill and experience of the endoscopist can all affect results.

In conclusion, MRCP is currently gaining wider use as a non-invasive alternative to ERCP. The techniques are comparable with respect to diag-nostic accuracy but MRCP offers the advantages of 3D imaging and imaging reformatting, as well as having no morbidity and mortality. MRCP is non-invasive and well tol-erated, and in cases where it is not possible to carry out interventional endoscopy, MRCP should be the first choice of diagnostic tool. However, in cases where cholestasis is evident and the patient is expected to need a therapeutic procedure as well as diagnostic assessment, ERCP remains the procedure of choice.

References1. Adamek HE et al. A prospective evalu-

ation of magnetic resonance cholan-giopancreatography in patients with suspected biliary obstruction. Gut 1998;43:680-683.

2. Halefoglu AM. Magnetic resonance cholangiopancreatography: a useful tool in the evaluation of pancreatic and biliary disorders. World J Gastro-enterol 2007;13:2529-2534.

3. Kaltenthaler EC et al. MRCP compared to diagnostic ERCP for diagnosis when

biliary obstruction is suspected: a sys-tematic review. BMC Medical Imaging 2006;6:9-24.

4. Soto JA et al. Detection of choledo-cholithiasis with MR cholangio-pancreatography: comparison of three-dimensional fast spin echo and single- and multisection half-fourier rapid acquisition with relaxation enhancement sequences. Radiology 2000;215:737-745.

5. Calvo MM et al. Role of magnetic resonance cholangiopancreatography in patients with suspected choledo-cholitiasis. Mayo Clinic Proceedings

2002;77:422-428.6. Adamek HE et al. Pancreatic cancer

detection with magnetic resonance cholangiopancreatography and endo-scopic retrograde cholangio-pancre-atography: a prospective controlled study. Lancet 2000;356:190-193.

7. Vogl TJ et al. Staging of klatskin tumors (hilar cholangiocarcinomas): comparison of MR cholangiography, MR imaging and endoscopic retro-grade cholangiography. Eur Radiol 2006;16:2317-2325.

8. Ganguli SC, Pasha TM, Peterson MD. The evolving role of endoscopic

retrograde cholangiography before and after cholecystectomy. Can J Gastroen-terol 1998;12:187-191.

9. Keulemans YC et al. Improvement in the management of bile duct injuries. J Am Coll Surg 1998;187:246-254.

The authorKoray Hekimoglu MD Ass. Prof. Department of RadiologyUniversity of BaskentAnkara,TurkeyContact for correspondence:[email protected]

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– Issue N°6 – Nov. 2009

28 MEdiCAL iMAGiNG

PrincipleMRE is a non-invasive method for the quantifi-cation of tissue elasticity through the use of spe-cial imaging sequences. The technique provides quantitative measurements of the mechanical properties of a particular tissue, even if it is in a very deep-lying position. The tissue may be close to important structures, such as nervous tissue and main vessels, and consequently very difficult to access physically [1]. In contrast, conventional palpation relies on a clinician using his hands and fingers to search for and examine any path-ological changes in the targeted tissue, which is a subjective technique and only effective in regions close to the surface [2]. With the use of a phase encoding sequence, MRI is capable of vis-ualising motion in a phase contrast image, and MRE is based on the principle that local tissue shear modulus in the imaged area can be com-puted by the measurement of a wave propagat-ing in the target tissue directly after an external mechanical excitation [3]. Given that kinematic properties of mechanical wave propagation are related to the elasticity of the traveling medium, it follows that local tissue shear modulus can be calculated by measuring the wavelength and traveling velocity. Mechanical vibration in the tissue can be measured in terms of the tissue’s spin displacement, by use of the phase encoding sequence. In this way the mechanical properties of tissue located in a deep area can be evaluated so long as a controllable mechanical vibration can be propagated to it [3].

Integration of MRE hardware and the scannerThe integration of MRE equipment and the imager is shown schematically in Figure 1. While the wave generating device is mechanically excit-ing the targeted tissue, a phase encoder sequence

is implemented to measure the tissue spin dis-placement, and hence compute the mechani-cal wave travelling speed and wavelength in the tissue medium. The captured MRI data are then converted into phase and vibration wave ampli-tudes, and are subsequently used to construct the elastogram which contains the spatial informa-tion of the variation of shear modulus in the local tissue region. A 3D elastic tissue model is applied in this construction step to derive the elastogram. The imaging sequence and the mechanical exci-tation are synchronised by the triggering pulse from the scanner — this is of importance for the acquisition of an accurate vibration phase and the minimisation of any cumulative errors in the wave measurement [4].

MR compatibility in elastography mechatronicsMR compatibility is the term given to general medical devices that are suitable for use with MRI

and comprises several component factors that determine whether a device will operate normally, will not affect the MRI operation significantly, and will overall be ‘MR safe’.

Ferromagnetic or paramagnetic materials are commonly found in medical devices and in com-ponent parts such as conventional electric motors; such materials experience elevated attractive forces or torques, giving rise to the “missile effect” that is a danger to patients and staff [5]. Conse-quently, all magnetic materials must be avoided in MRE hardware design, especially for devices which are placed very close to the imaged volume. Electrical and electronic components generate electro-magnetic (EM) fields, which are picked up by the receiver coil of the imager and cause deg-radation of signal to noise ratio (SNR) [6]. Their use in MRE devices requires careful selection and testing, according to the criteria suggested by the ASTM standard [7], the SNR reduction test and the image distortion qualification test [8]. Elec-trical signal amplifiers and electronics that are used to power up the MRE devices for high fre-quency vibration use alternating currents which may have frequency components near to the Larmor frequency (64 MHz for an 1.5T imager) and can thereby cause EM interference to the scanner; proper shielding and low-pass filtering of all signal cables can reduce the disturbance [9, 10]. Eddy currents can be induced in conduc-tive materials near to the scanner because of the fast switched gradients and RF pulses; they can affect the imaged area with image artefacts and can potentially lead to heating and malfunction of electronic components [6]. Conductive parts of an MRE device should be grounded to the scanner, and earth loops must be avoided in the ground cable as this can lead to further sources of EM interference.

the case for Mr elastography mechatronicsthe technique of magnetic resonance elastography (MrE) takes full advantage of the fast scan rate of modern scanners, to determine non-invasively the shear modulus of tissue to which a varying mechanical displacement is applied over a certain period of time. the additional information on the mechanical properties of the tissue makes it much easier for clinicians to make accurate assessments of particular conditions, for example the staging of a tumour. Actuating mechanisms applied directly to the patient create the actual tissue displacement. However, such mechanisms are subject to considerable design constraints due to the nature of the Mri environment. this article reviews the current state of the art in the MrE mechatronics and assesses the performance of various devices in terms of specifi-cations, actuation principles, Mr compatibility, scanner synchronisation issues, and application-specific vibration frequency and amplitude.

by dr Z. t. H. tse and dr A. Hamed

Figure 1. Integration of the MRE hardware and the scanner. The MRE wave generating device mechanically excites the targeted tissue, and its vibration amplitude and phase are captured with a phase encoding sequence. Both the mechanical excitation and the imaging sequence are triggered by the scanner for sychronisation. A 3D elastic tissue model is applied to compute the spatial shear modulus in the elastogram. The inputs of the model are the phase and

amplitude which are processed from the acquired MR data.

– Issue N°6 – Nov. 2009

29

Design solutionsThe stringent requirements for MR compatibility present tight constraints on the design of MRE devices so alternative methods have been investigated to replace or mini-mise conventional actuation meth-ods. Published designs aiming to ensure actuator compatibility can be categorized as follows:

Remote excitation source A passive end-effector is located near to the area of interest and is linked to an excitation source placed away from the imager for minimisation of EM interference [1, 11-13]. Of these systems, pneumatic actuation is a promising solution as it allows the use of a non-MRI compatible actuation system, anyway placed away from the scanner or even outside the scanner room, by use of air tubes for transmis-sion of actuation to a compatible end-effector in contact with the target area. However, the inherent problems of phase delay and inaccuracy of pneu-matic control can lead to difficulty in synchronisation with the phase encod-ing sequence [5]. Talwalkar developed a pneumatic device shown in Figure 2 for liver elastography, consisting of a passive driver placed directly on top of the chest, a loudspeaker located away from the magnetic field generat-ing 60Hz-mechanical excitation, and a plastic tube transmitting the excitation pneumatically from the active driver to the passive one [11]. Reports of two other remote actuation designs have been published using a magnetism

free ultrasound motor [13] or electro-magnetic vibrators and speaker-like devices [1].

Electromagnetic principle: Designs based on the electromagnetic principle are found in a number of MRE devices [14, 15], in which recip-rocating torque is induced in a coil positioned perpendicular to the main field (B0) when alternative currents are applied, according to Lorentz’s law. The principle was used in a breast elastography device shown in Figure 3 [15]. An optimised coil configura-tion in terms of diameter and number of turns can diminish the effect of the uneven magnetic field which is caused by the switched gradients, although this can never be eliminated completely [16]. The electromagnetic principle is able to generate stable and synchronised mechanical excita-tion, with desirable and controllable vibration amplitude determined by the applied currents, although most of the designs can only cater for excitation in a single direction.

Piezoelectric stack Yet another approach is to place an MR-compatible active driver in con-tact with the target area near to the isocentre [4, 17-19]. The whole driver including its components, casing and actuating elements are absolutely required to be non-magnetic and the presence of the device should not produce any significant SNR reduc-tion in the images. Piezoelectric stacks are a commonly adapted solution for

this type of MRE device. Piezoelectric material elongates when a potential difference is applied across it, allowing a short range of linear motion with fast response and precise accuracy — such a device for general purpose elastog-raphy is shown in Figure 4 [19]. Cou-pled to a simple lever mechanism for mechanical amplification, the device is capable of generating excitation frequencies of up to 500 Hz and dis-placements up to 1 mm. Ease of syn-chronisation to the image sequence and stable excitation makes it a good solution for actuation in MRE. Conclusion and future chal-lenge in MRE mechatronicsThe three types of actuation principles described above all have advantages and disadvantages. For example even

though the use of piezoelectric stacks seems to be an elegant solution for actuation in terms of sychronisation and stability, all designs involving elec-tronics operated near the scanner will produce a certain amount of image disturbance. Designs based on elec-tromagnetic principles have the ben-efit of good synchronisation but their presence in the scanner may affect the main field, and the design is relatively less flexible in terms of its excitation orientation as well as its location in the scanner. Devices operating with pneu-matic principles present the best MR compatibility, but the compressibility of air leads to the issue of relatively poor synchronisation and unstable mechanical excitation. Additionally, most of the elastography pneumatic devices described in the literature

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Figure 2. Actuation by a remote excitation source: setup of liver elastography with a passive driver on top of the chest and an active driver located away from the magnetic

field [11].

Figure 3. Actuation by the electromagnetic principle: a device for breast elastography in which alternating currents pass though the two coils and a reciprocating mechanical

motion is generated [15].

– Issue N°6 – Nov. 2009

can only be operated up to 100 Hz. The best MRE design depends on the nature of the intended application and is a compromise between the required MR compatibility, design complexity, flexibility, cost and the ability to accurately synchronise with the scanner.

In the transition of the concept of MRE from the laboratory to clinical application several factors are impor-tant so that clinical justification of the system functionality is possible: ease of use, high repeatability, speed and cost effectiveness are particularly important. The MRE device must be made to be intuitive and robust, and the procedure should be able to be car-ried out in a significantly short time, as the MR suite is always a scarce and costly resource being shared for both

clinical and research purposes. The hardware system should be design to be as “plug-and-play” as possible and should not require the presence of technical staff to supervise and moni-tor it during a procedure. Also, the time for training that is needed for busy clinicians to learn how to use the system should be as short as possible, meaning that a system with a relatively simple design is preferable. A system designed for the MRE examination of a specific tissue can mean a lower number of components and joints, and a simplified system design often results in a shortened set-up time and learning curve, thus making it more cost-effective. Three Tesla scanners can provide bet-ter image quality than their 1.5T coun-terparts, and are beginning to be intro-duced into hospital environments,

although 1.5T scanners are still prom-inent in clinical diagnosis. Adaptation of MRE devices to 3T scanners is an inevitable future trend, meaning that the active mechatronic components as well as the elastography device itself will have to be evaluated once more in the 3T environment before com-patibility can be claimed at the new field strength.

References1. Sack I et al. Non-invasive measurement

of brain viscoelasticity using magnetic resonance elastography NMR in bio-medicine 2008; 21: 265-271.

2. Hamed AM. Applying tactile sensing with piezoelectric materials for mini-mally invasive surgery and magnetic-resonance-guided interventions. Pro-ceedings of the Institution of Mechanical Engineers; Part H: Journal of Engineer-ing in Medicine 2009; 223: 99-110.

3. Manduca A et al. Magnetic resonance elastography: non-invasive mapping of tissue elasticity. Medical image analysis 2001; 5: 237-254.

4. Chan QC et al. Needle shear wave driver for magnetic resonance elastography. Magnetic resonance in medicine 2006; 55: 1175-1179.

5. Elhawary H et al. The case for MR-com-patible robotics: a review of the state of the art. The international journal of medical robotics and computer assisted surgery 2008; 4: 105-113, .

6. Chinzei K et al. MR Compatibility of Mechatronic Devices: Design Criteria presented at proceeding of the second international conference on medical image computing and computer-assisted Interventions, Cambridge, UK, 1999.

7. ASTM, Standard Test Method for Evalu-ation of MR Image Artifacts from Pas-sive Implants, Designation F2110-01. ASTM: American Society for Testing and Materials, 2001.

8. Chinzei K et al. MR compatible surgi-cal assist robot: System integration and preliminary feasibility study presented at proceedings of the third interna-tional conference on medical image computing and computer-assisted intervention, Pittsburgh, Pennsylvania, USA., 2000.

9. Tse ZTH et al. A 3 Degree Of Freedom MR Compatible Device for Magic Angle Related in Vivo Experiments,” ASME/IEEE transactions on mechatronics 2008;13: 316-324.

10. Elhawary H et al. A modular approach to MRI compatible Robotics: Inter-connectable one DOF stages. IEEE

engineering and medicine in biology magazine 2008; 27: 35-41.

11. Talwalkar JA et al. Magnetic resonance imaging of hepatic fibrosis: emerging clinical applications. Hepatology 2008; 47: 332-342.

12. Bishop J. Two-dimensional MR elas-tography with linear inversion recon-struction: methodology and noise analysis. Physics in medicine & biology 2000; 45: 2081.

13. Plewes DB et al. Visualization and quantification of breast cancer biome-chanical properties with magnetic res-onance elastography. Physics in medi-cine & biology 2000; 45: 1591-1610.

14. Braun J et al. Electromagnetic actua-tor for generating variably oriented shear waves in MR elastography. Mag-netic resonance in medicine 2003; 50: 220-222.

15. Rossman PJ et al. Driver Device for MR Elastography. U. S. Patent, Ed. United States, 1999.

16. Uffmann K et al. Characterization of an electromagnetic actuator for MR elastography presented at proceedings of the 9th annual meeting of Interna-tional Society for Magnetic Resonance in Medicine, Glasgow, 2001.

17. Doyley MM et al. Thresholds for detect-ing and characterizing focal lesions using steady-state MR elastography. Medical physics 2003; 30: 495-504.

18. Weaver J et al. Measurement of har-monic motion for MR elastography,” presented at proceedings of the 7th annual meeting of International Soci-ety for Magnetic Resonance in Medi-cine, Philadelphia, 1999.

19. Uffmann K. Design of an MR-com-patible piezoelectric actuator for MR elastography. Concepts in magnetic resonance 2002; 15: 239-254.

The authorsZ. T. H. Tse1 and A. Hamed2

1Department of Radiology Brigham & Women’s Hospital, Har-vard Medical School Boston, MA, USA

2Mechatronics in Medicine Laboratory Department of Mechanical Engineering Imperial College London, South Kensington CampusLondon, UK

Corresponding author: [email protected]

30 MEdiCAL iMAGiNG


Figure 4. Actuation by a piezoelectric stack: (a) a general purpose MRE wave genera-ting device with the use of piezoelectric stack and (b) its internal design with a simple

lever mechanism to amplify the vibration amplitude [19].

– Issue N°6 – Nov. 2009

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32

The ability to ‘see’ within the living human body and understand its biological complexities for the treatment of disease is known as molecular imag-ing; this is one of the most exciting and rapidly growing areas of science [1]. The key is to scruti-nise the molecular abnormalities that are the basis of disease rather than to image the end effects of these molecular alterations i.e. earlier detection and characterisation of disease, earlier and direct molecular assessment of treatment effects, and a more fundamental understanding of the disease process. Various imaging modalities [e.g. positron emission tomography (PET), single photon emis-sion computed tomography (SPECT), magnetic resonance imaging (MRI), optical, ultrasound] can be used to assess specific molecular targets. Certain modalities are well suited for some applications, whilst very poorly suited for others. For instance, optical fluorescence imaging is difficult to quantify – especially in tissue more than a few millimetres in depth within a subject; MRI has superb resolution but low sensitivity and PET has very high sensitiv-ity but poor resolution. As no one imaging modality can provide information on all aspects of struc-ture and function, interrogation of a subject using multiple imaging modalities is clearly attractive.

Dual- or multi-modality molecular imaging is the synergistic combination of two or more detection techniques, made possible by multi-modal probes [Figure 1], [2]. The advantages of one technique can be combined with the advantages of another, whilst at the same time reducing the disadvantages of both. However the problem cannot be solved by simply adding two different classes of imaging probe together, unless they happen to have identical pharmacody-namic properties. Dual imaging agents have exciting potential as, for example, they can be used in surgery to guide the scalpel (via fluorescence imaging), to ensure all cancerous material has been removed (MR imaging), and to track and identify tumour cells and physiological processes (PET or SPECT imaging).

Dual-modality imaging probes1. The area of (MRI)/optical imaging is the most well developed in terms of dual-modality imaging, and applications have been found in biomedical research and clinical practice. The last five years have seen a significant increase in MRI/optical probe development with particular interest in, for example, the utilisation of gadolinium chelates, functionalised quantum dots and iron oxide nanoparticles [3]. The starting point for the development of a dual MRI/optical probe has involved adaptation of the gadolinium chemistry used in the vast majority of clinical MRI. The unique magnetic properties of the gadolinium(III) ion are instrumental in enhancing the relaxation rate of water protons in tissues. The

toxicity of Gd3+ is reduced by complexation using stabilising chelates such as DTPA (diethylenetri-aminepentacetic acid) and DOTA (1,4,7,10-tetraaza-cyclododecane-N,N,N’,N’’-tetraacetic acid) enabling use of these agents in humans.

Multimodal imaging using a small molecule-based probe is challenging due to the limited number of attachment points and the potential interference with its receptor binding affin-ity. However, nanoparticles have large surface

areas where multiple functional moieties can be incorporated for multimodality molecular imaging. Quantum dots (QDs) are nanopar-ticulate clusters of semiconductor material that show quantum confinement effects – meaning that the optical properties of these nanoparti-cles are controlled by their size, rather than their composition, thus rendering them useful opti-cal imaging agents [4]. The size of their band gap dictates the energy of the photon emitted and also the wavelength of emitted light. QDs are of great interest due to their biological imaging capabilities, their bright fluorescence, photostability and their narrow and size tune-able emission spectrum. Solubility and toxic-ity issues are potential problems though, and hydrophilic surface passivating ligands need to be introduced around the QDs prior to any in vitro and in vivo investigations.

Superparamagnetic iron oxide nanoparticles (SPIOs) have been extensively studied as MR imaging agents due to their ability to enhance the T2 weighted MRI signal, and as biologically benign alternatives to Gd-based systems. With conventional paramag-netic contrast agents, 10-100 µM concentrations are required but with SPIOs (ca. 20 nm in size) these agents can be detected by T2-weighted imaging at sub-micromolar particle concentrations. For in vivo applications, these non-toxic magnetic parti-cles must be coated with a biocompatible polymer

dual-modality probes for molecular imagingMolecular or personalised medicine is the future for patient management and healthcare, and molecular imaging plays a key role towards achieving this goal. However, no single imaging technique is perfect and the combination of two or more imaging techniques can therefore offer synergistic advantages over any modality alone. suitable imaging probes are currently being developed and repre-sent an exciting challenge for chemists and imaging scientists.

by Prof. N. J. Long

Figure 1. Schematic diagram of dual- or multi-modality molecular imaging.

1

Figure 1

(this is my diagram but it first appeared in my review article L. E. Jennings and N. J. Long, Chem.

Commun., 2009, 3511 so may need copyright approval ?)

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Optical

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– Issue N°6 – Nov. 2009 MEdiCAL iMAGiNG

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during or after the synthesis process to prevent the formation of large aggregates and biodegradation when exposed to the biological system.

2. The fusion of optical and radionuclear meth-ods in PET/optical probes has the potential for widespread use in biomedical imaging [5]. The development of an optical-PET detector has been established; preliminary results are encourag-ing and suggest that a combined technique for dual imaging may just be over the horizon. The fusion of radionuclear and optical methods is still a infrequently used multimodal imaging strategy, perhaps due to misconceptions and technical dif-ficulties including the absence of a standard opti-cal imaging system and the lack of FDA-approved target specific optical molecular probes. PET is a powerful and rapidly developing area of molecular imaging that is used to study and visualise human physiology by the detection of positron emit-ting radiopharmaceuticals [6]. Short-lived radio-isotopes such as 11C and 18F are of great interest due to their biogenicity and low atomic mass so it is possible to directly label molecules/drugs of interest without interfering with their biological activity. The main challenge with these short-lived isotopes is time, with the labelled probe having to be synthesised, purified, analysed and formulated usually within the order of a few minutes.

3. MRI/PET probes - Combining PET and X-ray Computerised Tomography technologies has

proven to give valuable opportunities in imaging by the collection of physiological data and physi-cal mapping. There has been a great deal of inter-est in combining PET and MRI (or fMRI) which would be able to collect information in a similar way [7]. PET and MRI are largely complemen-tary techniques and the combination would cer-tainly be a ‘marriage of convenience’ – with PET (exceptionally sensitive, metabolically functional but with poor spatial resolution) synergistically

linked to MRI (giving supremely high-resolution anatomical information in the submillimetre range). Attempts to build a scanner with the capa-bilities to simultaneously image MRI and PET have been ongoing for over a decade [8]. The main issue to be overcome is the cost plus the deleteri-ous interactions caused by the high magnetic field environment of the MR scanner and the radi-ofrequency (RF) interference between the PET and MRI systems. Catana and co-workers have designed a multislice PET scanner to fit inside a preclinical MRI. Initial testing on mouse models with the PET insert and 7T MRI scanner again detected no deleterious interactions, with no vis-ible artefacts being noted on the mouse images. The group produced the first PET/MR image of a mouse head using the prototype device, simul-taneously acquiring both sets of information and using computer software to fuse the data together [Figure 2], [9].

It is interesting to note that virtually no combined PET/MRI probes have been reported to date - but now, with the development of suitable equipment, there is huge scope for development of novel mul-timodal MRI/PET probes. The issue to be tackled is the large difference in the sensitivities of the two techniques. PET agents are generally extremely small and can be used in tiny concentrations whilst MR probes must be administered in much higher concentrations – typically a thousand-fold higher than a PET agent.


Figure 2. Simultaneously acquired PET (filtered back projection, 2.5-mm Gaussian post-smoothing filter) and coronal unenhanced fast low-angle shot MR

(394/5.9, 40° flip angle, six signals acquired, 1-mm section thickness, 256 x 256 pixels) images of a

mouse head injected with FDG. The fused PET/MR images show good alignment of images acquired with the two imaging modalities. The increased uptake of

the PET images correlates with the location of the Hard-erian glands behind the eyes in the MR images [9].

1

Figure 2

Figure 2 Simultaneously acquired PET (filtered back projection, 2.5-mm Gaussian post-

smoothing filter) and coronal unenhanced fast low-angle shot MR (394/5.9, 40° flip angle, six

signals acquired, 1-mm section thickness, 256 x 256 pixels) images of a mouse head injected with

FDG. The fused PET/MR images show good alignment of images acquired with the two imaging

modalities. The increased uptake of the PET images correlates with the location of the Harderian

glands behind the eyes in the MR images. 9

( I got copyright approval for use in my Chem Comm review – but I suppose may need approval

again ?)

– Issue N°6 – Nov. 2009

Conclusions and the futureThe area of multi-modality molecular imaging is moving from a research curiosity to one that has real pre-clinical and clinical application. By facili-tating the development, validation and testing of new reporter systems in animals and translating them into humans, multi-modal probes are substantially greater than the sum of their individual parts.

One of the key growth areas will be ‘theranostics’ – where a diagnostic and a therapeutic can be combined into the same compound or probe. As the cellular processes imaged by probes are often the same processes that a therapeutic can target, a diagnostic imaging agent can be equipped to deliver a therapeutic compound directly to a diseased site – an excit-ing and powerful combination. Nanoparticles, offering multi-functional nanoplatforms, certainly have a role to play here with the ultimate goal for nanoplatform-based agents being efficient, specific in vivo delivery of drugs without systemic toxicity.

Forming ‘smart’ or switchable probes or new ways to deliver reagents with enhanced properties will also be a ‘hot topic’. For instance, enzyme-activated opti-cal probes can be harnessed in which the probes have a low fluorescence signal until they are activated by target enzymes such as proteases, after which their signal is amplified [10]. Alongside probe development, advances in imaging tech-nology and equipment will be sought. Prototype PET/MRI scanners are already in production and eventually these will become mainstream. The technology is challenging due to the radiofrequency interference between the two imaging sys-tems, which must be avoided, and the fact that the PET detectors must work in relatively high magnetic fields. The major uses of PET/MRI scanners will initially be in research, both human and animal – applications driving the commercial success of PET/MRI are perhaps not yet apparent but they will come.

In summary, multi-modal molecular imaging approaches will have a signif-icant impact on biomedical research and drug discovery and development. Imaging targets in body/cell/tissue, and investigating interaction of targets with substrates and receptor occupancy are vital in preclinical and clinical research. Perhaps the greatest challenge is to encourage chemists and clini-cians to work alongside each other and begin dialogue over research questions at an early stage. There is no point in a chemist making an exciting, novel probe that has no application. Conversely, the clinicians need to move on from tried and tested contrast agents that ‘do the job’ but could be improved in terms of sensitivity, efficiency, cost and toxicity. The design of the appropriate (multi-modal) imaging probe is key and any real advances in molecular imaging will be due to the interdisciplinary efforts of synthetic chemists, molecular biolo-gists, imaging scientists and clinicians.

References1. Rudin M. Molecular Imaging – Basic Principles and Applications in Biomedical

Research, Imperial College Press, London, 20052. Jennings LE and Long NJ. Chem Commun 2009; 3511.3. Frullano L and Meade TJ. J Biol Inorg Chem 2007; 12: 939.4. Gao X et al. Curr Opin Biotech 2005; 16: 63. 5. Culver J et al. J Nucl Med 2008; 49: 167.6. Miller PW et al. Angew Chem Int Ed 2008; 47: 2.7.Gerstl F et al. Neuroimage 2008; 41: 204.8. Woody C et al. Nuclear instruments & methods in physics research. Section A,

Accelerators, spectrometers, detectors and associated equipment 2007; 571: 102.9. Catana C et al. Proc Nat Acad Sci 2008; 105(10) 3705.10. Louie AY et al. Nat Biotech 2000; 18: 321.

The authorProfessor Nicholas J. Long Department of Chemistry Imperial College London South Kensington, London SW7 2AZ, UK e-mail: [email protected]

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36 HEALtHCArE it

Data-intensive modalities and burgeoning depart-mental information systems are stretching both the resources and budgets of healthcare IT staff while physician productivity is also hindered by the need to learn multiple systems and apply dif-ferent user interfaces and tools. The maintenance and support of such disparate systems is currently a PACS administrator’s nightmare.

Creating a link between RIS/PACS platforms from different vendors is made difficult because these systems were not designed to communi-cate with each other. IT professionals are taking on this challenge because sharing patient records and imaging studies across a healthcare system can create a more efficient diagnostic process and enhance management of decentralised archives.

In the past, sharing information either required converting to a single vendor’s RIS/PACS platform for all sites, or mastering and managing diverse systems. While standardising on a single platform can work for a large hospital that wants to link its affiliated imaging centres into an existing plat-form, this approach is not financially feasible for imaging providers that each have their own RIS/PACS, and in cases where information needs to be shared with competing or unaffiliated facilities.

Fortunately new technologies and approaches are now being applied to join disparate systems into an enterprise-wide PACS. There are three critical components that must be achieved:

• There must be one central database manager for all imaging studies regardless of where they are stored, and the ability to import DICOM and non-DICOM patient data from multiple systems.

• There must be one global worklist that is shared among users at all facilities. It must offer continuous updates and reconcile dif-ferent patient identification numbers used by each facility.

• Use of streaming technology is essential in order to deliver data rapidly to users—even over lower-bandwidth connections.

A new approach from Carestream Health addresses each of these issues. The SuperPACS

Architecture collects patient and study informa-tion from each site’s RIS and PACS through a local Carestream Agent and creates a centralised, synchronised database. This flexible, affordable solution achieves the desired efficiency and pro-ductivity gains without requiring local facilities to replace existing RIS/PACS systems. In addition, it can be expanded beyond radiology to include other “-ologies” to further simplify management, optimise resources and reduce expenses.

Achieving a centralised databaseA centralised database is essential to ensure that all prior imaging exams and other relevant information is available for review with the cur-rent study. It is possible to query other sites for patient information, but that is cumbersome and time-consuming. It is much more produc-tive to design a database that synchronises exam information from all of the sites on an ongo-ing basis. These data includes exam metadata, study status, patient name changes and other related information.

For maximum efficiency, the exam data should be automatically synchronised on a priority basis—important information related to exam status, for example, should be updated frequently while less important data could be updated once or twice a day.

Migrating metadata into the database also performs another important function—it can eliminate the need for a very costly migration

since imaging services are often deliv-ered across multiple facilities, there is a pressing need to share patient records and imaging studies to create a more efficient diagnostic process and pro-vide enhanced management of decen-tralised archives. this article presents a new approach that allows disparate systems to be joined into an efficient enterprise-wide PACs.

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technologies to transform disparate systems into efficient enterprise-wide PACs

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– Issue N°6 – Nov. 2009

of existing imaging studies. Once the database has the exam meta-data, the study becomes part of the global workflow, including automatic pre-fetching of required information from the local archive. Metadata for several years of imag-ing exams can often be migrated to the database in just a few days, whereas migrating pixel data often takes years. By incorporating meta-data into a central database, facili-ties can preserve their investment in existing archives and systems and build the foundation for a global worklist.

The resulting virtual database allows patient data and images to be easily accessed by authorised users such as radiologists or other clinicians at on-site or remote locations. Under SuperPACS management, infor-mation can be efficiently shared among different facilities without the technical and network overhead required by direct PACS-to-PACS communication. Furthermore, data are efficiently transmitted by using lossless compression techniques, instead of uncompressed DICOM files that offer low performance.

The new architecture also creates a global worklist that streamlines radiology workflow by allow-ing radiologists at any location to view a list of unread exams across the entire healthcare system. Prior exams and patient history related to the current exam are also immedi-ately available, regardless of where they are stored.

Building a global worklistIn a multi-site environment, a global worklist is needed to sup-port productive reading from any on-site or remote location. Cre-ating a global worklist for dispa-rate PACS is challenging: it must be able to accurately identify the patient who goes to multiple sites and therefore has several numbers, as well as being able to handle two different patients who have the same ID number.

To accomplish accurate patient identification, the PACS should be configured with either a central RIS that manages the local and global patient logic, or a third-party PIX manager or local master patient

index that is configured with the RIS. The enterprise PACS will adopt an expanded patient ID number that typically includes an issuer field to identify the origin of the patient ID as well as the number itself.

Using HL7 or other processes, the worklist can assign a patient and site to each exam and then recon-cile those factors as needed. This is in order to link individual patients to multiple exams at different sites as well as to separate patients that have the same ID number. The

system also needs to offer the same response to DICOM queries regard-less of which patient ID is used, and it should display all identification numbers for a patient in the data-base and in the radiology reports.

A global worklist speeds read-ing and reporting since radiolo-gists can review exams captured anywhere in the system—not just local exams. The IT staff can give specialists higher priority for specific types of exam and create specialised reading protocols and

folders. Images, annotations and measurements can be automati-cally sent back to the original RIS and PACS.

Linking patient information with imagesMost PACS vendors do not want to support non-DICOM infor-mation because of its complexity. However delivering effective care requires that the data presented in imaging studies be evaluated in the context of other pertinent patient records. Often that necessitates

37

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importing non-DICOM information and associating it with the patient and the imaging exam.

Carestream Health has created a unique proc-ess that uses XDS protocols to import non-DICOM data and store them side-by-side with DICOM data. Other methods require inte-gration of multiple systems but this solution does not—making it both more efficient and more effective.

Achieving high speeds over low bandwidthThe final element in an efficient multi-site work-flow is being able to provide rapid transmission of image and information to users at any onsite or offsite location. Modern streaming technology makes it possible to determine the fastest route between where the data are stored and each user’s location. This capability ensures rapid, respon-sive access even over low bandwidth lines, such as cable modem or DSL connections. Streaming technology enables remote radiologists, special-ists and other clinicians to read or review large data sets effectively.

This intelligent streaming technology expedites the transmission of imaging studies—even over 10 megabit connections. The technology makes it practical for radiologists to read large image files from remote home or office locations that

are outside the hospital network—and elimi-nates complaints about slow loading speeds. Push technology and management is also available, optimising the communication process, while maintaining access and synchronisation with the global worklist.

Managers faced with tight budgets are able to consolidate IT infrastructure across all sites to achieve higher data availability and disas-ter recovery solutions. Expensive and time-consuming data migrations can be reduced or eliminated, since data are easily accessed regard-less of the system where data are stored or the physical location. Service to radiologists, refer-ring physicians and their patients, and clinicians is improved—while the total cost of ownership is reduced. IT staff also gain the flexibility to build more efficient enterprise repositories of patient-centric information.

Compelling benefits for all partiesLinking RIS/PACS and other departmental sys-tems to form an enterprise system can deliver greater user efficiency and streamlined manage-ment. New architectures that allow healthcare professionals to link existing RIS/PACS plat-forms are the first step in the latest evolution of healthcare information management technol-ogy. Converting isolated PACS platforms into an efficient enterprise-wide solution can transform the practice of radiology—benefiting patients,

hospitals and physicians. Patient care is improved, since prior imag-ing studies and other records are available for review with the current imaging exam. Hospi-tals gain greater productivity as manual proc-esses are replaced with automatic ones, and a streamlined workflow leads to faster delivery of radiology reports. Operating costs are reduced through utilisation of existing resources and avoidance of costly data migration. Creating a virtual enterprise-wide PACS also maximises the productivity of IT staff and PACS administra-tors. Radiologists and referring physicians gain both convenience and efficiency from enhanced access to imaging exams from on-site and off-site locations.

The practice of healthcare has evolved in the last decade. Efficient, enterprise-wide systems are now a necessity to support the success-ful deployment of radiology services across local and regional networks with multiple imaging providers.

The authorChristophe Chapot Europe North, Regional Business Manager, Healthcare Information Solutions, Carestream Health Hemel Hempstead, Herts, UK www.ihe-online.com & search 45426

38 HEALtHCArE it – Issue N°6 – Nov. 2009

Extrapulmonary ventilation system Indicated for the therapy of respiratory acidosis in hyper-capnic patients with exacerbated chronic obstructive pul-monary disease, the iLA Membrane ventilator provides efficient CO

2 removal, thanks to the high diffusive con-

centration gradient across the membrane. The membrane unit is connected via an arteriovenous shunt and is driven only by the patient’s blood pressure so no pump is neces-

sary. Gas exchange is achieved through the highly biocompatible heparin-coated diffusion membrane which is resistant to plasma leakage. The unit is connected to the patient via arterial and venous femoral cannulae.

NoValuNg Talheim, germany www.ihe-online.com & search 45439

Cardiac output/cardiovascular monitors The AESCULON and ICON devices from Osypka Medical are non-invasive monitors for use with adults, children and neonates, and provide con-tinuous measurements of various haemodynamic parameters. The systems use electrical cardiom-etry, an innovative method that determines stroke

volume (SV), cardiac output (CO), cardiac index (CI), index of contractility (ICON), thoracic fluid index (TFI), and other parameters through the use of four standard ECG leads. The AESCULON boasts a 12” screen, virtually unlim-ited patient data storage, and also measures non-invasive blood pressure and SpO2. The compact and portable ICON records and stores patient data, has two hour battery life and is also equipped with Bluetooth technology.

osypka medicalBerlin, germany www.ihe-online.com & search 45438

ProdUCt NEWs 39



FroNt CovEr ProdUCt3D tomosynthesis and mammography

In the first ever example of the combination of these technologies, Siemens has integrated 3D tomosynthesis into its Mammomat Inspiration digital mammography platform so that three-dimensional images of the breast can be com-piled. The new system means that there is now a greater chance of tumours being detected even if they are hidden by overlapping tissue, thus facilitating a more accurate diagnosis

and reducing the number of false positive findings. Up till now, conventional analogue mammography and digital full-field mammography were only able to display the three-dimensional anatomical structure of the breast on a two-dimensional basis. This made diagnosis more difficult and limited the pos-sibility of the physician identifying certain types of tumour, since anatomical structures could overlap and obscure lesions. The 3D tomosynthesis technol-ogy in the Mammomat Inspiration overcomes these limitations: the technol-ogy acquires several projections of the breast from different angles using a fast detector based on amorphous Selenium (aSe) and uses these raw data to gener-ate a 3D volume set. This enables a better analysis of the type and size of lesions, as well as of microcalcifications compared to conventional methods.

siemeNs healThcareerlangen, germany www.ihe-online.com & search 45440

Hall 9

Stan

d B05

– Issue N°6 – Nov. 2009

Defibrillator/monitorThanks to its four-in-one design, the B eneHear t D6 defibril-lator/moni-tor can carry out several f u n c t i o n s , n a m e l y

monitoring, manual defibrillation, AED and as a pacer. The compact design makes the device easy to carry and operate and the 8.4“ TFT dis-play with four waveforms ensures easy viewing of ECG and vital signs. The rugged construc-tion enables the device to withstand even the shocks typically encountered in emergency care and out-of-hospital situations. Defibrillation, synchronised cardioversion and AED are carried out with biphasic technology.

miNdrayshenzhen, chinaMedica Hall 9 A74 / Hall 3 F26 www.ihe-online.com & search 45441

Plasma filtration adsorption system for sepsis patients

The aim of the coupled plasma filtration adsorption CPFA system from Bellco is to remove the excess mediators such as cytokines

and chemokines which are excreted into the cir-culation of sepsis patients. The plasma is sepa-rated from an extracorporeal blood flow from critically ill sepsis patients and is then passed over an adsorbent cartridge which removes a wide array of mediators (both inflammatory and immunosuppressive). The plasma is then returned to the blood flow back to the patient. The high performance of the adsorption resin means that the mediators are removed quan-titatively and rapidly, allowing re-infusion of albumin and amino acids. Studies have shown that the CPFA system increases the mean arte-rial pressure and reduces the need for vaso-pressors, as well as improving cardiac and respiratory parameters. The system is appli-cable to both severe sepsis and septic shock patients with either gram positive or gram negative infections.

Bellco mirandola, italyMedica Hall 6 A39 www.ihe-online.com & search 45443

Scalp coolers for chemotherapy patientsThe loss of hair during cancer treatments is a traumatic and psychologically devastating side effect and a constant reminder of the disease. Designed to provide cancer patients with the best possible chance of retaining their hair whilst undergoing chemotherapy treatment, the new range of scalp coolers from Paxman aims to minimise patient distress. Studies have shown that on average 70-90% of patients who use the system do not require a wig. Made from lightweight, silicone tubing, the scalp cooling cap is soft and flexible so creating a snug yet comfortable fit during treatment. Moulding to all head shapes and sizes, the

specially devel-oped liquid cool-ant passes through the cap extract-ing heat from the patient’s scalp, so ensuring that the scalp remains at an even, constant temperature. The caps are worn 30 minutes before the start of chemo-therapy, during the treatment itself

and, depending on the toxicity of the drugs, for a period of time after infusion of the chemo-therapy. The cap is connected to a cutting edge and easy to use refrigeration system which uses up-to-the-minute touch screen display and simple switch operation, making it easy for both the patient and staff to operate.

paxmaN coolershuddersfield, yorks, ukMedica Hall 16 G10 www.ihe-online.com & search 45444

Easy-to-use blood glucose monitorCompact and light (only 43g includ-ing batteries), the GL-40 blood glu-cose monitor from Beurer is a pocket-size device with an illuminated test strip slot, large backlit display and extra-wide test strips. Designed to be especially easy to use, the device offers new

standards of user-friendliness. The GL 40 is particularly useful for those diabetics who need to check insulin levels at very frequent inter-vals, enabling measurements to be taken even in public with the utmost discretion. The device stores 480 readings labelled with date and time; data are retained even during a change of bat-tery. Previous readings can be recalled and the monitor has a USB port for connection to a computer. A feature of the GL-40 is its code-free operation; measurement can be performed immediately with no need for pre-identification of the test strips.

Beurer ulm, germanyMedica Hall 12 F55 www.ihe-online.com & search 45442

MEdiCA HiGHLiGHts40

‘Cost saving of up to 80%* andevery patient warmed’

www.inditherm.com/medical*Savings are based on experience in UK NHS and private hospitals.

Inditherm Patient Warming• Unrivalled warming performance – Patented Carbon Polymer Technology – No hot air – No consumables• Unhindered clinical access• Simple, versatile, effective and silent• Cost saving of up to 80%* and every patient

warmed.

Seeing is believing, so contact any of our Medical team todayfor further information or a free trial, on +44 (0) 1709 761000or email: [email protected], and quote Ref: IHES1109

‘The new standard in patient warming’

2342_IND_MED_IHES_Sep09_v3:Layout 1 01/10/2009 11:50 Page 1


– Issue N°6 – Nov. 2009

MEdiCA HiGHLiGHts 41

Hybrid operating room for minimally invasive surgery Worldwide, there has been a shift away from open surgical procedures as hospitals increasingly move towards more same-day and minimally invasive sur-gery. As a result, over half of patients leave hospital on the same day as their operation. The number of cath-eter-based cardiac treatments has also risen greatly in comparison to open vascular procedures. As a result, hospitals today require rooms for minimally invasive procedures that are flexible and easily adaptable, and are able to accommodate the full range of current and future surgical technologies. The solution proposed

by Philips to meet the above developments is to integrate the MAQUET ‘Mag-nus’ surgical table with Philips’ cardiovascular X-ray systems to create an efficient ‘hybrid operating room’ environment for a full range of minimally-invasive and open surgical procedures. The new hybrid operating room allows optimisation of workflow and simplifies room planning and installation processes.

philips healThcareeindhoven, The Netherlands Medica Hall 10 A22 www.ihe-online.com & search 45434

Accurate weighing of patients in standing or sitting position

The new ARNOLD weighing system from CAE is a “3 in 1” weighing system that allows patients to be weighed, with the same accuracy and using the same device, either in a sitting or standing position. The system is robust, ergo-nomic and extremely mobile (even when fitted with its optional accessories such as printer, telescopic electronic height rod, etc.,) so that patients can be weighed wherever desired. In the standing position, the patient can hold on to the back-rest or the retractable arm-rests without affecting the accuracy of the weighing. Easy to use and to

maintain, the system has a capacity of 200 kg or 300 kg with an accuracy of 50g to 100 g respectively.

cae Tenneville, BelgiumMedica Hall 14 D47 www.ihe-online.com & search 45432

Digital colour doppler ultrasound imaging systemThirty years of R&D experience in ultrasonic imag-ing systems enable SIUI to fully understand what ultrasonic users really need, such as clear image quality and smooth operation procedures. The new Apogee 3500 Touch system from SIUI is designed to satisfy these user requirements. The new system incorporates many of the latest imaging technolo-gies and produces high-resolution image quality.With its image processing features and measure-ment and calculation functions the system is suit-able for many different clinical applications, such as

investigations of the abdomen, obstetrics and gynaecology, cardiology and studies of the peripheral vasculature.

shaNTou iNsTiTuTe oF ulTrasoNic iNsTrumeNTsshantou, chinaMedica Hall 16 C80 www.ihe-online.com & search 45433

LED lighting system for treatment and examination tables The new saturn LED lighting system from Derungs Licht is particularly suitable for use in dermatology, gynaecology and general medicine. The system pro-duces ideal light colour and colour rendering so that nuances of colour, such as those occurring on the skin or in skin rashes can be correctly identified. Another important characteristic of the system is the flexibil-ity of setting the luminous power which can even be

set to dim. Since there is virtually no heat radiation from the light, it is much easier for the treating physician to maintain a high level of mental concentra-tion; dehydration of the patient’s tissues is also minimised. The use of the latest LED technology means that the energy consumption is very low and the system is virtually maintenance-free. Individual and variable positioning of the area of illumination is also possible. The position of the light cone is fixed and stable thanks to its fine engineering and weighted joint system.

deruNgs lichT aggossau, switzerland Medica Hall 13 A14 www.ihe-online.com & search 45431

– Issue N°6 – Nov. 2009

Dmed® halux LED 20 C L1Dmed® halux LED 20 P LX

Medica 2009, Düsseldorf, Hall 13 / Booth A 14

• 45 000 lux/0.8 m

Optimum colour rendering• Perfect recognition of colour shades

Concentrated working• Low release of heat close to the

body

• 55 000 lux/1.0 m

Intensely illuminated work field• Perfect viewing

Fixed position of the light cone• Noloweringofthelighthead

Huge energy savings• Minimisedelectricity consumption

gOOD lIgHtIng FOr DeMAnDIng vIsuAl tAsks

DerungsLichtAG(DerungsMedicalLighting)•Hofmattstrasse 12 •9200Gossau•SwitzerlandTelefon +41 71 388 11 66 •Fax +41 71 388 11 77 • [email protected] •www.derungslicht.com


Premium ultrasound performance in compact unit

The latest member of Toshiba’s premium ultra-sound product line, the Aplio MX, provides cut-ting edge performance in a compact platform to pro-vide superior diagnostic precision in a small, envi-ronmentally friendly unit. Toshiba’s already well estab-lished flagship product, the

Aplio XG, has been very successful, in part because of its powerful and advanced clinical applications, such as differential tissue harmonics and precision imaging. Many of these applications, such as quan-titative elastography and acoustic structure quantifi-cation, are based on Toshiba’s raw data technology. The company believes that there is a big demand for a premium platform capable of supporting such technologies but at a price below that of the Aplio XG. The new Aplio MX platform is aimed at pre-cisely this market segment and shares its core imag-ing architecture as well as its transducers with the flagship product. The new system is extremely lightweight and easy to move and incorporates a complete set of innovations designed for better ergonomics, operator comfort and productivity. The system’s fully programmable user interface and its adjustable main panel and 19” monitor with fully articulating arm allow sonographers to optimally configure their work environment according to their clinical needs and personal preferences. The system’s 3D/4D imaging software package, including the newly introduced third-generation high frequency volume transducer PVT-675MV, extends diagnostic capabilities into the next dimension of imaging and intervention by providing accurate renderings and arbitrary volume cuts in real time or offline.

ToshiBa Zoetermeer, The NetherlandsMedica Hall 9 D5 www.ihe-online.com & search 45447

Flat panel detector for mobile digital X-ray

The PaxScan 4336R from Varian is the first ruggedised port-able X-ray flat panel detector designed for mobile digital radio-graphic X-ray systems

to fit existing 14”x17” standard bucky trays. Using a new Gigabit Ethernet interface, images are displayed on a user-supplied workstation.

VariaN medical sysTemspalo alto, ca usaMedica Hall 10 A78 www.ihe-online.com & search 45446

Immediate detection of cervical cancer Designed for routine use by medical practitioners,

the APX is a porta-ble hand-held device that uses pioneering new technology to provide a quicker, more accurate detection of cervical

cancer in real time. The system measures the resis-tivity of cells by electrical impedance spectroscopy and detects any changes from normal to cancerous. Safe and painless, the system has two functionalities within the one unit - the APX 100, which supports clinicians within their diagnostic procedure and the APX 200, which is a point of care test. The APX100 enables colposcopists to better target biopsy sites helping to reduce the number of diagnostic biopsies and avoid the gross over-treatment of mild abnor-malities. The APX 200 application is targeted at the cervical screening market, as it provides real-time diagnosis at the primary point-of-care.

Zilicosheffield, ukMedica Hall 16 G10 www.ihe-online.com & search 45448

Transportation of highly infectious patients

Specially designed for the transportation of patients with highly infectious conditions such as swine flu, SARS or plague, a range of new patient transpor-tation systems has been introduced to the mar-ket. Suitable for both

adults and children, the new systems are based on negative-pressure chambers mounted on a trans-portation stretcher trolley, which can be motor-ised. Designed for first line patient transportation from initial patient reception through to hos-pitalisation in sterile isolation units, the mobile stretchers provide complete air circulation within the chamber through the use of carbon filters and blowers. This enables patients to be kept inside the chamber for a time sufficient for full diagnosis and initial treatment yet with no danger of release of contaminated air from inside the chamber. Fit-ted with a series of conduit sleeves through which patients can receive active medical treatment, the chambers also allow the connection of cables for monitoring equipment or tubes for intravenous drips or ventilation.

saVioNashdod, israelMedica Hall 14 D28 www.ihe-online.com & search 45445

MEdiCA HiGHLiGHts42




– Issue N°6 – Nov. 2009


Compact monitor for CO2 and SpO2 In settings such as emergency care, patient transport and neonatal units it is impor-tant that the devices used for the monitor-ing of vital parameters are not only totally reliable but also compact and light-weight. The new ergonomically designed, ultra-compact CapnoTrue device from bluepoint

Medical has been developed to fulfil these requirements and provides reliable, high performance in both mainstream and sidestream capnography and pulse oximetry. The system exists in two versions: the light-weight and shock-resist-ant AMP model for advanced high-performance mainstream CO2 measure-ment using an IRMA CO2 analyser, and the ASP model which enables low flow, sidestream CO2 measurement. The ASP system is equipped with Nomo fluid protection technology incorporating a water separation section with built-in bacterial filter. A large choice of accessories, such as high-quality reusable, autoclavable and disposable SpO2 sensors is available for both systems.

bluepoint medicalselmsdorf, germanyMedica Hall 10 F78 www.ihe-online.com & search 45427

Instant accurate temperature measurements

Providing accurate and reliable body temperature using the measurement of infrared radiation from the eardrum, skin, forehead or other places on the body for taking temperature, the Doc ThermoRR professional thermometer system has a wide measurement range and can provide real time scanning with no waiting or response time.

comdek Taipei, TaiwanMedica Hall 11 D11 www.ihe-online.com & search 45429

Filling the gap between workstation storage and PACSDeveloped to meet the increasing demand for cost-effective storage of temporary data sets or permanent archives, the new line of affordable medical image servers from Codon-ics, the Infinity medical image servers, combines simplicity and speed in a highly-reliable DICOM storage device. All Infinity models provide flexibility for permanent and temporary storage

of DICOM images, reports and raw data in a compact unit. The unique, expand-able design of the system allows growth as storage needs increase. Additionally, the new systems provide optional web viewing capabilities so that medical images can be accessed over the network from any PC. Base models provide between 3 TB (terabyte) and 8 TB of storage. The high-performance architec-ture delivers ultra-fast data transfer speeds starting from 25 Mbytes per second to well over 50 Mbytes per second (DICOM store). Thin slices, raw data, 3D reconstructions and multi-frame studies can be quickly saved and retrieved for future reconstruction or review. Automatic image management removes older studies tagged for temporary storage whenever space is needed.

codoNicscleveland, oh, usaMedica Hall 9 A46 www.ihe-online.com & search 45430

Electrosurgical smoke evacuators Designed to eliminate bacteriological risk for both surgeons and patients two new smoke evacuators from ALSA provide significant benefits during laparoscopic procedures, thanks to improved operating conditions produced by the systems which result in shorter intervention times. The devices can be automatically activated either by a sen-sor, or by a pedal foot-switch and are com-patible with all types of electrosurgical units, laser or ultrasound systems. Suitable for use both in standard open surgery or gynaeco-

logical surgery, both models are equipped with an adjustable suction deac-tivation delay system. The smoke evacuators are fitted with an antibacterial filter and a highly efficient microprocessor-controlled anti-smell filter.

alsa apparecchi medicali castel maggiore, italy Medica Hall 12 A48 www.ihe-online.com & search 45428

EnviteC-Wismar GmbH a Honeywell CompanyAlter Holzhafen 18, 23966 Wismar, Germany

Phone: +49 (0) 3841 / 360-200 · Fax: 360-222www.envitec.com

For more informationplease contact:

[email protected]

Meet EnviteC at Medica 2009Hall 11 Stand B22

SoftTip® plus – No compromises

A finger sensor that can be

seamlessly integrated in exist-

ing cleaning, disinfection and

sterilization processes.

The sensor is suitable for the

standard steam sterilization

method.

This simplifies handling, especially in clinics, whilst

ensuring maximum safety for patients and users.

The only autoclavable SpO2 sensor

Made in Germany

IHE_Rahmen_prod 19.10.2009 18:40 Uhr Seite 1


– Issue N°6 – Nov. 2009

Highly specific and sensitive liver function test

Indocyanine Green (ICG) is a water-soluble tri-car-bocyanine dye that has been used clinically for many years. ICG is a strong absorber of infra red light, with an absorption maximum of 805 nm at which wavelength the dye concentration can be quantified spectrophotometrically. The dye is stable in blood and plasma and when infused intravenously into the bloodstream it rapidly binds to plasma proteins and is thereby confined to the vascular space. ICG is not metabolised and is exclusively eliminated by the liver into the bile without any entero-hepatic re-circulation. For this reason the rate at which the dye disappears from the circulation can be used to assess liver function. In such a test a bolus of ICG is injected intravenously and the dye concentration measured by a photometric sensor so that a plasma disappear-ance rate, the PDRICG expressed in %/minute, can be calculated. With a normal liver function the elimi-nation of ICG follows an exponential curve and has a half-life of 150 –180s. Particularly suitable for ICG measurement, the Limon system from Pulsion Medical Systems uses a non-invasive measurement system via a finger-clip photometric detector and gives results in 5-10 minutes. Up to 10 measure-ments can be taken in 24h. Unlike laboratory blood tests for liver function, changes can be detected instantly and since no lab blood tests are needed there is a significant cost saving. The technique can be applied in general intensive care to provide an early indicator of liver dysfunction, but also in liver resection cases and in liver transplantation where the technique has been shown to be the best indi-cator of graft dysfunction. Recent studies (Kortgen et al. Shock 2009; 32: 358) have shown that PDRICG is both more specific and sensitive for detecting liver dysfunction than bilirubin measurement.

pulsioN medical sysTemsmunich, germanyMedica Hall 11 D31 www.ihe-online.com & search 45418

Nesting IV poles

The unique nesting design of the SmartStack I.V. stand means that stands can be stored in half the

space required by traditional designs, thus mak-ing hospital facilities neater and safer, a particu-larly important advantage in cramped patient care areas when multiple poles are needed. The base of the new system is 100% cast aluminium and has five symmetrically placed casters for extra sup-port, durability and easy manoeuvring. The large smooth rolling casters and the nesting design enable multiple poles to be moved with one hand. With a powder-coat paint finish to protect against chipping or rusting, the spring-loaded pole is eas-ily adjustable and is strong enough to hold sig-nificant weight. Each pole comes with 4 ram-horn hooks and accessories such as single or double tank holders are also available.

sharN aNesThesiaTampa, Fl, usaMedica Hall 16 E06 www.ihe-online.com & search 45417

Mattress for uniform perioperative warming

There is compelling clinical evidence to support the need for active patient warming in the peri-operative period to avoid inadvertent hypother-mia. This has a profound effect on post-operative mortality and morbidity, and in particular wound infection rates and recovery times. Hitherto, forced air warming has been considered the only effective option available, but such systems have major cost implications. Conventional electri-cally-heated mattresses using resistive wire ele-ments have also been used but have limited per-formance. To meet these challenges, Inditherm has introduced a new mattress that is compatible with all standard operating tables and incorporates a proprietary flexible carbon polymer technol-ogy. This provides unique high thermal transfer characteristics to produce a completely uniform warming effect, with no hotspots, nor the uneven warming that characterised traditional electric mattresses. Lightweight and X-Ray translucent, the mattresses are designed to minimise pressure points so there is no need for gel pads. The sys-tem operates at low-voltage and has precise dig-ital temperature control and independent thermal cut-outs for complete patient safety.

iNdiTherm rotherham, ukMedica Hall 16 G20-1 www.ihe-online.com & search 45416

MEdiCA HiGHLiGHts44

Distributors Wanted Little Sucker has become the product of choice with nurses, respiratory therapists, and in many hospitals in the U.S. Little Suckers replace up to three products with just one Little Sucker. Our three sizes, Preemie, Standard, and Nasal Tip, are ideal for oral and nasal suctioning in the nursery (labor and delivery), neonatal intensive care, pediatric intensive care, and emergency departments. Please contact us for samples and pricing.

MED 12179

Dave BerberianMedcorp International, Dept. CN25612 Stratford PlaceLaguna Hills, CA 92653 USA

TEL: 949-582-0313FAX: [email protected]. Neotechproducts.com

Medcorp International



– Issue N°6 – Nov. 2009


Autoclavable SpO2 finger sensors

A revolutionary new generation of SpO2 fin-ger sensors that can be sterilised both by rigor-ous, standard steam sterilisation processes and by thermal disinfection has been introduced by

EnviteC. The SoftTip plus finger sensor is able to withstand maximal stress and can thus be intro-duced seamlessly into existing cleaning, disinfec-tion and sterilisation procedures so that it can be reused safely again and again, with obvious and significant clear cost advantages. In addition to disinfection and steam sterilisation, the sensor can also be sterilised by the Sterrad low-temper-ature hydrogen peroxide gas plasma sterilization process. Because SoftTips have a longer life-time than other SpO2 sensors, costs can be reduced by more than 40%. The German-made sensors are available for many common brands of monitors and come with a 24 month warranty. envitecWismar, germanyMedica Hall 11 B22 www.ihe-online.com & search 45420

High performance infant incubatorThe latest infant incu-bator from Dräger, the Isolette 8000, has been designed to provide precise thermoregu-lation, ease and com-fort for the caregiver and parents as well as increased efficiency in the NICU. The latest member of the Isolette

family builds on the range’s proven design while incorporating advanced features to facilitate best possible care for the fragile neonate. As a familiar name in the NICU, the Isolette brand has always been associated with a proven and reliable per-formance and has been known as such by caregiv-ers across the globe for many decades. The Iso-lette family of infant incubators has introduced such innovation as the proprietary Dual Air Cur-tain. This thermal management capability, which is also built into the Isolette 8000, reduces radi-ant heat loss from the infant and contributes to a cocoon-like environment, where the neonate can thrive. In addition, the new incubator offers con-tinuous monitoring of both central and periph-eral body temperature for the baby. By monitor-ing both temperatures, caregivers are better able to anticipate the changing needs of the baby. Facilitated by the compact design of the evapo-ration chamber, additional humidification can be precisely regulated if required. A new condensa-tion management system removes the condensate from the incubator compartment and separates it from the clean water supply. This feature supports infection control practices and enables a more hygienic approach

drägerlübeck, germanyMedica Hall 11 J39 www.ihe-online.com & search 45421


Inviting Participation

Interferential Non Invasive Temporary Pacer * (INTP):

Enabling life to be sustained for days after a sudden cardiac arrest, these innova-tive temporary pacemakers and emergency pacing devices maintain heartbeat by Interferential Non Invasive Pacing. A clinical trial with the prototype device will take place soon.

* patent pending

ISO 9000ISO 1348

CE 0197

Sans titre-1.indd 1 28/10/09 10:42:32



FroNt CovEr ProdUCtNew system links real-time patient monitoring data with medical records

Providing a unique level of integration between patient monitoring data and hospital information systems, the FDA-approved CARESCAPE Moni-tor B850 is unlike traditional patient monitors in that it directly links hospital networks, electronic medical records (EMRs), diagnostic images, lab results and third-party devices with real-time patient monitoring data. The monitor integrates its continuous clinical measurements with other elements of the patient record and delivers them to the point of care. The new system provides clinical information displays customised by care area and clinician preference, while also enabling hospitals to standardise on a monitoring platform throughout the whole organisation. Developed after thousands of hours of field and in-house testing, the new monitor is part of an easy-to-use system that can be customised to meet a variety of clinical needs. These include ECG where the B850 not only enables ‘cart-less’ diagnostic ECGs at the bedside, but also exchanges data with the MUSE ECG repository, facilitating analysis and comparisons with the patient’s prior ECG. The new system also allows the integration of anaes-thesia delivery and patient monitoring systems so that modelling and prediction of the effect of anaesthesia-related drugs and drug interactions can be carried out and the predictions visualised against live patient data. The new system also ena-bles bedside viewing of hospital EMRs, as well as X-rays, lab data and other diagnostic reports.

ge healThcare helsinki, FinlandMedica Hall 10 A56 / Hall 10 B44 www.ihe-online.com & search 45419

– Issue N°6 – Nov. 2009

Fingertip pulse oximeter for patient’s own use Designed for patients who are able to manage their own oxygen, the GO2 Achieve fingertip pulse oxime-ter from Nonin provides the patient with the knowl-edge of reliable oxygen saturation and heart rate val-ues. The rugged construction enables the device to

be used while the patient is active out-doors without compromis-ing the quality and accuracy of the data.

Not only does the device give instant feedback on the effectiveness of the patient’s breathing tech-niques, but it also results in an improvement in the level of communication with the clinician. Designed and constructed so that it can be conveniently car-ried in the patient’s handbag or pocket, the oximeter has a display range for oxygen saturation of 0% to 100% and for pulse rate from 18 to 321 pulses per minute and can be operated reliably in an ambient temperature from 5°C to +40°C.

NoNiN minneapolis, mN, usaMedica Hall 11 D42 www.ihe-online.com & search 45436

Patient ID systems

Every day throughout the world thousands of hospi-tal patients are victims of identification breakdowns and errors. Providing a cost effective but high quality solution, Brenmoor’s range of identification bands all contain a barcode, the patient’s name and date of birth and can thus help reduce identification errors.The bands are easy to print, extremely comfortable for the patient and are resistant to soaps, alcohol, water and chemicals commonly used in hospitals.

BreNmoorcross hill, yorks, uk Medica Hall 16 G10 www.ihe-online.com & search 45437

MEdiCA HiGHLiGHts46


CALENdAr oF EvENtsDecember 10-11, 2009China International Medical Device Summit 2009Beijing, ChinaTel. +86 21 5258 8005Fax +86 21 5258 8011e-mail: [email protected]://chinamdsummit.com

December 13-16, 2009Update on Hemodynamic MonitoringRome, ItalyTel. +32 2 555 3631 Fax +32 2 555 4555 e-mail: [email protected]

January 25-28, 2010Arab Health Dubai, United Arab EmiratesTel. +971 4 3365161Fax +971 4 3364021www.arabhealthonline.com

February 25-28, 2010Early Disease Detection and Prevention (EDDP) conference 2010Munich, GermanyTel. +41 22 5330 948Fax +41 22 5802 953e-mail: [email protected]/eddp2010/

February 26-28, 2010 2010 First International Meeting on Cardiac Problems in Pregnancy (CPP)Valencia, SpainTel. +41 22 5330948 e-mail: [email protected] www.CPP2010.com

March 4-8, 2010ECR 2010Vienna, AustriaTel. +43 1 533 40 64 - 0Fax +43 1 533 40 64 - 448e-mail: [email protected] http://myESR.org

March 9-12, 201030th international Symposium on Intensive Care and Emergency Medicine (ISICEM)Brussels, BelgiumTel. +32 2 555 3631 Fax +32 2 555 4555 e-mail: [email protected]

March 15-18, 2010World of Health IT Conference & ExhibitionBarcelona, SpainTel. +32 2 793 76 37Fax +32 2 793 76 31e-mail: [email protected] www.worldofhealthit.org

March 18-21, 2010KIMES 2010Seoul, KoreaTel. +82 (2) 551 0102Fax +82 (2) 551 0103e-mail: [email protected]

April 6-9, 2010Salon de la Santé 2010Casablanca, Moroccoe-mail: [email protected]

April 14-16, 2010Med-e-Tel 2010Luxembourg, LuxembourgTel. +32 2 269 84 56Fax +32 2 269 79 53e-mail: [email protected]

April 18-21, 200963rd CMEF Spring 2010Shenzhen, ChinaTel. +86 10 6202 8899 ext 3825Fax +86 20 6235 9314e-mail: [email protected]://en.cmef.com.cn

May 19-20, 2010World Health Care Congress - Europe 2010Brussels, BelgiumTel. +1 800 767 9499Fax +1 781 939 2692e-mail: [email protected] www.worldcongress.com/europe

May 25-28, 2010Hospitalar 2010São Paulo, Brazilwww.hospitalar.com/ingles/

June 12-15, 2010Euroanaesthesia 2010Helsinki, FinlandTel. +32-2-743 3290Fax +32-2-743 3298e-mail: [email protected] www.euroanaesthesia.com

June 16-19, 2010World Congress of Cardiology Scientific Sessions 2010Featuring the 3rd International Conference on Women, Heart Disease and StrokeBeijing, Chinae-mail: [email protected]

June 16-19, 2010CARDIOSTIM 201017th World Congress in Cardiac Electrophysiology & Cardiac TechniquesNice , Francewww.cardiostim.fr?xtor=ADI-5

June 23-26, 2010CARS 2010 - Computer Assisted Radiology and SurgeryGeneva, SwitzerlandTel. +49 7742 922 434Fax +49 7742 922 438e-mail: [email protected]

August 28 – September 1, 2010ESC Congress 2010Stockholm, SwedenTel. +33 492 947 600Fax +33 492 947 601www.escardio.org/congresses/esc-2010

September 15-17, 2010Medical Fair Asia 2010Suntec SingaporeTel: + 65 6332 9620Fax: +65 6332 9655 / 6337 4633e-mail: [email protected]

dates and descriptions of future events have been obtained from usually reliable official

industrial sources. iHE cannot be held respon-sible for errors, changes or cancellations.

For more events see www.ihe-online.com/events/

FroNt CovEr ProdUCtDefibrillators with capnography and BP options

The R Series of code-ready defibrillators from Zoll now offer mainstream capnography (EtCO2) and non-invasive blood pressure (NIBP) options. With these additional monitoring capabilities, the R Series extends “Simple, Smart, Ready” defibrillation to every hospital department and also provides advanced solutions for resuscita-tion. There are several individual models in the series. The R Series BLS is an easy-to-use AED that can become a manual defibrillator with the press of a button. The R Series ALS is the most advanced life support defibrillator available and has “See-Thru CPR”, a unique technology to help minimise interruptions to CPR. The R Series Plus model combines the capabilities of the BLS and ALS models. All models offer Real CPR Help, a system that provides rescuers with immediate feedback on the quality of CPR.

Zollelst, The NetherlandsMedica Hall 11 E55 www.ihe-online.com & search 45435

– Issue N°6 – Nov. 2009

©2009 ZOLL Medical Corporation, Chelmsford, MA, USA. “Advancing Resuscitation. Today.”, Code-Ready, and R Series are trademarks of ZOLL Medical Corporation. ZOLL is a registered trademark of ZOLL Medical Corporation.

The worst time to find out your defibrillator isn’t ready is at the code.

A D V A N C I N G R E S U S C I T A T I O N . T O D A Y . ®

You’ve been there. A code is chaotic. People are demanding action, and a lifehangs in the balance. You reach for the defibrillator and discover it’s not ready. It could be delays and confusion from multiple cables, compromised or missingelectrodes, depleted batteries, unclear controls, or confusing alarms.

You need a Code-Ready® defibrillator – a simple defibrillator designed to provide clinicians with comprehensivesupport for defibrillation and CPR, one that gives you the confidence it’s always ready for resuscitation. Introducing the first and only Code-Ready defibrillator, R Series®.. For more information, visit www.zoll.com/ihe

or call +1-978-421-9655.

Simple. Smart. Ready. That’s Code-Ready. R Series from ZOLL®.

Visit us at ESICM 2009

in Vienna, Austria.Booth 32

October 11th–14th2009

IntensiveCareMedicineRSeriesAD:Layout 1 8/13/09 9:16 AM Page 1


Visit us at MEDICA 2009

Hall 11Booth E 55

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