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International

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Equipment & Technology Medical Management
Volume 37
March - April 2011 Weekly news updates on www.ihe-online.com

Advances in ultrasound molecular


imaging of inflammation

Also in this issue

Emergency medIcine focus :


Interpreting ST-segment elevation
Early identification of pre-eclampsia

Optimised imaging protocols in FMISO PET

Printers for high quality Software to customise QA Adhesive for use


medical images in the X-ray room with neonates
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Editor’s Letter 3 – March/April 2011

Cancer — the reality behind the statistics


Awaited with per- oping world are roughly half of those terrible truth is that, despite decades the IARC global statistics show that
haps not the bated in the developed world in both sexes, of health education, a huge propor- a substantial proportion of the awful
breath associated the overall cancer mortality rates tion of the overall cancer burden impact of cancer could be reduced
with such trivia are more or less similar. Some par- is due to the fact that, world-wide, simply by modifying life style fac-
as Oscar nomina- ticularly encouraging signs do exist, there is an increasing adoption of tors such as eating healthily, stop-
tions or football such as the downwards trend (most cancer–causing behaviours. While ping smoking and taking reasonable
World cup draws, marked in the developed world) of research-based developments aimed physical activity.
the annual pub- cervical cancer presumably due to at cancer prevention or cure (the
lication of the latest global cancer the impact of the HPV vaccination best example so far is the HPV vac-
statistics is, nevertheless, a veritable programmes. However to dampen cination case) are of course welcome,
gold-mine of data for all epidemiolo- any such grounds for optimism, the the hard reality is that, once again,
gists, oncologists and public health
professionals. After all, cancer is the
leading cause of death in economi-
cally developed countries and the
second leading cause of death in
developing countries, so the publica-
tion (CA Cancer J Clin 2011; 61:00)
of the latest statistics of worldwide
estimates of cancer incidence and
mortality produced by the Inter-
national Agency for Research on
Cancer (IARC) is of more than pass-
ing interest. For those of us more
focused on European statistics, the
global data are complemented by
the publication of European cancer
mortality predictions for the year
2011 (Annals of Oncology 2011;
10: 1093). Inevitably of course, with
the sheer volume of the information
published, there is a danger of being
overwhelmed in the details, but one
doesn’t have to be an epidemiolo-
gist or health statistician to grasp the

concept: www.glamlab.it
main messages. To over-simplify, the
good news is that the trend of total
cancer mortality levels is downwards
both for men and women while the

Anywhere,
bad news is that the absolute number
of deaths is still enormous (7.6 mil-
lion deaths world-wide per annum).
Worse, largely because of the ageing
and growing world population and
despite the slight decrease in cancer
rates, the overall global burden of
cancer continues to increase. Beneath
when (you) need.
these stark headlines there are many
other more detailed messages. For Cardiovascular diseases are the world’s largest killers, claiming
example, lung cancer in European 17.1 million deaths a year*. Over 40% are caused by heart attack
in the presence of a witness. Today the defibrillator is one of the
women continues to rise inexorably most effective solutions to help save life.
(except in the UK where the inci- * World Health Organization, Fact sheet No. 317, Sept, 2009

dence is more or less static, perhaps


Rescue SAM Rescue Life
because the UK rates of female lung Public access defibrillator Professional monitor defibrillator

cancer have already been extremely


high for a decade or so now). Glo-
bally, female lung, breast and color- www.progettimedical.com
ectal cancers still occur in high
frequencies and although overall
cancer incidence rates in the devel-
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News in brief 5 – March/April 2011

Researchers predict increasing steadily everywhere causal mechanism. The genetic


nearly 1.3 million cancer apart from in the UK, which codes of the relevant genes in
deaths in Europe in 2011 has had the highest rates in tumour and normal tissue were
women for a decade and is now analysed by means of exome
seeing a levelling off. In the sequencing, a new technique.
EU as a whole, world stand- The results showed that muta-
ardised death rates from lung tion in a specific potassium
cancer in women have gone channel (KCNJ5) – which has a
up from 12.55 per 100,000 of role in the passage of molecules
the female population in 2007 into and out of cells – results,
to 13.12 in 2011. Lung cancer in a large number of cases, in
has overtaken breast cancer as tumour growth and overpro-
There will be nearly 1.3 mil- the first cause of cancer death Approximately 5 % of patients duction of the hormone aldos-
lion deaths from cancer in in Polish women, as well as with elevated blood pres- terone. This leads to increased
Europe in 2011 according to in women from the UK. The sure have benign endocrine levels of potassium and water
predictions from a study pub- number of women who will tumours in their adrenal gland. in the blood, which raise the
lished in the cancer journal, die from lung cancer this year The tumours produce abnor- blood pressure. The same muta-
Annals of Oncology recently. in the UK is 15,632 (com- mally high levels of the hor- tion turns out to underlie a
The estimates, which have been pared to 14,900 in 2007); this mone aldosterone (the con- rare genetic disease character-
reached after researchers used represents a slight drop in dition is known as primary ised by a difficult-to-treat high
a new mathematical model for the death rate from 20.57 per aldosteronism), which in turn blood pressure condition. The
predicting cancer mortality for 100,000 women in 2007 to causes blood pressure to rise. discovery may help to improve
the first time in Europe, show 20.33 in 2011. In Poland, 6,343 Why the tumours arise has thus diagnostics in connection with
a fall in overall cancer death women will die from lung far been unknown. primary aldosteronism and
rates for both men and women cancer this year compared to Researchers at the Endocrine cases of severe blood pressure
when compared to 2007. But 5,643 in 2007, and this repre- Surgery Unit at the Department elevation. The mutated potas-
they also highlight some areas sents an increase in the death of Surgical Sciences at Uppsala sium channel also represents
of concern, particularly rising rate from 15.53 per 100,000 University Hospital, Sweden in a potential target molecule
rates of lung cancer in women. women to 16.60 in 2011. The collaboration with colleagues for treatment of the tumours
Researchers from the University overall downward trend in at the Yale School of Medicine, in question.
of Milan, Italy and the Centre cancer death rates is driven USA, have now identified a http://tinyurl.com/6zo42ao
Hospitalier Universitaire Vau- mainly by falls in breast cancer
dois and University of Lausanne, mortality in women, and lung
Switzerland, used data on cancer and colorectal cancer in men. Medcorp International
deaths in the European Union Declines in mortality from
for the period 1970-2007 to cal- other major cancers such as
culate rates of death each year stomach, uterus, prostate and
and to identify trends which leukaemia are likely to be seen
they used to predict death rates in 2011. A worrying increase
for 2011. They looked at over- in deaths from pancreatic can-
all rates in the EU (the EU was cer in women, which had been
defined as the 27 member states observed in 2004, appears to
as of January 2007), and also have levelled off. The research-
individual rates in six major EU ers plan to repeat the study to
countries: France, Germany, predict cancer deaths for 2012.
Italy, Poland, Spain and the UK. They believe that such predic-
They predicted there would be tions can help countries to plan
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– March/April 2011 6 emergency medicine

Interpreting ST- segment elevation in


electrocardiograms
Elevation of the ST segment of the ECG is characteristic of myocardial infarc- and ≥1mm in all other leads, irrespective of
tion but can also occur in many other conditions, often in the absence of any age and gender. So-called reciprocal changes
myocardial blood supply/demand problem. An awareness of such condi- occur when there is a deviation of the ST-
segment in any ECG lead accompanied by
tions is necessary for the appropriate management of the patient: this article
a deviation in the opposite direction in ECG
briefly reviews the characteristics of cases where ST-elevation can be seen. leads directly opposite to the first lead. The
amplitude of such reciprocal changes may
by Dr Vikas Singh and Dr Subhash Chandra not be identical as it depends on the distance
of the recording lead from the ischaemic or
infarcted area and axis of the primary lead.
The electrocardiogram is one of the most In a healthy myocardium, the ST-segment
revolutionary inventions in the history of is isoelectric. An ischaemic injury second- Elevation of the ST-segment on ECG is most
cardiophysiology, and the one for which Dr ary to a decrease in perfusion results in the commonly the result of myocardial ischae-
Willem Einthoven was awarded the Nobel progressive decrease of levels of the high- mia, infarction secondary to atherosclerotic
Prize in Medicine in 1924 [1]. Since then, the energy molecule ATP in cardiac myocytes. stenosis or occlusion of coronary arteries. In
easy availability, and the fast and inexpensive Dysfunctional ATP-dependent pumps lead current practice, almost all cases presenting
nature of the test, have made ECG a main- to loss of homeostasis and the resting mem- to the emergency department with chest pain
stay of the initial diagnostic work-up of all brane potential of the cardiac myocytes and ST-segment elevation on electrocardio-
patients presenting to the emergency depart- decreases with the shortening of the dura- gram (ECG) are assumed to be suffering
ment (ED) with signs and symptoms sugges- tion of the action potential. This creates an from atherosclerosis disease and reperfusion
tive of acute coronary syndrome (ACS), or energy gradient between the healthy and therapy is instituted. This is an acceptable
with a myriad of other cardiac conditions. ischaemic myocardium leading to a current practice considering the risk and benefits of
Abnormalities on an electrocardiogram flow which alters the morphology of the ST- management and the high mortality associ-
(ECG) can be an early manifestation of ACS. segment on the surface ECG. Such changes ated with condition. Occasionally, there are
In 2007, a new definition of MI was proposed in the ST-segment depend on the extent of patients admitted with ST-elevation who
by the joint European Society of Cardiology/ the ischaemic injury to the cardiac myocytes, do not show obliteration of coronaries on
American College of Cardiology Founda- the duration of the injury, the spatial orienta- angiography. The reported number of such
tion/American Heart Association/World tion of the particular ECG lead and the area cases is currently rising, possibly because of
Heart Federation task force who defined MI involved, which in turn depends on the site greater number of angiographic procedures
as “evidence of myocardial necrosis in a clini- of occlusion of the supplying coronary artery being carried out. Such patients either have
cal picture aligned with myocardial ischae- and the presence of collaterals. In order of transient abnormalities, coronary anomalies
mia” [2]. According to this definition, new appearance, the changes on the ECG include or absolutely normal coronaries, conditions
ST-T wave changes, a new left bundle branch a hyperacute T-wave, an ST-segment devia- which could broadly be classified (see below)
block and the development of a pathological tion, changes in the QRS complex and t-wave as either benign and not requiring any active
Q wave on ECG are considered to be evi- inversion. A deviation of the ST-segment of management or serious-to-critical where
dence of myocardial ischaemia. Such ECG more than the threshold value in more than their recognition is vital for further manage-
changes, together with the rise and/or fall two consecutive ECG leads is suggestive of ment. Table 1 summarises key ECG features
of the level of relevant cardiac markers in a myocardial ischaemia or infarction. and the management of conditions that could
patient are suggestive of MI. present with ST-segment elevation.
In 2009 the American Heart Association, the
The ST-segment correlates with the pla- American College of Cardiology, and the Benign conditions
teau phase of myocardial repolarisation. Heart Rhythm Society updated the stand- Over 90% of healthy young men have up to
ardisation and interpretation of ECG [3] 3 mm ST-elevation in one or more precor-
and in particular pointed out that threshold dial leads, more often in lead V2 [4]. In such
values for ST-segment deviation depend on instances, the ST-segment is concave [Figure 1].
age, gender and ECG leads. For example an
elevation of the J-point (the junction of QRS Normal variant or early repolarisation: In
complex and ST-segment) ≥2mm in V2 and some members of adult male black popula-
V3 and ≥1mm in other leads is the threshold tions, an ST-elevation of 1 to 4 mm is seen
in men older than 40 years, whereas in men in the mid-to-lateral precordial leads. ECG
younger than 40 years of age the threshold tracing shows a prominent J wave (notch or
is ≥2.5mm in V3 and V3. For women, the slur on the downsloping portion of the QRS
threshold ST-segment value is 1.5mm in complex), symmetric ST-elevation concord-
Figure 1. Normal ST-segment elevation in the V2 and V3, and 1mm in all the other leads. ant with the QRS complex and a large ampli-
precordial leads, most prominent in leads V2 The threshold value for abnormal J-point tude positive T wave. Reciprocal changes may
and V3, with concavity upwards.
depression is ≥0.5mm in leads V2 and V3, be present[5].
7 – March/April 2011

Precordial lead: Misplacement of precor- Conditions Characteristics for diagnosis Initial management/ management over view
dial leads (either too high or too low) can Acute myocardial infarction New ST-elevation of ≥2mV in men and ≥1.5mV in STEMI pager activation,
cause significant ST-T deviation [6]. A lead women at the J point in two contiguous leads,
Elevated segment has a plateau or shoulder or upsloping,
Immediate thrombolysis or percutaneous coronary
intervention
positioned even 2 cm too high can produce Reciprocal changes seen,
ST-elevation is usually limited one coronary artery
an ECG that mimics an anterior infarction. supplied area.
Lead misplacement should be suspected
Normal ST-elevation The ST-segment is concave,
from inverted P waves in V1, V2 and V3. Limited to one or more precordial leads, more often in
lead V2.

Transthoracic cardioversion: Transient post- Normal variant or Early


Repolarization
Prominent J wave (notch or slur on the downsloping
portion of the QRS complex),
shock ST-segment elevation without any Symmetric ST-elevation concordant with QRS complex,
A large amplitude positive T waves, These are benign conditions and do not require treatment
rise in the serum level of cardiac biomar- Reciprocal changes in aVR, for the ST-elevation per se.
kers has been reported in up to 19% of More common in young athlete black population.

patients who received transthoracic shocks Precordial Lead Mispla-


cement
Mimics an anterior infarction,
Associated with inverted P waves in V1, V2 and V3
[7, 8]; no evidence of cardiac damage has
Transthoracic Cardioversion Transient, last only couple of minutes,
been found in such patients [9]. Immediately after cardioversion.

Primary Anomalies of the ST-elevation on ECG do not match the infarct related “Do not bother to look for these innocent anomalies, but be
Serious-to-critical conditions Coronary Arteries
• Ostial stenosis or atresia,
artery or has a missing artery on angiography prepared to recognize them as benign if one is accidentally
found, typically at coronary angiography”
1. Haemodynamically significant • Fistula, - Dr. Paolo Angelini14
• Origin of the LCA from the
primary anomalies of the coronaries pulmonary artery,
Several conditions can produce myocar- • A coronary artery from
the opposite sinus with
dial ischaemia/infarction: ostial stenosis or intramural course

atresia, coronary artery fistula, anomalous Myocardial Bridging Presentation is similar to AMI, First line of management - negative inotropic and chrono-
origin of the left coronary artery from the In most cases, ST-segment changes limited to LAD tropic agents,
distribution Antiplatelet agents for risk prevention,
pulmonary artery, a coronary artery from Q wave might present suggesting old infarctions. Stents, minimally invasive coronary artery bypass grafting or
surgical myotomy for refractory cases.
the opposite sinus (ACAOS) with intramu-
ral course, and myocardial bridging [10]. Transient Coronary Presentation is similar to AMI, Risk of recurrent MI and death is comparable with
Of these a pre-capillary fistula connecting Abnormalities
In-situ thrombosis or emboli-
History of hypercoagulable stage/ smoking significant coronary stenosis. Hence, should manage inline
with CAD.
a major coronary artery with the cardiac zation with subsequent clot
lysis and recanalization
chamber or superior vena cava is the most
Coronary Artery Spasm or Severe chest pain, which usually comes without physical Nitrates and calcium channel blockers,
common implying in most the existence of Variant Angina effort Long term supplement of Mg and statins are proven
a left-to-right shunt [10]. An ACAOS is usu- Transient ST-elevation in absence of raise in serum
cardiac biomarker levels
protective,
Refractory cases may need stent placement and defibrillator
ally asymptomatic or present with atypical implantation for arrhythmic complications.

chest-pain but some patients die at a young Systemic inflammatory condi- Known history Trial of immunosuppressive drugs is helpful in resolving acute
age after extreme exertion [11]. An anoma- tions (SLE, RA, Wegener’s AMI as a first manifestation of these conditions too has ischemic event.
Granulomatosis etc. been reported Overall risk of AMI in future remains high
lous origin of the left coronary artery (LCA)
from the pulmonary artery always results in Conduction Abnormalities ST- elevation of ≥1 mm which is concordant with the QRS In absence of clinically significant cardiac disease, isolated
LBBB complex (score 5); ST-depression of ≥1mm in lead V1, LBBB does not decrease overall survival but increases the
myocardial ischaemia. V2, or V3 (score 5); and ST-segment elevation of ≥5 mm prevalence of cardiovascular disease
that is discordant with the QRS complex

Myocardial bridging (MB) is described as Wolf Parkinson White Transient ST-elevation in leads V1-V6, With symptomatic arrhythmias - radiofrequency ablation.
(WPW) syndrome Q wave-T wave vector discordance. Choice of antiarrhythmics depends on type of arrhythmia.
systolic narrowing of a coronary artery and
Acute Pericarditis ST-elevation is concave upwards and diffuse covering Management of pericarditis is based on suspected etiology
is observed in at least one angiographic more than one coronary artery supplied region and
projection [12], with the degree of coro- PR segment depression

nary artery compression by the myocardial Myocarditis ST-elevation is not limited to one coronary artery supplied
area and Disproportionate elevation in serum cardiac
Differentiation from AMI is very crucial since use of
thrombolytics and anticoagulants are very detrimental in
bridge depending on the precise location of markers compared to ST-elevation myocarditis.
MRI detects the myocardial edema and the myocyte Initial management of myocarditis is supportive focusing
the artery, the thickness and length of the damage. on hemodynamic stability.
muscle bridge and the degree of cardiac con- Hyperkalemia ECG changes are progressive. Potentially life threatening medical emergency and needs
tractility. It is commonly seen in the middle ST-elevation reversible correction of hyperkalemia immediate correction of extra potassium level by albuterol,
Tall, peaked and tented T wave as an initial findings. insulin, and cation exchange resin
to distal part of the left anterior descending
Brugada Syndrome The ST-elevation is primarily seen in leads V1 and V2, Amiodarone is most commonly used antiarrhythmic but
(LAD) artery [13]. Although by itself, this ST segment begins from the top of R’ wave, is downs- only implantable cardioverter-defibrillator is successful in
does not usually cause significant haemody- loping, and ends with inverted T wave preventing sudden deaths.

namic compromise to the myocardium, rare Pulmonary Embolism ST-elevation was limited to V1-V3
Clinical history and use of cardiac ultrasound are helpful
Early thrombolysis is life potentially saving.

incidents of myocardial ischaemia have been in differentiation of these subjects from true AMI

reported in stress testing[14]. Head Injury and Intracranial Can mimic AMI on ECG, echocardiographic and Before starting thrombolytics for AMI, intracranial hemor-
hemorrhage cardiac biomarker level rhage should be ruled out cautiously.

2. Transient coronary abnormalities Takotsubo Cardiomyopathy ST-elevation associated with prolonged QT interval and
deep precordial or global T-wave inversion on serial
In case of suspicion, case should be managed like AMI
and once the diagnosis of TC is established, management
In situ thrombosis or embolisation with sub- ECGs. is mainly supportive.
Minimal elevation of cardiac biomarkers despite of large
sequent clot lysis and recanalisation. area of akinesis/dyskinesis seen on echocardiography.
In situ thrombus formation in normal coro- Scorpion Envenomation ST segment elevation mimics AMI Prazosin to combat the autonomic storm.
naries is associated with hypercoagulability Syndrome Presents with history of scorpion bite, vomiting, sever pain
at bite site and profuse sweating.
(Factor V Leiden), the use of oral contra-
Ventricular Aneurysm Persistent ST segment elevation and pathologic Q wave, Medical management of complications and surgical
ceptives or oestrogen replacement therapy, Usually limited to leads I, aVl, and V1 through V6 due to correction of aneurysm
the common location of aneurysm.
cigarette smoking and excess of levels of
lipoprotein(a) and type-1 plasminogen Table 1. Key ECG features and management of conditions that could present with ST-segment elevation.
– March/April 2011 8 emergency medicine

activator inhibitor. The risk vasospasm, which is associated


of recurrent MI and death is with transient ST-segment
comparable to that of patients elevation in the absence of
with significant coronary ste- an increase in serum cardiac
nosis [15]. Embolisation of biomarker levels.
the coronaries is theoretically
possible and more common Endothelial dysfunction
in the left coronary due to the Detected by an impairment of
preferential flow. the acetylcholine-induced vaso-
constrictor response, endothe-
Coronary Artery Spasm (CAS) lial dysfunction of the epicar-
or “variant angina” is a tem- dial coronary arteries has been
porary increase in coronary advanced as an independent
vascular tone (vasospasm) of AMI mechanism with normal
an epicardial artery, causing a coronaries and without appar-
marked but transient reduc- ent arterial spasm [18]. The Figure 2. ST and T wave changes on serial ECG in Takotsubo Cardiomyopathy.
tion in the luminal diameter. altered local milieu of various
Sometimes thought to be sec- vasoactive entities secondary common conduction abnor- 4. Acute pericarditis and
ondary to endothelial dys- to the dysfunction is believed malities where ST-segment myocarditis
function, this coronary vasos- to promote occlusion in the elevation does not always indi- In acute pericarditis, the ST-
pastic state is usually focal and absence of any underlying sten- cate myocardial infarction. segment elevation is diffuse,
can occur in either a normal otic lesion [18]. The prognosis In a left bundle branch block concave upwards and associ-
or diseased vessel [16]. CAS in these groups of patients is (LBBB) an abnormal ven- ated with PR segment depres-
is associated with cigarette variable but in general better tricular depolarisation leads sion although this is not specific
smoking, marijuana smoking, than those with atherosclerotic to secondary alteration in the to pericarditis. The ratio of the
alcohol intake, butane inha- MI [19]. recovery process. This appears amplitude of the onset of the
lation, cocaine abuse, pseu- on the ECG as repolarisa- ST-segment to the amplitude of
doephedrine, calcium channel 3. Conduction abnormalities tion changes in a direction the T wave in lead V6 has been
blockers withdrawal etc. [17]. The left bundle branch block opposite to that of the main put forward as being the most
Early atherosclerotic lesions (LBBB) and Wolf Parkinson QRS-deflection (the so-called reliable discriminator between
can predispose coronaries for White (WPW) syndrome are “appropriate discordance” pericarditis and normal [23].
between the QRS complex and The ST-segment elevation in
the ST-segment) and produces both pericarditis and myocar-
a predominantly negative QRS ditis is not limited to any area
complex with ST-segment supplied by a particular coro-
elevation and positive T waves nary artery; there is a dispro-
(an appearance similar to that portionate elevation in the level
Summer Conference of anterior AMI). Sgarbossa of serum cardiac markers.
criteria are widely accepted for
the differentiation of an ST- 5. Hyperkalaemia
23-25 June 2011 segment elevation of ≥1mm ECG changes in hyperkalae-
which is concordant with the mia are progressive: the earli-
Turin, Italy
QRS complex (score 5); an ST- est changes are tall, symmetri-
segment depression of ≥1mm cally peaked, and tented T
in lead V1, V2, or V3 (score 5); waves, followed by a decrease
Mechanical Ventilation and an ST-segment elevation in amplitude of the P wave and
An Update of ≥5 mm that is discordant
with the QRS complex (score
a widening of the QRS as the
serum concentration of potas-
2) [20]. sium increases. Even though
ST-segment elevation is not
Although ST-segment eleva- common, a few case reports
tion is rare in WPW syndrome, have been published where
transient ST-elevation has also the ST-segment has closely
been described in leads V1-V6 mimicked AMI [24]. The tall T
Join us ! [21]. In the majority (up to waves of hyperacute ischaemic
94%) of such cases, a charac- changes are usually associated
Endorsed by For more information contact teristic “Q wave-T wave vector with a long QT interval, and
European Society of Intensive Care Medicine
Rue Belliard 19 discordance” is present where the T waves are broad rather
1040 Brussels, Belgium positive or iso-electric T waves than narrow.
Tel: +32 2 559 03 71
Fax: +32 2 559 03 79 are seen with the inferior lead
Email: Turin2011@esicm.org Q waves, in contrast to the T 6. Brugada syndrome
Internet: www.esicm.org
wave inversion expected in This is an inherited cardiac dis-
cases of ischaemic injury [22]. ease causing life-threatening
9 – March/April 2011

ventricular tachyarrhythmias but ST-elevation is also seen 85: 878. 1982;65: 1004.
in individuals with structurally in inferior leads in cases of  ikenes K et al. Am Heart J
9. V 24. S ims DB et al. Circulation
normal hearts and character- inferior wall aneurysm. The 2000;140: 690. 2005;111: e295.
istic ECGs. The ST- segment morphology of ST-elevation is 10. L evin DC et al. Circulation 25. O zeke O et al. Mount Sinai J of
elevation is primarily seen in variable, and ranges from min- 1978;58: 25. Medicine 2006;73: 627.
leads V1 and V2 and can have a imally elevated and concave 11. Angelini P. Circulation 2007;115: 26. Kawasaki T et al. Circulation J
“saddle back” shape, but in typi- to the ominously significant 1296. 2002;66: 567.
cal cases the ST segment begins convex elevation [28]. Another 12. Bourassa MG et al. J of the Am Col- 27. Wittstein IS et al. N Engl J Med
from the top of the R’ wave, is associated ECG finding seen in lege of Cardiology 2003;41: 351. 2005;352: 539.
downsloping, and ends with an such cases is the loss of R wave 13. C ay S et al. Anadolu Kardiyol 28. E ngel J et al. The Am J of Emer-
inverted T wave. This pattern is deflection in precordial leads. Derg 2006;6: 9. gency Medicine 2002;20: 238.
so distinctive that it should not 14. Soran O et al. Tokai J of Experi- 29. L in JF et al. Circ J 2009;73: 1157.
be mistaken for an acute antero- Other rare occurrences mental & Clinical Medicine 34. Korkmaz C et al. Lupus 2007;16: 289.
septal MI complicated with Very occasionally, ST-segment 2000;25: 57.
RBBB where the down stroke elevation can be seen in patients 15. Kereiakes DJ et al. J of the Am Col- The authors
of the R’ wave and ST segment with massive pulmonary embo- lege of Cardiology 1991;17: 304. Vikas Singh1, Subhash
have a distinct transition [25]. lism and scorpion envenoma- 16. G insburg R et al. Western J of Chandra2*
tion syndrome, and vasculitis Medicine 1982;136: 398. 1
Department of Medicine, Uni.
7. Neurological conditions (systematic lupus erythemato- 17. El Menyar AA. J of Postgrad Med of Pittsburgh Medical Center,
The incidence of ST-segment sus, Wegener’s granulomatosis 2006;52: 51. Pittsburgh, PA, USA.
elevations in cases of subarach- and rheumatoid arthritis) [29], 18. Sztajzel J et al. Postgraduate Medi- 2
Department of Emergency
noid haemorrhage (SAH) has [34]. Due to their rarity, there cal J 2000;76: 16. Medicine, Mayo Clinic, Roches-
been reported as 7.5% to 31% is no consensus on the charac- 19. R aymond R et al. J Am Coll Cardi- ter, MN-55902, USA
[26]. A putative explanation is teristic morphology of ST-seg- ology l1988;11: 471.
that the altered autonomic tone ment elevation in such cases. 20. Sgarbossa EB et al. [erratum appears in *Corresponding author:
affects the duration of ventricu- N Engl J Med 1996 Apr 4;334(14):931]. Subhash Chandra
lar repolarisation, and so pro- Conclusion N Engl J Med l1996;334: 481. Dept of Emergency Medicine,
duces the changes which are All of the conditions described 21. Guler N et al. Angiology 2001;52: 293. Mayo Clinic, Rochester,
not found to be associated with in the current clinical review can 22. K han IA et al. Am J of Emergency MN-55902, USA
myocardial injury or increased electrocardiographically mimic Medicine 2000;18: 807. Tel. +1-507-293-0794
mortality risk [9]. ST elevation MI in one way or 23. G inzton LE et al. Circulation e-mail: chandra.subhash@mayo.edu
another, and frequently do so in
8. Transient Left Ventricular the absence of any myocardial
Apical Ballooning syndrome demand-supply abnormality.
or Takotsubo Cardiomyopa- An awareness of all these con- The complete Oral Care
thy (TC) ditions and their characteristic programme for ICU
TC is characterised by transient features is vital for appropriate A range of toothbrushes and mouthwash targeting
wall-motion abnormalities patient management. Though the prevention of Ventilator Associated Pneumonia
involving the left ventricular occasionally it can be extremely
apex and the mid-ventricle in difficult to distinguish some of
the absence of obstructive epi- these conditions from others,
cardial coronary artery disease. it is hoped that a brief review
ST-segment elevation has been of the pathologies as presented
reported in up to 11% of TC here should be helpful to
patients [27], [ Figure 2]. The internists and emergency medi-
unique pattern of left ventricu- cine physicians.
lar dysfunction is characterised
by apical and mid-ventricular References
contractile abnormalities with 1. Cooper JK. N Engl J Med
sparing of the basal segments. 1986;315: 461.
The minimal elevation of car- 2. Thygesen K et al. Circulation
diac enzymes despite large 2007;116: 2634.
focal akinesis is suggestive of 3. Wagner GS et al. Circulation
TC [27]. 2009;119: e262.
4. Surawicz B et al. J of the American We’re at ISICEM in Brussels
9. Ventricular aneurysm College of Cardiology 2002;40: 1870. Come and visit us (Stand 2.53 & 2.54) and receive a free sample
March 22nd - 25th, 2011
This produces persistent ST- 5. K latsky AL et al. The Am J of Medi-
segment elevation and patho- cine 2003;115: 171. For more information including a ‘how to’ video visit
www.intersurgical.com/oralcare
logic Q waves. In these cases 6. Marafioti V et al. Am J of Emer-
ST-elevation is usually limited gency Medicine 2004;22: 62.
to leads I, aVl, and V1 to V6 7. Van Gelder IC et al. Am Heart J
Quality, innovation and choice
due to the most common loca- 1991;121: 51.
tion of the aneurysm formation, 8. Kok LC et al. Am J of Cardiology
www.ihe-online.com & search 45788
– March/April 2011 10 EMERGency medicine

Psychological support improves outcomes


of critically ill patients
Because of the hormonal, inflammatory and neuroendocrine responses they Relaxation response versus stress
elicit, stress and negative emotions are potent pathogenetic factors in criti- response in critical illness
cal illness and are linked to increased morbidity and mortality. Research A large body of evidence suggests that stress
and molecules, such as neuropeptides and
evidence shows that psychological support intervention, including guided
cytokines involved in stress, may contribute
relaxation and imagery techniques, can result in significant improvements to the pathophysiology prevalent in critical
in patient outcomes, vital signs and decrease pain, anxiety, complications illness, including systemic inflammation
and length of stay. Therefore, support interventions in critical care need to [4], cellular stress and oxidative damage
be investigated and in future should be vigorously implemented. [5], endothelial dysfunction and coagulopa-
thies [6], which account for high mortality
by Dr Elizabeth D.E. Papathanassoglou and morbidity. On the other hand, positive
affective states, such as hope and relaxation
may reverse these adverse consequences
Critically ill individuals suffer high levels factor in disease, the potential organismic [7]. The relaxation response may be viewed
of stress and intense adverse emotions, effects of stress and the means to alleviate as the opposite of the stress response. It is
ranging from fear, anxiety, agony, lone- them have not received enough attention an integrated psycho-physiological reac-
liness, depersonalisation, hopelessness, in critical care. tion, primarily elicited by hypothalamic and
bewilderment and acute confusion, to ter- limbic system sites [8], and mediated by the
ror attacks and panic [1]. With its ensuing Evidence on the effect of mind-body vagus nerve and cholinergic neurotransmis-
progressive organ dysfunction that may interventions, together with the often sion. It leads to reduction of sympathetic
lead to sepsis and vital organ failure, criti- expressed need of families and patients activity, thus reversing the effects of stress
cal illness is itself a state of uncompensated for psychological support intervention, on the body, including counterbalancing of
stress with physiological and psychologi- have fuelled new interest for the explo- negative emotions, and decreased oxygen
cal correlates. Although through use of ration of the effects of stress in critical consumption, blood pressure, heart rate and
sophisticated life support technology we illness [3]. This paper aims to present rate of respiration [9,10]. Even more impor-
can sustain vital functions, there is almost research evidence on the effects of psy- tantly, recent evidence shows that relaxation
nothing we can do to counteract the chological support, including guided may interrupt the inflammatory vicious cir-
effects of stress on the cell. Stress is a key imagery and relaxation, on the psycho- cle of critical illness. Activity of the vagus
factor in critical illness, since it may be the logical and physiological outcomes of nerve, such as is involved in relaxation, may
cellular response to stress that shapes the intensive care patients. A narrative criti- prevent tissue injury and death in animal
trajectory of disease and may lead to the cal review methodology of published models of sepsis, ischaemia/reperfusion
development of one of the most fatal syn- studies involving adult intensive care and haemorrhagic shock [11,12]. Moreover,
dromes, the multiple organ dysfunction patients was used. Databases searched pharmacologic cholinesterase inhibition,
syndrome (MODS) [2]. Although psycho- included Medline, CINAHL, PubMed, which accentuates vagus neurotransmis-
logical stress has long been recognised as a PsychInfo and the Cochrane Library. sion, increases survival in mice with severe
11 – March/April 2011

sepsis [13], and activation of the cholinergic lack of random assignment in the study. Two studies explored the impact of relax-
anti-inflammatory pathway protects against In another small experimental study, 25 ation on sleep quality. Richardson showed
toxin-induced organ failure [14]. Activity of cardiac surgery patients were randomised that autogenic relaxation combined with
the vagus nerve may be stimulated via bed- to either foot massage or relaxation or to imagery improved patients’ sleep [23].
side techniques such as relaxation, imagery a control group [22]. Only a non-signif- Remarkably, men responded immediately,
and biofeedback. A recent critical review icant trend for decreased anxiety in the while in women the improvement was
documented an association between guided relaxation group was observed. delayed. This may suggest that gender, as
imagery/relaxation and the functioning
of the immune system [15]. Relaxation Authors/ Type of Study Patients Main Physiological
has been reported to elicit specific gene- year -Main Intervention outcomes
expression changes [16]. It may therefore Relaxation Techniques
be appropriate and timely to overcome per- 1. Guzzetta, Randomized controlled trial- 80 coronary care patients Lowered heart rate, lowered
spective and culture barriers and examine 1989 Guided relaxation & music randomized into two intervention temperature and decreased cardiac
such interventions more actively. therapy and one control group complications in both relaxation and
music therapy groups. Increased
patient satisfaction with intervention.
Effectiveness of psychological sup- 2. Miller & Perry, Pre- & post-test quasi-experi- Convenience sample of 29 Lowered blood pressure, heart rate,
port interventions in critical illness 1990 mental study-Deep-breathing cardiac surgery patients respiratory rate and pain
In critical care, supportive clinician-patient relaxation technique

relationships are deemed very important 3. Hattan et al., Pre- & post-test experimental 25 cardiac surgery patients No significant differences between
2002 study -Guided relaxation or randomized to either one of physiological parameters. A trend
[17]. Research has identified specific sup- foot massage two intervention groups or to a for higher levels of calm in the
portive interventions, such as the providing control group relaxation group.
of explanations, giving advice, reassuring 4. Richards, Experimental design- 6-mi- 69 older ICU patients with a Significant improvement of sleep
and raising faith and hope, cheering-up, 1998 nute back massage or cardiovascular illness quality measured by polysomnogra-
relaxation audiotape phy between the back-massage and
strengthening patients’ self- esteem, giv- control group
ing emotional warmth, offering empathetic 5. Richardson, Experimental design-Relaxa- 38 critically ill randomized into Improved subjective quality of sleep
listening, presence, emotional care, speak- 2003 tion and imagery two groups to determine the ef-
ing calmly, empathetic touch and spending fects of relaxation and imagery
on sleep
extra time with patients [18]. Imagery and
6. Friesner et al., Pre- & post-test quasi-expe- 40 CABG patients during chest Decreased pain ratings immediately
relaxation may be viewed as a means of psy- 2006 rimental study- Slow deep- tube removal after and 15 minutes post chest tube
chological support since they encompass breathing relaxation removal
supportive nurse-patient interactions, and 7. Houston & Quasi-experimental study- 24 CABG patients during chest No significant decrease in pain
they may raise hope and positive emotions. Jesurum, Quick relaxation tube removal ratings immediately after and 30
1999 minutes post chest tube removal.
Trend for decreased pain in older
Relaxation studies male patients, and for increased
pain in older female patients.
The evidence provided by relaxation and
guided imagery studies is quite compelling. Imagery Techniques
Overall, in all intervention studies involv- 8. Tusek et al., Randomized controlled trial- 65 cardiac surgery patients Decreased pain & length of stay
1999 Guided imagery randomized into one interven-
ing approximately 15 or more patients per tion and one control group
group, significant improvements in physi-
9. Deisch et al., Quasi-experimental Convenience sample of 100 Reduced pain, fatigue, narcotic
ological and psychological measurements 2000 prospective study -Guided Cardiac surgery patients use and decreased length of stay
were observed [Table 1]. imagery
10. Halpin et Retrospective review of pa- 134 non-randomized critically Decreased length of stay
al., 2002 tient data- Guided Imagery ill patients having participated Decrease in required pain medica-
In an early experimental study with acute with music in guided imagery compared tion not statistically significant.
myocardial infarction patients, Guzzetta to 655 normal care patients.
[19] showed that there were improved vital Interaction With Health Care Professionals
signs and a lower rate of complications in 11. Hwang et Prospective randomized Convenience sample of 60 Increased peripheral temperature,
patients randomised to a relaxation inter- al., 1998 study- Tape-recorded mes- post-operative cardiac surgery decreased pain, tension, anxiety
vention based on Benson’s method [20], sage from physician patients and depression. Patient expressed
a high need for this support
compared to a standard care group. Notably, program.
despite the short relaxation training, cumu- 12. Bergmann et Prospective randomized Convenience sample of 60 No effects on the perioperative
lative effects over time were seen, which may al., 2001 study- Preoperative exten- patients undergoing cardiac psychoendocrinologic course of
imply that the relaxation response persists, sive information & personal surgery stress (plasma & salivary cortisol
attention from surgeon and anxiety reports).
and/or that, with practice, patients become
13. H
 enneman, Prospective randomized 24 mechanically ventilated No differences in heart rate, arte-
more proficient in eliciting the response. 1989 study- Touch and verbal patients randomized to one rial pressure, and respiratory rate
interaction intervention and one control
group
Miller and Perry [21] tested the effects of
a relaxation technique based on slow deep Long-term effects of psychosocial support
breathing on the postoperative pain of 15 14. Deja et al., Prospective correlational 65 ARDS survivors Perceived social support was
2006 study to explore the effect associated with a reduction in
coronary artery by-pass graft (CABG) of recalled social support PTSD symptoms and improved
patients. Significant decreases were demon- while in the ICU health-related quality of life.
strated in blood pressure, heart rate, respi-
ratory rate and pain ratings. Nonetheless, Table 1. Psychosocial intervention studies in intensive care (ARDS: adult respiratory distress syndrome;
the validity of these results is limited by the CABG: coronary artery by-pass graft; PTSD: post-traumatic stress disorder).
EMERGency medicine 13 – March/April 2011

well as time, must be taken into consid- 2. P apathanassoglou E et al. Nursing in Critical
eration in relaxation studies. Richards Care 2009;15:204.
also explored support interventions for 3. M ellott KG et al. J of Holistic Nursing 2008;
the improvement of sleep and found no 26:128.
significant effects [24]. 4. Elenkov IJ et al. Pharmacological Reviews 2000;
52:595.
In two quasi-experimental studies the 5. S obocanec S et al. Physiological Research 2005;
effect of relaxation on pain as an adjunct 54:97.
to opioid therapy was tested during chest 6. N emccsik J et al. Eur J of Pharmacology 2004;
tube removal in coronary artery by-pass 498:195.
graft (CABG) patients. Friesner et al 7. G itto E et al. Pediatric Research 2001; 50:756.
reported that slow deep-breathing relaxa- 8. Jacobs GD. J of Alternative and Complementary
tion accounted for significantly decreased Medicine 2001;7 Suppl 1:S83.
pain ratings [25]. However an earlier study 9. F riesner SA et al. C. Heart Lung 2006; 35:269.
showed no significant effect of a quick 10. M  andle CL et al. J of Cardiovascular Nursing
relaxation technique on pain during chest 1996; 10(3):4.
tube removal [26]. 11. O  ke SL et al. J of Leukocyte Biology 2007;
83:512.
Guided imagery studies 12. H  uston JM et al. Critical Care Medicine 2007;
Three studies have been carried out on the 35:2762.
effects of guided imagery in ICU patients. 13. H  ofer S et al. Critical Care Medicine 2008; 36:
Tusek et al. showed that pain ratings and 404.
length of stay decreased in cardiac patients 14. M  abley JG et al. Molecular Medicine 2009 Feb
randomised to a guided imagery interven- 11.
It has been shown that pain ratings and length
tion administered via an audio tape [27]. of hospital stay are decreased in cardiac 15. T  rakhtenberg EC. Int J of Neuroscience 2008;
Deisch et al. replicated Tusek’s study with patients who received guided imagery interven- 118:839.
100 patients undergoing CABG and found tion administered via an audio tape [27]. 16. D  usek JA et al. PLoS ONE 2008; 3:e2576.
reduced pain, anxiety, fatigue, narcotic usage 17. W  ilkin K et al. J of Clinical Nursing 2004;13:50.
and length of stay and increased patient sat- pressure; however, the power of this study 18. F  razier SK et al. Am J of Critical Care 2003;
isfaction in the experimental group [28]. was limited due to the small sample size. 12:19.
19. Guzzetta CE. Heart Lung 1989;18:609.
A retrospective data review of 134 patients Social support studies 20. B  agheri-Nesami M et al. Int J of Nursing Prac-
one year after the implementation of guided At a prospective correlational study on the tice 2006; 12:214.
imagery found that length of stay was influence of perceived social support dur- 21. M  iller KM, Perry PA. Heart Lung 1990; 19:136.
shorter, pharmacy and pain medication ing ICU treatment on the quality of life 22. H  attan J et al. J of Advanced Nursing 2002;
costs were decreased, while high overall in 65 survivors of acute respiratory dis- 37:199.
patient satisfaction was maintained [29]. tress syndrome (ARDS), it was found that 23. R  ichardson S. Dimensions of Critical Care
increased perceived social support was Nursing 2003; 22:182.
Clinician-patient interaction studies associated with a reduction in symptoms 24. R  ichards KC. Am J of Critical Care 1998;7:288.
In an experimental study involving cardiac of post traumatic stress disorder [33]. The 25. F  riesner SA et al. Heart Lung 2006; 35:269.
surgery patients [30], the mere fact of listen- authors concluded that social support from 26. H  ouston S et al. Applied Nursing Research
ing to a physician’s tape-recorded message family members might improve coping in 1999;12:196.
providing information and emotional sup- critically ill individuals. 27. Tusek DL et al. J of Cardiovascular Management
port was found to give rise to effects similar 1999; 10:22.
to those of Guzzetta [19] in terms of periph- Conclusion 28. Deisch P et al. Nursing Clinics of North Amer-
eral vasodilation — but not of heart rate — Although the literature describing the effects ica 2000; 35:417.
as well as a decrease in pain, tension, anxi- of supportive psychological support interac- 29. H  alpin LS et al. Outcomes Management 2000;
ety and depression. In a subsequent study of tion on the outcomes of critically ill patients 6:132.
cardiac surgery patients, no effect on patient is limited, there is evidence that imagery 30. H  wang SL et al. J of the Formosan Medical
stress of preoperative oral information com- and relaxation techniques, as well as psy- Association 1998; 97:191.
bined with more personal attention by the chosocial support in the ICU, are linked to 31. B  ergmann P et al. Anesthesia & Analgesia 2001;
surgeon was observed [31]. improved short- and long-term patient out- 93:1093.
comes. More research is needed to evaluate 32. Henneman EA. Heart Lung 1989;18:483.
Henneman carried out a prospective ran- the effect of planned emotional support by 33. Deja M et al. Critical Care 2006;10:R147
domised study to determine the effect nurses on patient outcomes, both through
of direct nursing contact on the stress of randomised and interpretively designed The author
patients being weaned from mechanical clinical trials. Issues of gender, diagnoses, as Elizabeth D.E. Papathanassoglou, PhD,
ventilation [32]. Twenty-six patients were well as the effect of time on outcomes should MSc, RN
randomly assigned either to an experimental be taken into account in such trials. Associate Professor
group involving touch and verbal interaction Intensive Care Nursing
during the weaning, or to a control group. References Cyprus University of Technology
No significant differences were observed in  usk B et al. Dimensions of Critical Care Nursing
1. L Limassol, Cyprus
heart rate, respiratory rate and mean arterial 2005; 24:25. e-mail: e.papathanassoglou@cut.ac.cy
– March/April 2011 14 Technology Watch

Contact-free patient supervision system


detects hospitalised patient deterioration
Critical events such as cardiopulmonary and respiratory events are estimated to unequal sections in each single respiration
occur in 4% to 17% of in-patient admissions. A significant number of these events cycle), patients who are likely to deterio-
are preceded by warning signs. Based on a non-contact piezoelectric sensor rate are effectively identified. A risk factor
of 12.2 was shown for major patient dete-
placed underneath the patient’s mattress, an innovative system, the EverOn, meas-
riorations, i.e. there was a dramatic 12.2
ures respiration and heart rates as well as bed movements. The system provides times greater chance of a major deteriora-
clinicians with a valuable tool for timely recognition of vital sign deterioration. tion in patients where the system alerted
versus patients where it didn’t.

station allow easy integration with the Improved outcomes and


current nurse work flows. reduced costs
The system provides continuous surveil- The EverOn Patient Monitoring System was
lance of several parameters, including evaluated by a team of clinicians at a com-
heart rate, respiratory rate and movement munity hospital in California, USA. The
rate of the patients. Alerts are given if hospital selected a 33-bed, medical-surgical
any of the parameters exceed predefined unit for the study, and included general
thresholds set by the clinicians. A bed medical, trauma and post-surgical patients.
exit alert is provided for high risk patients To establish a control level, patients’ out-
such as those at risk of a fall. The system come variables including patients’ length
also includes a display that alerts medi- of stay, total ICU days, number of falls and
The EverOn system: sensor and bedside monitor.
cal staff regarding a patient’s motion level in-hospital-developed pressure ulcers were
A significant number of avoidable adverse and verifies patient turns as indicated by reviewed for six months. EverOn was then
and sentinel events occur on the general nurses, helping to prevent the develop- introduced to the same unit and was used
care floor, where nurse-to-patient ratios ment of pressure ulcers. The Central Dis- to monitor every patient admitted for the
often prevent continuous direct patient play Station displays live updates from up subsequent six months. The study evalu-
observation. Numerous studies have to 36 bedside monitors on large screens ated patient outcomes before and after
shown that many of the patients that suf- placed at the nurse station and the unit introduction of the system.
fer serious deterioration in their condition walls so clinicians can see updates in real
or sudden death have preceding predictive time as they walk by the displays. In addi- Overall positive nursing satisfaction
events. Thus, monitoring of vital signs may tion, alerts can be transferred to nurses’ results were associated with acceptable
improve prediction of deterioration as well mobile phones or pagers. level of alert frequency and overall ease of
as improve patient outcome. use with the system. The decrease in the
Multi-centre study average length of stay in the hospital and
Designed specifically to address patient A multi-centre study was conducted at the total “higher level of care days” had a
care, safety and quality issues in the envi- several hospitals in the US and Israel to positive impact on the cost of patient care.
ronment of the medical-surgical unit, the evaluate the correlation between the dif- Particularly significant was the decrease
EverOn Bed-side units and Central Dis- ferent parameters measured by the EverOn in the development of pressure ulcers, a
play Station (CDS) enable continuous system and the detection of patient dete- preventable hospital complication. The
supervision of patients where nurse-to- rioration in hospitals. More than 200 incidence of falls also trended downward,
patient ratios prevent continuous patient patients were monitored on the medical/ but did not reach statistical significance.
observations. The system also transfers surgical floors of three medical centres Actionable alerts at the bedside led nurses
alerts directly to the nurse’s cell phone or with the EverOn system. The results show to take immediate clinical actions for
pager. Setup is rapid and flexible. All mon- that by combining the measurements of dangerous conditions that would have
itoring is performed without direct con- respiratory rate, heart rate and a new res- otherwise have gone unnoticed.
tact between the patient and the device, piratory pattern alert called Double Respi-
using a sensor that is placed under the ration Pattern (DRP, characterised by two In conclusion, the implementation of
mattress. Staff can easily adjust thresholds EverOn on a Medical/Surgical unit
for alerts utilising the user-friendly touch resulted in measurable improvements in
screen. The system produces a low rate patient care and safety, nursing accept-
of false alerts, and parameters and alerts ance and reduced costs. The system is
can be easily customised per patient. The currently installed at several medical cen-
information stored in the display unit can tres in the USA and Europe.
be accessed at any time and reports can
be printed for off-line documentation and EarlySense
review. The flexibility and user-friendli- Ramat-Gan, Israel
ness of the system and its Central Display Central display station at nurse’s station. www.ihe-online.com & search 45794
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– March/April 2011 16 cover story

Molecular imaging with ultrasound:


a burgeoning technology for
inflammation assessment
Ultrasound is a favoured clinical imaging modality due to its convenience, Targeted contrast agents
low cost, high frame-rate capability, and safety. Although traditional ultra- Contrast agents being studied for ultra-
sound is primarily an anatomical imaging modality, recent studies have sonic molecular imaging applications
include emulsion nanoparticles, echogenic
demonstrated the potential for ultrasound as a molecular imaging technique
liposomes and microbubbles [1, 4]. How-
through the use of intravascular contrast agents targeted to specific cell ever, microbubbles are the most common
receptors of disease. agent used in this imaging modality due
to their high echogenicity and their non-
by Dr Jason E. Streeter and Dr Paul A. Dayton linear response to ultrasonic stimuli [1, 5].
Targeted microbubble contrast agents are
similar to microbubbles used for perfusion
Medical ultrasound has long been used in pathologic tissue that might otherwise be imaging contrast agents in that they are
clinical applications both as a primary modal- difficult to distinguish from normal tis- composed of a gas core and are usually sta-
ity and as a supplement to other diagnostic sues. Since ultrasonic molecular imaging bilised by a lipid, protein or polymer shell
procedures. The basis for ultrasound imag- has the potential to provide information [4]. The lining of the gas core is usually of
ing is the transmission of high frequency prior to the appearance of phenotypic a high molecular weight to limit the diffu-
(megaHertz) sound waves that propagate changes, it is proposed that this method sion of the gas out of the bubble for longer
through tissue. These sound waves back- can facilitate early assessment of disease persistence times [4]. Unlike perfusion
scatter from the interfaces between tissue progression or response to therapy [1]. agents, contrast agents for molecular imag-
components with different acoustic proper- Preclinical imaging studies have demon- ing incorporate high-affinity adhesion lig-
ties and are detected by the imaging system, strated the efficacy of ultrasonic molecu- ands (such as an antibody, peptide etc.) into
allowing the creation of images based on tis- lar imaging for applications including, their shell, which is specific for a particular
sue characteristics and spatial location. Thus, assessment of tumour angiogenesis, the disease epitope [4].
traditional ultrasound has focused primarily diagnosis of myocarditis, the evaluation
on the imaging of anatomical structures and of transplant rejection, the evaluation of The mismatch in acoustic impedance (a
analysis of blood flow in large vessels. Until cardiovascular disease and imaging dys- function of an object’s density and com-
recently, there has been no mechanism by functional endothelium, thrombus and pressibility) between the microbubble gas
which ultrasound has been able to detect inflammation [2, 3]. This article sum- core and blood (or tissue) is several orders
changes at the cellular and molecular level. marises the basics of ultrasonic molecu- of magnitude, resulting in substantially
lar imaging, recent developments and higher scattering from a bubble than an
Molecular imaging is a broad term for future directions as we progress towards equivalent volume of tissue or blood. Addi-
describing a technique designed to evaluate clinical relevance. tionally, microbubbles oscillate in response
cellular and molecular activity in biological to an ultrasonic field, and respond non-
systems [1, 2]. Traditionally, the modalities linearly to acoustic pulses even at low ener-
associated with molecular imaging have gies, unlike tissue [1]. The non-linear prop-
been positron emission tomography (PET), erty of microbubbles in an ultrasound field
single-photon emission computed tomog- allows for the use of various pulsing and
raphy (SPECT) and optical imaging. How- signal processing strategies to detect the
ever, in recent years, ultrasound has gained backscattered signal from contrast agents
interest in the area of molecular imaging and segment it from tissue, thus providing
due to the practical advantages over these a high contrast-to-noise ratio [1]. Due to
other imaging modalities: it is inexpen- these unique acoustic properties, a clinical
sive, safe (no ionising radiation), portable ultrasound system can detect even single
and readily available with fast acquisition microbubble contrast agents, providing
times [1, 2]. exquisite sensitivity.

The principle behind ultrasonic molecular One limitation to this type of agent is that
imaging is the selective targeting of acous- because of their size (typically between
tically active intravascular microbubbles 1 and 10 microns in diameter), they are
Figure 1. Molecular imaging concept cartoon:
to biomarkers expressed on the endothe- confined to the vascular space [2]. There-
Endothelial cells express biomarkers correlated
lium [Figure 1], [1-3]. Once accumu- with pathology. Targeted microbubble agents in fore, microbubbles are unable to target
lated at the target site, the microbubbles the vascular space adhere to the biomarkers, pro- extravascular cell receptors. Another
enhance the acoustic backscatter from viding image contrast during an ultrasound exam. significant limitation of microbubble
MOLECULAR IMAGING 17 – March/April 2011

contrast agents is that they to cell receptors [examples: may span the course of the life of to effectively and noninvasively
have relatively short life spans P-Selectin, intercellular adhe- the patients [10]. Therefore, the detect acute cardiac rejection.
(in the order of minutes), sion molecule (ICAM-1), vas- development of a sensitive and
which prohibits long-term tar- cular cell adhesion molecule noninvasive method for deter- Ischaemic memory
geting applications such as the (VCAM-1)] on the surface of mining failure of organ trans- It has also been proposed that
tracking of labelled cells in cell inflamed endothelial cells [2, plant is of critical importance. molecular imaging with ultra-
therapy applications [2]. 3]. Regardless, in the future, It is proposed that ultrasonic sound could aid in the analysis
ultrasonic molecular imaging molecular imaging can help of recent myocardial ischaemic
Molecular imaging of may offer clinicians the ability, identify acute cardiac transplant events (ischaemic memory)
inflammation in real time, to detect inflamed rejection by targeting inflamma- [2, 3, 6]. Currently, diagnosing
Noninvasive assessment of tissue during the active phase tory tissue, specifically the over- acute coronary syndrome in the
inflammatory markers is one of leukocyte recruitment. expression of ICAM-1 on the absence of ECG abnormalities
of the more promising applica- surface of endothelial cells. It has can be challenging. Patients expe-
tions of ultrasonic molecular Atherosclerosis been shown from in vitro experi- riencing chest pains are often sent
imaging. Inflammation plays an Molecular imaging with ultra- ments that microbubbles tar- home prematurely from emer-
important role in most cardio- sound also offers the possibil- geted to ICAM-1 will selectively gency departments due to misdi-
vascular diseases [2, 3]. Since ity to detect atherosclerosis, the adhere to rejecting tissue versus agnosis (2 to 7%) [6]. Up to 26%
traditional ultrasound methods chronic inflammatory disorder non-rejecting myocardium [2, of these high-risk patients may
do little to quantify the mecha- that is one of the most important 3, 10]. Therefore, in the future, experience fatal complications
nisms of inflammation, the ext- contributors to cardiovascular ultrasonic molecular imaging [6]. Acute myocardial ischaemia
sitence of a noninvasive imag- disease, and often progresses may offer clinicians the ability and subsequent reperfusion is
ing method, such as ultrasonic for decades before the onset of
molecular imaging, would be symptoms [2]. Inflammation in
invaluable as a diagnostic test, atherosclerosis involves plaque
and in evaluation of response to initiation and progression and
therapy applications. In recent is characterised by inflamma-
years, microbubbles have been tory tissues. Using ultrasonic
shown to target either acti- molecular imaging to assess the
vated leucocytes or endothelial extent of vascular inflamma-
cell receptors that are upregu- tion could potentially provide
lated during inflammation [2]. powerful information for early
These methods have allowed stages of disease as well as pre-
significant progress to be dict future risks. ICAM-1 and
made in identifying inflamma- VCAM-1, which are cell recep-
tory response in such fields as tors expressed on the surface
assessing reperfused myocar- of endothelial cells, contribute
dial infarction, atherosclerosis, to leukocyte adhesion during
intraplaque neovascularisation inflammation and play a criti-
from the vasa vasorum, trans- cal role in the progression of
plant rejection and ischaemic atherosclerosis [2]. Ultrasonic
memory [2, 3, 6-8]. molecular imaging has shown
that microbubbles targeted to
Reperfusion Injury ICAM-1 and VCAM-1 can help
Currently, there is no optimal localise inflammatory tissue
clinical method that is capable related to atherosclerosis. Moreo-
of quantifying the postischae- ver, imaging of newly formed vas-
mic inflammatory response culature sprouting from the vasa
of the immune system after vasorum using ultrasonic molec-
reperfusion of the myocardial ular imaging of angiogenesis
infarct [3]. By using micro- (microbubbles targeted to avb3)
bubbles targeted to leukocytes has recently gained traction as a
(example: neutrophils via com- potential way to predict plaque
plement receptors, monocytes rupture [2, 8].
via a5b1), which will respond
to the inflamed region, the spa- Acute cardiac rejection Figure 2. Molecular imaging with ultrasound data for microbubbles
tial location of the ischaemic One of the leading causes of targeted to three different molecular biomarkers. Each panel includes the
risk area can be identified with mortality in patients undergo- quantification of signal enhancement from targeted microbubbles, an over-
great sensitivity [Figure 2], [9]. ing heart transplant is acute lay of bound bubbles on traditional brightness mode ultrasound imaging,
It is important to note, how- cardiac rejection. Currently, the and immunohistochemical images at various time points in the study. Panel
A: Microbubbles targeted to activated leukocytes (neutrophils) via comple-
ever, that molecular imaging of “gold standard” for transplant ment receptors. Panel B: Microbubbles targeted to leukocytes (monocytes)
inflammation with ultrasound rejection diagnosis is endomyo- via 51 surface cell receptor. Panel C: Microbubbles targeted to vascular
has also been achieved via cardial biopsy, which is a repeti- cell adhesion molecule (VCAM-1) biomarkers expressed on the endothelial
the targeting of microbubbles tively invasive procedure that cell surface. Reproduced with permission from Behm et al [9].
– March/April 2011 18 MOLECULAR IMAGING

associated with the upregulation of leuko- been used in animal studies for nearly two
cyte adhesion molecules (P-selectin) on the decades, the safety and clinical utility of ultra-
surface of endothelial cells, which persist sound molecular imaging has only recently
even after ischaemia has been resolved. By begun to be evaluated in humans. However,
targeting acoustically active microbubbles to considering the potential advantages of this
P-selectin, it is possible to detect the inflam- technique, it is reasonable to expect that
matory tissue and obtain useful information ultrasonic molecular imaging may have a key
about recent myocardial ischemic events. By role in the clinic in the future.
detecting molecular markers that persist for
hours after ischaemia, ultrasonic molecular References
imaging may provide a novel bedside detec- 1. Gessner R, Dayton PA. Advances in molecular
tion scheme for the diagnosis of acute coro- imaging with ultrasound. Mol Imaging 2010; 9:
nary syndrome [2, 3]. 117-27.
2. Lindner JR. Molecular imaging of cardiovascular
Other applications of disease with contrast-enhanced ultrasonography.
molecular imaging Nat Rev Cardiol 2009; 6: 475-81.
Other promising targets for ultrasonic 3. Villanueva FS, Wagner WR. Ultrasound molecular
molecular imaging include angiogenesis imaging of cardiovascular disease. Nature clinical
and thrombus imaging [2, 7]. Angiogenesis practice Cardiovascular medicine 2008; 5 Suppl 2:
and arteriogenesis relate to the physiological S26-32.
process concerning the growth of new blood 4. Ferrara KW, Borden MA, Zhang H. Lipid-shelled
vessels and are critically involved in cardio- vehicles: engineering for ultrasound molecular
vascular disease as well as cancer growth [2]. imaging and drug delivery. Acc Chem Res 2009;
150 exhibitors
During this process, endothelial markers 42: 881-92.
3,000 visitors
such as VEGF-2, avb3 and VCAM-1, provide 5. Dayton PA, Rychak JJ. Molecular ultrasound
500 delegates
6 parallel congresses
suitable targets for molecularly targeted con- imaging using microbubble contrast agents. Front
trast agents. It has been shown that imaging Biosci 2007; 12: 5124-42.
of endothelial receptor of angiogenesis can 6. Villanueva FS, Lu E, Bowry S et al. Myocar-
provide information on vascular remodel- dial ischemic memory imaging with molecular
Exhibtion and congress ling or response to therapy before blood flow echocardiography. Circulation 2007; 115: 345-52.
for hospital construction changes occur [2]. This type of information 7. A lonso A, Della Martina A, Stroick M et al. Molec-
and operation in Europe! can help elucidate plaque neovascularisation, ular imaging of human thrombus with novel
chronic ischaemic heart and limb disease as abciximab immunobubbles and ultrasound.
well as cancer therapy response and tumour Stroke 2007; 38: 1508-14.
The congress topics: growth characteristics. 8. Ten Kate GL, Sijbrands EJG, Valkema R et al.
Leaders in Healthcare Molecular imaging of inflammation and intra-
Process Optimization in Hospitals Targeting thrombus, which is the aggrega- plaque vasa vasorum: A step forward to identifi-
Design, Build & Upgrade of tion of platelets forming a blood clot, is also cation of vulnerable plaques? Journal of nuclear
Healthcare Facilities possible with ultrasonic molecular imaging. cardiology: official publication of the American
Patient hotels, Rehab, Medical Spa This is accomplished by designing contrast Society of Nuclear Cardiology 2010; 17: 897-912.
Surgery Management agents to target platelets or fibrin using anti- 9. Behm CZ, Kaufmann BA, Carr C et al. Molecu-
Imaging & Radiology Management bodies against glycoprotein IIb/IIIa recep- lar imaging of endothelial vascular cell adhesion
tor or RGD oligopeptides [2, 7]. It has been molecule-1 expression and inflammatory cell
shown that this technique can enhance the recruitment during vasculogenesis and ischemia-
surface of newly formed thrombi in vivo mediated arteriogenesis. Circulation 2008; 117:
using animal models with carotid artery 2902-11.

oo k youR stenosis, thus providing an early detection 10. Weller GER, Lu E, Csikari MM et al. Ultrasound
B ow! strategy against thrombus [2]. imaging of acute cardiac transplant rejection
k e t n
tic 238B Future directions
with microbubbles targeted to intercellular adhe-
e: Z1 sion molecule-1. Circulation 2003; 108: 218-24.
Ticket cod Molecular imaging with ultrasound is an
exciting new field that, by the use of inexpen- The authors
sive and portable ultrasound systems with- Jason E. Streeter and Paul A. Dayton*
Register here: out ionising radiation, offers the potential to Joint Department of Biomedical Engineer-
www.hospitalbuildeurope.com/reg detect pathology before phenotypic changes ing University of North Carolina - North
occur. Although significant advances have Carolina State University, USA
Phone: +49 (0)2 11/96 86–36 21
been made, the technologies enabling molec- *Corresponding author:
ular imaging are still in development. Com- Paul A. Dayton
4–6 April 2011 mercial imaging systems are still being opti- 304 Taylor Hall, 109 Mason Farm Road,
NürnbergMesse Germany mised for molecular imaging, and targeted Chapel Hill, NC 27599-6136, USA
contrast agents for clinical and veterinary Tel. +1 (919) 843-9521
www.hospitalbuildeurope.com use are still not widely available. Although Fax +1 (919) 843-9520
molecularly-targeted contrast agents have e-mail: padayton@bme.unc.edu
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– March/April 2011 20 molecular imaging

Optimised imaging protocols for


enhanced contrast in FMISO PET
The technique of 18F Fluoromisonidazole positron emission tomography using FMISO can be considered as the
(FMISO PET) has been shown to be able to image and quantitate hypoxia, converse of that used in standard imaging
which is one of the most important prognostic factors in several cancers. technique using FDG PET in which the
FDG accumulation is measured. In contrast
However, compared to FDG PET images, images FMISO PET have a much
FMISO accumulates in hypoxic regions
lower contrast between the target and background, so improvements in but it is washed out of normoxic tissues so
image quality, especially in noise reduction, would be of great benefit. it is not tracer accumulation, but rather the
Such improvements can be achieved using simple adjustments to the imag- washout effects that are of major interest
ing protocols. This article describes a way of improving image quality by in FMISO PET measurements. In addition
adjusting the image protocol, without increasing the risk to the patient or these effects are more easily observed after
the tracer is distributed throughout the
generating costs for the hospital.
whole body. While static FDG PET images
are usually acquired about one hour post
by Dr R Haase and Prof. N Abolmaali injection (p.i.), static FMISO-PET is car-
ried more than two hours p.i., — in our
opinion 4 hours p.i. is preferable [6].
Hypoxia imaging in oncology research studies have been carried out Another distinctive difference between
Non-invasive imaging techniques for the to evaluate the prognostic potential of FMISO and FDG PET is image contrast.
visualisation of physiological processes are FMISO measurements [3] and for treat- Unfortunately the contrast between the
gaining more and more interest in clinical ment adjustment tests [4]. The acquisition presumptive hypoxic region and the sur-
oncology, with positron emission tomog- of in vivo FMISO PET data before the start rounding tissue is comparatively low in
raphy (PET) techniques playing an impor- of therapy allows the oncologist to get a FMISO PET; this lower signal-to-noise
tant role in this field. In addition to the well more detailed view of the initial tumour ratio interferes with FMISO image analy-
known glucose metabolism tracer [18F]- microenvironment, and when the tech- sis. There is thus a real need for new image
fluorodeoxyglucose (FDG), other tracers nique is applied during therapy, it allows analysis tools that would allow the han-
have been synthesised for visualisation of the effects and progress of the therapy to dling of image data with low contrast, high
different metabolic pathways. In oncology, be monitored [5]. noise, inhomogeneity and non-spherical
one of the most important additional pieces target volumes [7]. The relatively poor
of information besides energy turnover is Nevertheless there are challenges to be reproducibility of FMISO measurements
tumour hypoxia, since it has been shown overcome before FMISO PET can be intro- is also discussed in this article [8]. Each
that hypoxic tumours have a worse prog- duced into clinical routine. Unfortunately, of these aspects requires intensive effort
nosis and an increased resistance to radio- FMISO PET images provide a much lower in order to improve imaging technology
therapy. Several new tracers, for example contrast between the target and back- and image processing; every enhancement
[18F]-fluoromisonidazole (FMISO), have ground compared to FDG PET images of image quality or reproducibility is a
been developed and assessed for use in [Figure 1]. This complicates data analysis welcome development.
the evaluation of hypoxia [1, 2]. Clinical and increases the potential effect of the
observer on the interpretation. Several Improving PET image quality
methods of improving FMISO PET image Improvements in PET image quality, espe-
quality are being considered. This article cially noise reduction, could in theory be
highlights a way to improve image qual- achieved through simple adjustments to the
ity by adjustment of the imaging protocol, imaging protocols. One (clinically imprac-
without increasing the risk to the patient or tical) way to do this is simply to prolong
generating costs for the hospital. acquisition time since, technically, the signal-
to-noise ratio increases with the duration of
Principle of FMISO PET imaging data acquisition. However, the requirement
There are two main approaches for PET for a patient to keep still for a longer period
image acquisition. The first is dynamic of time is very difficult to achieve, and any
4D-PET image acquisition immediately eventual patient movement can nullify any
after tracer injection. Using this method, improvement in image quality. Additionally,
the tracer uptake can be observed in detail a long acquisition time leads to a decreased
at high temporal resolution, but image throughput of the number of patients being
analysis is very complex. The second examined per day.
approach is static 3D-PET imaging after a
defined waiting time. The trend in FMISO Another way to improve image quality is
Figure 1. Visual comparison of sagittal slices of a) PET imaging is to use the second approach, to increase the amount of tracer injected.
FDG PET and b) FMISO PET from the same patient. because the principle behind PET imaging Although this would indeed improve image
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www.ihe-online.com & search 45762


– March/April 2011 22 molecular imaging

radiochemotherapy (RCT) and twice being developed at our partner institution


during RCT. After injection of 256±37 Helmholtz-Zentrum Dresden-Rossendorf
MBq tracer image acquisition was taken (HZDR), Germany. In addition it is impor-
at 126±11 minutes p.i. (data set known tant that observer-independent image anal-
as MISO2) and 241±16 minutes p.i. (data ysis tools for volume data with low contrast
set known as MISO4). In total, 61 pairs of and high noise should be developed.
data sets (MISO2 + MISO4) were further
analysed. The analysis included measure- Even though the development of FMISO
ment of the standard uptake value (SUV) PET has now been going on for more than
in predefined volumes of interest (VOI) a decade, it has not yet become widely
of the data sets. Mean and maximum SUV accepted in the clinic largely because of
were measured for three volumes in each some outstanding challenges to be over-
data set: tumour-VOI, defined using a cor- come, such as limited reproducibility
Figure 2. An example of FMISO PET data sets responding FDG-PET data set, contrast- and low image contrast. However even
acquired at different time points after injection. VOI, a small ellipsoid around the activity small improvements increase the qual-
The top row shows the sagittal plane of an
oropharyngeal carcinoma, and the bottom row
hot spot in the tumour-VOI, and back- ity of images. The proposed improvement
shows corresponding axial slices. The window- ground-VOI, a volume in the neck mus- of image quality by extending the waiting
ing properties are identical for both data sets. culature delineated on a corresponding CT time between the tracer injection and the
dataset. These measures of SUV were fur- PET scan may be challenging for patient
quality, the higher dose to which the patient ther processed to analyse changes of image scheduling in routine clinical practice, but
would be exposed is not acceptable. When contrast between corresponding MISO2 is an excellent approach to enable further
using FMISO, the tracer also accumulates and MISO4 data sets. For objectivity and image analysis.
in normoxic tissue, so a higher tracer vol- comparability the analysis was carried out
ume might not lead to an increased con- using different definitions of image con- References
trast between target and background. trast: tumour-to-muscle ratio (TMR) and 1. Rasey JS et al. Int J Radiat Oncol Biol Phys 1996;
The resurgence of time-of-flight (TOF) contrast-to-noise ratio (CNR). We found 36(2): 417-28.
reconstruction techniques is a better that, no matter which contrast definition 2. Rajendran JG et al. Clin Cancer Res 2006;
approach for improving PET image quality was chosen, the measured contrast in the 12(18): 5435-41.
without changing imaging protocols, but data set always increased during the two 3. Lee N et al. Int J Radiat Oncol Biol Phys 2009;
this method requires high precision detec- hours between the acquisition of MISO2 75(1): 101-8.
tors resulting in higher scanner costs. and MISO4. A Wilcoxon-matched-pairs 4. Thorwarth D et al. Int J Radiat Oncol Biol Phys
test of the data was performed and showed 2007; 68(1): 291-300.
Early on, it was demonstrated that static a statistically significant difference between 5. Eschmann SM et al. Radiother Oncol 2007;
magnetic fields of about 4.5 Tesla were corresponding MISO2 and MISO4 con- 83(3): 406-10.
capable of reducing the high energy posi- trast measurements. An example of a pair 6. Abolmaali N et al. Nuklearmedizin 2010; 50(1).
tron range resulting in improved spatial of data sets is shown in Figure 2 and dem- 7. Lee JA. Radiother Oncol 2010; 96(3): 302-7.
resolution [9]. However, especially for [18F]- onstrates the effect on the image quality. 8. Nehmeh SA et al. Int J Radiat Oncol Biol Phys
fluorine, this effect is negligible due to the Finally it must be noted that, since the half 2008; 70(1): 235-42.
already short mean range of about 0.3 mm. life of [18F]-fluorine is 110 minutes, the 9. Wirrwar A et al. IEEE Transactions on Nuclear
One biological feature that is sometimes count rates at MISO4 were approximately Science 1997; 44(2): 184-189.
overlooked is the observation of FMISO halved compared to MISO2. Nevertheless, 10. Dubois L et al. Eur J Nucl Med Mol Imaging
tracer washout with time. Based on this, the reduced number of events measured 2009; 36(2): 209-18.
PET data sets can be acquired at different was still high enough for further image
time points after tracer injection to evalu- analysis to be carried out. The authors
ate the influence of washout in hypoxic and Robert Haase1
normoxic tissues. If the washout tracer in We would therefore recommend using data and
tissues is significantly different, this effect sets acquired four hours p.i. when working Prof. Nasreddin Abolmaali 1, 2 (correspond-
could be used to enhance the ratio of activ- with FMISO as a hypoxia tracer. The idea ing author)
ity between the target volume and the of increasing waiting time before measure- 1
OncoRay - Imaging, National Centre
surrounding tissue. ments has also investigated by Dubois et al for Radiation Research in Oncology, TU
using the hypoxia tracer [18F]-EF3 in a rat Dresden
Optimised waiting time model [10] Their conclusions were similar Medical Faculty and University Hospital
post injection to ours, but they found that contrast values Carl Gustav Carus, TU Dresden
Our investigation on the influence of wait- four hours p.i. were similar to the values for Fetscherstraße 74, P.O. Box 41
ing time post injection was carried out by FMISO data sets two hours p.i.. 01307 Dresden, Germany
analysing FMISO PET patient data sets Tel: +49 351 458 7414
[6]. A group of patients was selected for Further development Fax: +49 351 449 210 394
an ongoing prospective study on head and and conclusions e-mail: nasreddin.abolmaali@oncoray.de
neck squamous cell carcinomas (HNSCC). The research on improvement in quality 2
Institute and Policlinic for Diagnostic
Data sets were analysed from 23 patients of FMISO-PET data should not only focus Radiology, Medical Faculty and University
of median age of 55 years in clinical stages on improved image protocols. Imaging Hospital Carl Gustav Carus, TU Dresden
III (n = 9) and IV (n = 14) . The patients devices and reconstruction algorithms to Fetscherstr. 74, P.O. Box 45
were imaged twice before combined improve spatial resolution are currently 01307 Dresden, Germany
See us at

ECR 2011 BOOTH 210 EXPO B

Who is Carestream?
We are a global company of passionate professionals dedicated to the cause
of healthcare. We use our extensive experience, insights and innovative medical
imaging and healthcare IT solutions and services to improve outcomes, lower
costs, simplify the work for healthcare professionals, and give you exactly
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OPEN.
Healthcare IT is rapidly evolving around Electronic Medical Records and integrated R I S + PA C S . A S M A R T E R W AY F O R W A R D .
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Start with a partner who can put it all together for you. When you sit at a CARESTREAM
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FROM
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IS THE
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CLEAR?
A S M A R T E R W AY F O R W A R D .

www.ihe-online.com & search 45763


Women’s Health Special International

hospital
Looking at industry’s contribution to
breast tomosynthesis and beyond
The advent of 3D imaging for breast examination America, Canada, Mexico and Thailand, and
March/April
has opened a new era in mammography and breast
cancer diagnosis. Unlike conventional mammog-
raphy, which is based on a stationary tube and
several hundred more sites in the USA ready to
switch to tomosynthesis now that the company
has received final FDA approval for its Selenia
2011
produces a 2D projected image, 3D systems use Dimension 2D/3D mammography system –
a moving X-ray source that swivels in a 50-degree currently the only breast tomosynthesis product
arc over the breast to acquire multiple projection approved by the FDA for marketing in the USA.
images. These individual slices of the breast are
subsequently reconstructed into a 3D image. The
3D technology offers a number of advantages,
Siemens has quickly followed by expanding
its Mammomat Inspiration system with a 3D
tomosynthesis capability, while GE is expected
Women’s
health
such as improved detail recognition and easier to announce its latest developments in 3D breast
localisation of micro-calcifications, while over- imaging at the 2011 European Congress of Radi-
coming the limitations of conventional 2D mam- ology (ECR) in Vienna.
mography resulting from tissue overlapping that For the 40% of women with especially dense breast

special
may hide lesions or cause benign areas to appear tissue (e.g. in small breasts), 3D tomosynthesis
suspicious. The fact that there are fewer false posi- image generation uses an algorithm to remove
tives and fewer inconclusive images could also superimposed dense gland tissue. Dense breast
significantly reduce the number of biopsies. tissue also constitutes a particular indication for
“Tomosynthesis will make mammography less an additional ultrasound examination which is
stressful to both the physician and the patient. now greatly facilitated by automatic breast scan-
According to first impressions, additional
examinations and interventions can be omit-
ning (as provided by the Acuson S2000 ABVS).
The next step will be fusing mammography with
Early identification of
ted in all good conscience. Lesions hiding in ultrasound images. While some ultrasound scan- pre-eclampsia
the gland tissue are detected earlier”, says Dr. ners (such as GE’s LOGIQ E9) are capable of
Renate Tewaag of the Radprax group, a net- fusing ultrasound with previously acquired CT, Page 26 - 28
worked practice for radiology, nuclear medicine MR or PET images, the technology for creating a
and radiation therapy in Wuppertal, and one of composite image generated by both mammogra-
the first radiologists in Germany to have started phy and ultrasound modalities is not yet on the
working with the new technology.
Hologic has been a pioneering company in this
market (although Siemens is actively currently
working on it). It could provide physicians with
The success of a
field, selling Tomosynthesis commercially in 40 a unique insight into the patient’s anatomy and multidisciplinary breast
countries for almost two years with hundreds
of install sites in Europe, the Middle East, South
set new standards of accuracy and sensitivity in
breast cancer diagnosis.
and breast screeening
clinic
Trade fair and congress “Hospital Build” in Europe for the first time
The trade fair and congress “Hospital Build” has already established its presence in Asia and the Page 30 - 31
Middle East over the last two years. Held from 4–6 April 2011 in Nuremberg, Germany, the trade
fair and congress will now offer European directors, CEOs and CFOs of hospitals, as well as sup-
pliers and service providers in the areas of process, project and change management, business
development, procurement and logistics, a new cross-border platform for exchange and discussion. Increased diagnostic
The affiliated three-day congress featuring international speakers will, in a parallel series of confer-
ences, focus on the topics of design, building and refurbishment of hospitals, as well as healthcare
accuracy in breast
management, process optimisation, non-medical services and patient hotels. screening
A “Leaders in health care” conference will also take place during the trade fair and congress. In
this sub-conference international experts will discuss issues related to health care policy and man-
agement. For instance, Frédéric Dubois from Médi-Partenaires, France’s largest operator of private
Page 32 - 33
clinics, will report on trends in restructuring and turnaround management in the French hospi-
tal market. Eke Zijlstra from MC Atrium, one of the leading general hospitals in the Netherlands,
will provide an insight into the Dutch hospital market. Prof. Dr Thomas Ittel, from the University
Hospital Aachen, Germany will discuss the issues of factuality, transparency, efficiency through
joint action, personal responsibility, quality and swiftness. Other managers from leading European
hospitals will share practice-oriented insights within the Leadership conference.
For more information visit www.hospitalbuildeurope.com
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– March/April 2011 26 Women’s health

Pre-eclampsia: new biomarkers aid


in early identification
Pre-eclampsia (PE) is a clinical syndrome that affects 2-8% of pregnancies, 15-20% of pregnant women will become
and which is associated with high maternal and perinatal morbidity and hypertensive, only a small proportion of
mortality if it is not identified and managed. The condition typically occurs them will actually develop PE [1].
after 20 weeks gestation, and while clinical signs are hypertension and
Similarly, proteinuria is not always indica-
proteinuria, around 15-20% of pregnant women develop hypertension and tive of PE, nor even associated with hyper-
many pregnant women develop proteinuria, but only a small proportion of tension. Thus at the point-of-care there is
them will develop PE. Measurement of biomarkers that are a direct reflec- a clinical tendency for ‘over diagnosis’ and
tion of placental function can enable more effective diagnosis and manage- unnecessary monitoring, with decisions
ment of PE. A highly sensitive and specific test for placental growth factor based on non-specific signs with arbitrary
cut-off values. As the NIH working group
(PlGF) that can be carried out at the Point-of-Care is showing great promise
reported: ‘Although our understanding
for early diagnosis of the pre-35 weeks form of the PE syndrome. of this syndrome has increased, the crite-
ria used to identify the disorder remain a
by Brian Conibere subject of confusion and controversy. This
doubtless reflects the fact that pre-eclampsia
is a syndrome, and that attempts at definition
It is now 45 years since the eminent women with suspected PE is resource- and use arbitrarily selected markers rather than
gynaecologist Professor T. N. A. Jeffcoate time-intensive, with much effort wasted changes of pathophysiologic importance.’
described pre-eclampsia as a ‘disease of the- on attempts to diagnose accurately, stratify
ories’. In his 1966 presidential address to the risk and ensure an appropriate level of care This is not to say, however, that today’s
British Royal Society of Medicine, Jeffcoate for those women who need it. precautionary approach is misdirected. PE
urged obstetricians to be ‘extremely criti- Now, however, with the recognition of more is still associated with high rates of mor-
cal’ in diagnosing pre-eclampsia: countless specific parameters in the pathophysiology bidity, both for the mother and the baby.
studies, he said, had failed to reveal a cause of PE and the availability of tests for their A Lancet review from 2005 described the
because the ‘laboratory worker, dependent measurement, the diagnosis of PE and the maternal syndrome as ‘probably more
on the obstetrician for his material, was accurate risk assessment of hypertension than one disease with major differences
often investigating a wide variety of dis- look set to move from an imprecise evalua- between near-term pre-eclampsia with-
eases whilst under the impression that he tion based on clinical symptoms and labo- out demonstrable foetal involvement and
was dealing with one’. ratory parameters, to an accurate scientific pre-eclampsia that is associated with low
evaluation that achieves both diagnosis birthweight and preterm delivery’ [2]. This
Today those warnings seem just as relevant and risk assessment with high specificity. two-stage manifestation of PE - maternal
as ever. Pre-eclampsia (PE) remains a clini- The Alere Triage PLGF (placental growth and foetal syndromes - and the factors
cal challenge, with its diagnosis still defined factor) assay [Figure 1] is a new biomarker which link them add further complexity
by non-specific markers, its severity imper- test whose initial use will help confirm a to the diagnosis and increases the chal-
fectly stratified, and patient progression diagnosis of early onset PE; it is now known lenge of explaining PE’s pathophysiology.
unpredictable. As a result, the evaluation of that a low level of placental growth factor is Yet the bare facts remain that PE is one of
diagnostic of PE in pregnant women with
classical but non-specific signs of the con-
What is pre-eclampsia? dition. Moreover, in women who develop
* A clinical syndrome affecting 2-8% of hypertension in pregnancy, a low level of
pregnancies placental growth factor indicates a high
- Pregnancy-specific multi-organ risk for a complication.
syndrome
- Typically occurs after 20 weeks gestation PE: a clinical syndrome
- Clinical signs are raised blood pressure As Jeffcoate suggested, PE is a clinical syn-
and proteinuria drome, not a single disease, whose principal
features are raised blood pressure (usually
* 15-20% of pregnant women develop
defined as >140/90 mmHg) and an excess
high BP
- 20-25% of these develop pre-eclampsia of serum proteins in the urine (>300 mg
(3-5%) in a 24-hour collection). As with any syn-
-  Much higher rates in developing coun- drome, the presence of one feature is not
tries; associated with high maternal and necessarily indicative of the other. Indeed,
Figure 1. Alere Triage PLGF and Alere Triage
perinatal morbidity and mortality if not an NIH (National Institutes of Health) MeterPro. Using the system, assays of PlGF can
identified working group on high blood pressure in be carried out at the bedside or other Point-of-
pregnancy reported in 2000 that, while Care situations.
27 – March/April 2011

the most common complications of preg- flow [Figure 2]. Accompanying this is an
Where PlGF levels may be low
nancy, affecting between 2 and 8% of all angiogenic imbalance (both pro- and anti-
pregnancies, and causing a high propor- Patients may test positive in angiogenic factors) which can be quantified
tion of premature deliveries, many of them * PE and atypical PE by measuring circulating biomarkers, and in
as a result of treatment [3]. As many as (eg, non-hypertensive) particular PlGF. Levine et al showed that in a
14% of all maternal deaths in the UK are * Placental insufficiency normal pregnancy PlGF levels begin to rise
attributed to PE. Similar data on PE-attrib- * Foetal growth restriction at around ten weeks, from around 100 pg/
* HELLP syndrome
utable maternal deaths are found in other mL to 900 pg/mL at 29-32 week. Thereaf-
countries in Western Europe. Pre-existing ter levels declining until delivery. However,
hypertension, renal disease and diabetes pathophysiology of PE. The recent avail- in PE this rise and fall is considerably lower
are all associated with an increased relative ability of clinically meaningful diagnostic throughout the pregnancy, and even at 13
risk of developing PE, making the diagno- tests to measure levels of these biomark- weeks it was found to be lower in women
sis even more difficult. ers now allows the accurate identification destined to develop PE (mean 90 pg/mL vs.
of women with ‘true’ PE, rather than just 142 pg/mL) [5].
Diagnosing PE identifying women with hypertension and
Even in the absence of pre-existing hyper- proteinuria. The latest biomarkers are a The PELICAN-1 study showed that the
tension, blood pressure measurements direct reflection of placental function and, Triage PLGF test had a 95% sensitivity and
in the ambulatory setting of an antenatal while having a clear application for facili- 95% specificity for the differentiation of
clinic - where PE is often first suspected tating the diagnosis of PE, will probably women with early onset PE from women
- will rarely be diagnostic or reliable. also have a further role in patients with with a normal pregnancy outcome, and
The cut-offs no doubt owe more to his- hypertension that typically precedes PE. identified 95% of women with and with-
torical acceptability than specificity, and out PE at less than 35 weeks gestation [6].
will inevitably lead to over diagnosis and Placental Growth Factor (PlGF) In fact, the two women with ‘PE’ missed
misaligned risk stratification. Similarly, The biomarker which appears to be most by the Triage PLGF test went on to have
measurement of excreted protein can- promising is placental growth factor normal uneventful pregnancies and were
not be reliably confirmed in a one-off (PlGF), a molecule that is essential for probably not affected by the condition.
ambulatory or even acute care setting; angiogenesis, whose concentrations in
24-hour (or an appropriately timed) urine pregnancy are dependent on the placenta; An accurate diagnosis at such an early stage
collection is necessary. studies have consistently shown that serum of pregnancy suggests that it is critical (as
levels of PlGF in both early and late onset it is at any time) that management plans
Nevertheless, it is the outcome of these ini- PE are lower than in healthy pregnancies. are made and triage begun. Of course any
tial assessments which defines the level of treatment during pregnancy, and the ulti-
risk and the extent of future surveillance. From around nine weeks into a normal mate timing of delivery, are central to the
Those patients perceived as high risk will pregnancy the uterine spiral arteries are obstetric outcome. Thus, suspicious signs
require close monitoring as in-patients or transformed from thick-walled, muscular in early pregnancy that are confirmed as
with frequent clinic visits. Patients will be vessels into more flaccid tubes to accommo- PE with PlGF testing can now alert the
monitored for sharp increases in blood date the increased uterine blood flow that physician to a very high likelihood of PE.
pressure, the presence of urinary proteins the pregnancy requires. However, in the
and evidence of foetal growth restriction. case of poor placental development as seen Additional biomarkers
Such monitoring is easily carried out (even in PE, these uterine arteries remain tightly PlGF is not the only biomarker in PE.
if from daily out-patient visits) but is lim- coiled, thereby restricting placental blood While PlGF is pro-angiogenic, and thus
ited in its specificity. Thus, while new onset
hypertension might be detected in 10% of
antenatal tests, only around one in five of
these cases will actually go on to have PE.
Conversely, there may be some women
who develop eclampsia who had no signs
of hypertension or proteinuria, and who, by
definition, would not be diagnosed as hav-
ing PE using current methods. Similarly,
women who develop HELLP syndrome
(haemolysis, elevated liver enzymes, and
low platelet counts), another variant of PE,
will also be outside the current diagnostic
definition of PE.

Biomarkers to facilitate
diagnosis of PE
Now, however, these serious and long-
standing shortcomings in the diagnosis and
risk assessment of PE look set to be bridged
by the discovery of biomarkers specifically
associated with the hitherto ill-defined Figure 2. Restricted placental blood flow seen in pre-eclampsia.
– March/April 2011 28 Women’s health

reflects blood vessel growth (circulating which of these earlier pregnancies require is fraught with uncertainties leading to
at high levels in a normal pregnancy), the early intervention will allow clinics to allo- over-management for many expectant
majority of PlGF in PE binds to an anti- cate resources more effectively. Tests using mothers while others have serious prob-
angiogenic inhibitory receptor, namely Triage PLGF can also be conducted simply lems that go undetected. A reliable diag-
fms-like tyrosine kinase (sFlt-1). Levels and reliably at the point-of-care on the nostic blood test, such as the Alere Triage
of the latter — as well as the sFlt-1:PlGF benchtop Alere Triage MeterPro analyser, PLGF, which potentially can be used close
ratio — have also been shown to reflect while the sFlt-1:PlGF assay is designed for to the mother without the need for elabo-
the risk of PE. Studies, however, have laboratory measurement. rate equipment or trained laboratory staff,
shown that ‘two-marker’ measurement is a major step forward for both pregnant
is unnecessary, and does not add further Evidence suggests that the measurement women and those who look after them.’
diagnostic information over and above a of PlGF levels will also indicate cases of
second-generation PlGF immunoassay atypical PE, in which there are some signs That ‘step forward’ may now, after so
such as Triage PLGF. Benton et al showed and symptoms of PE but not the usual many years, raise the diagnosis of PE from
in a study of 132 blood samples (45 cases hypertension or proteinuria. Thus, atypi- Jeffcoate’s ‘disease of theories’ to a more sci-
of PE and 87 matched controls) that the cal PE might be considered in cases of ges- entific and evidence-based level. Through-
Triage PLGF assay had a clinical sensitiv- tational hypertension without proteinuria out the last 45 years there has been a clear
ity of 100% [7]. but with at least one of the symptoms of need to redefine PE, and PlGF is likely to
PE, namely haemolysis, thrombocytope- play a significant role in that new definition.
The bottom line in the clinic is that women nia, and elevated liver enzymes. A similar With the opportunity to measure PlGF with
with low PlGF levels, and not hyperten- diagnosis might be suspected in cases of accuracy and reliability, it will be possible to
sion alone, detected before 35 weeks ges- gestational proteinuria without hyperten- develop appropriate clinical pathways spe-
tation will require close management. sion but with these same symptoms. Many cific to PE and its sub-types, and this should
Indeed, pregnancies with low PlGF levels of these cases will progress to PE (even if lead to improved standards of care, better
will require treatment (delivery) as soon as atypical) and in many the unchecked pro- allocation of health resources and lower
possible after testing; however, pregnancies gression will result in preterm delivery costs. For the patient, there are likely to be
with PlGF levels within a normal range are and/or foetal growth restriction [8]. Such fewer missed cases and fewer unnecessary
likely to progress longer, often to full term. women will require close observation for deliveries before full term.
the early detection of PE, including fre-
Of course, PlGF alone does not provide quent prenatal visits and serial evalua- References
all the answers, and it is not expected to tion of platelets and liver enzymes, and/ 1. Roberts JM, Pearson G, Cutler J, Lindheimer
do more than identify placental dysfunc- or foetal growth (serial ultrasound), as M. Summary of the NHLBI Working Group
tion as a cause of PE or hypertension in will women with the suspect symptoms of on Research on Hypertension During Preg-
pregnancy. As with any new biomarker, HELLP syndrome. nancy. Hyptertension 2003; 41: 437-445.
pregnancies will continue to be assessed 2. Sibai B, Dekker G, Kupferminic M. Pre-
using the currently available laboratory Commenting on the importance of an eclampsia. Lancet 2005; 365: 785-799.
parameters until clinicians are confident accurate diagnosis of PE, Christopher 3. Khan KS, Wojdyla D, Say L et al. WHO analy-
about using PlGF. At present, the Triage Redman, Emeritus Professor of Obstet- sis of causes of maternal death: a systematic
PLGF test is intended for use in suspected rics at Oxford, has said: ‘No complication review. Lancet 2006; 367: 1066–74.
PE before 35 weeks gestation, because late of human pregnancy is both so common 4. Steegers EAP, Von Dadelszen P, Duvekot
onset PE can be caused by maternal as well and so dangerous for both mother and JD, Pijnenborg R. Pre-eclampsia. Lancet
as placental factors. However knowing baby as pre-eclampsia. Yet its detection 2010;DOI:10.1016/S0140-6736(10)60279-6
5. Levine RJ, Maynard SE, Qian C et al. Circulat-
ing angiogenic factors and the risk of preec-
lampsia. N Eng J Med 2004; 12: 672-683.
6. Knudsen AB et al. A single rapid point-of-
care placental growth factor determination
as an aid in the diagnosis of pre-eclampsia.
Amsterdam, the Netherlands Submitted for publication.

20
2011
2 011
7. Benton SJ et al. Placental growth factor (PLGF)

Euroanaesthesia
as a diagnostic test for pre-eclampsia: a per-
formance comparison of two commercial
immunoassays. Submitted for publication.
The European Anaesthesiology Congress
June 11-14 8. Sibai BM, Stella CL. Diagnosis and manage-
ment of atypical preeclampsia-eclampsia. Am
J Obstet Gynecol 2009; 200: 481 e1-7.

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itoring. Since then the tech- its accuracy and capabil- other conventional transduc- In this way, the 12-crystal
nology has been extensively ity of providing a reliable ers, the 12-crystal probe offers transducer’s high sensitivity
tested and it has been proven signal, thus reducing the advanced performance, reli- and greater accuracy sub-
that the 12-crystal waterproof number of times the 12-crys- ability and ease of use. The stantially reduce the time nec-
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a wider beam area for a tioned for patients of different focal area and homogenous and measure the foetal heart
more homogenous signal at sizes and at different stages distribution, and the resultant rate, thus resulting in better
greater depths, thus provid- of gestation. increased sensitivity, allow overall performance.
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– March/April 2011 30 Women’s health

Trivialising breast cancer kills women


“As we become more successful in the early detection and treatment of The interior was designed by a female
breast cancer, we tend to trivialise it. Yet one out of nine women still get decorator who is also a patient, so she
breast cancer. Half of them become depressed, their partners don’t know knows the clinic. People see no evidence
of mammography equipment or technol-
how to react and their families are in disarray. We need to stop trivialising
ogy at the standalone clinic. All imaging,
breast cancer. It kills women”, says Dr Fabienne Liebens, Head of the Saint- interventions and surgical procedures
Pierre Hospital’s Breast Clinic, Brussels, Belgium and one of the world’s take place back at CHU Saint-Pierre.”
leading experts on breast cancer and mammography.
The clinic’s décor helps in gaining the loy-
alty of women who enter the screening
Dr Fabienne Liebens is gynaecologist- largest breast centres and a key referral programme, believes Dr. Liebens, but it is
oncologist and coordinator of the Multidis- clinic in the country. “Yearly we consult
ciplinary Breast Clinic and Breast Screen- 6,000 women and perform some 13,000
ing Clinic ISALA, part of CHU Saint-Pierre breast examinations”, explains Dr Fabienne
hospital in Brussels, Belgium. She is pas- Liebens. “Our staff numbers 40, of whom
“Our motto is: behind each
sionately involved in saving women’s lives 80% are women including eight radiolo- breast we treat, there’s
and assumes her societal responsibilities gists and seven breast clinicians. We also
as vice-president of the Belgian section of consult with gynaecologists, surgeons and also a woman to heal.”
Europa Donna, the independent European GPs, and work with an oncology service in
Breast Cancer Coalition that currently has our building.”
42 member countries. The coalition works no doubt the complete holistic focus that is
to raise awareness of breast cancer and The Breast Clinic was started in 1991 the most reassuring and comforting. “Our
mobilise the support of European women within the Saint-Pierre Hospital campus motto is: behind each breast we treat, there’s
in pressing for improved breast cancer and moved into its own facilities close also a woman to heal”, says Dr Liebens.
education, appropriate screening, optimal to the hospital in 2007. The facilities are
treatment and care as well as increased astounding because of their look and feel, Clinic’s staff reflect
funding for research. which is completely different from the multicultural dimension
classical hospital design. “We didn’t want Since the clinic is part of a public hospi-
A Breast Clinic with a heart women to feel as if they were coming to tal, all patients receive the same treatment
for women a hospital”, underscores Dr Liebens. “The regardless of ethnic background. About
With some 170 cases per year, the Multi- reception and waiting room area is more two thirds of patients are ethnic Belgians.
disciplinary Breast Clinic and Breast like a lounge, which allows women to wait The clinic’s recruitment is based on breast
Screening Clinic ISALA is one of Belgium’s for their consultation in a relaxed way. cancer prevention programmes. Screening

Closing in on DR image quality

Radiologist Dr Martine Van Beveren leads a team of seven


mammography radiologists who interpret images using two
Agfa HealthCare CR systems. They examine 45 women daily
for clinical purposes, proactive screening or medical follow-up
resulting in around 13,000 studies annually.

“As a mammography radiologist, I am particularly concerned


about breast image quality and dose reduction. To make the
patient as comfortable as possible, I also prefer fast solutions,
which significantly reduce waiting and examination times. Agfa
HealthCare’s DX-M Digital Mammography system, in combi-
nation with CR HM5.0 needle-based Mammo detectors, con-
siderably improves the performance of existing CR solutions.
Our tests show that image quality using this approach is very
close to full Direct Radiography (DR) image quality, but with a
considerable dose reduction.” Dr. Martine Van Beveren sees a considerable dose reduction with the
DX-M CR solution.
“I appreciate Agfa HealthCare’s commitment to mammogra-
phy. The company seeks solutions that provide the best care for profiles for radiologist efficiency. Generally speaking, in the
patients. I particularly like the low dose for patient safety, easy future, I think radiology will see further enhancements in areas
to manipulate tools for examination speed, and personalised such as lower doses and better contrast for dense breasts.”
31 – March/April 2011

release of Marie Mandy’s book, have no knowledge whatsoever


‘Through the eyes of an Ama- of risk factors for breast can-
zon’. This remarkable publica- cer.” Video displays in the clin-
tion conveyed, through both ic’s lounge provide preventive
words and art, the real-life information, and displays in a
experiences of Marie, a breast separate area convey results of
cancer survivor. The book will prevention studies.
give heart to women who must
face this disease, its social and The situation is even more
emotional ramifications, and worrying for breast cancer
treatment up to and including preventive research, feels Dr.
partial or radical mastectomy.” Liebens. “In Belgium, where
breast cancer incidence is
Encouraging society to 33% higher than the European
support breast cancer average, there’s just one study
prevention research currently underway in pri-
Dr Liebens is highly concerned mary prevention for women
about the lack of focus on pri- after menopause, while there
The reception and waiting room area of the breast clinic is more like a
lounge, which allows women to wait for their consultation in a relaxed way. mary prevention efforts involv- are hundreds of studies on
ing breast cancer. The incidence therapeutic products. To meet
is voluntary in Belgium, with Patients appreciate holis- of this disease in developed my concerns, I have developed
only one woman out of two tic guidance countries is increasing, but a risk calculator based on the
entering a programme. This “From a study of 1,000 patients there’s little focus by institu- Tyrer-Cuzick International
explains the relatively high leaving the surgical oncology tions and industry on primary Breast Cancer Intervention
number of ethnic Belgian department, 92% are satis- prevention. “The knowledge Study Model for Breast Cancer
patients compared to the more fied with their care,” she adds. women have on how to prevent Risk Prediction. It allows us to
multicultural patient popula- “Key to this satisfaction is that breast cancer is astonishingly predict the breast cancer risk
tion of CHU Saint-Pierre. Dr psychological support is not little. The first Belgian research of an individual woman and
Liebens says “Regardless, we an option; rather it is a fully on this issue was, surprisingly, determine whether pharmaco-
integrate the multicultural integrated component of all done
92 X only
132 last year. EXAGO
IMAGYNE It showed logicalen
ARAB:Mise preventive
page 1 treatment
30/11/10 is 12:13
aspect into our staff: we have treatment. Few if any patients that 85% of women questioned appropriate in her case.”
Belgians that are French-, refuse this, and we found that
Dutch- and English-speaking. even six months after the surgi- Manufactured

We also have staff from Greece, cal procedure, 65% considered in France

&
by

Poland, Morocco, Chile, Iran the psychological support and


and Vietnam. This allows us counselling to have been very Noveko International Inc.

to cover most of the languages useful. This proves the impor- New color Doppler
needed by patients. CHU tance of our holistic view of
Saint-Pierre‘s multicultural the patient.” ultrasound scanners
section provides interpreters,
but we don’t often need them.” Dr Liebens continues: “The
clinic’s technological support
The clinic has two sites of digital mammography sys-
where it is active and there- tems, image enhancement
fore requires strong quality software and associated prod-
control. Dr Liebens is keenly ucts is ‘well hidden’, but it is of
focused on quality in treat- course key to our success. We
ing a patient. The breast nurse need fast and productive solu-
is key to this concept. She’s tions and immediate support
the patient’s personal guide in case of problems.”
www.ecmscan.com

throughout the complete proc-


ess. She is also the person to “Agfa HealthCare is commit-
liaise immediately with medi- ted to the fight against breast Contact
VISIT US AT
cal and clinical staff on behalf
of the patient, and is present
cancer. The company provides
reliable technology, but is also
ARABus HEALTH
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“We have one breast nurse, patient-focused programmes
supported by four assistants, through support of a wide
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cal disciplines,” Dr. Liebens breast health awareness among
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– March/April 2011 32 Women’s health

Increased diagnostic accuracy in


breast screening
Breast Imaging is considered to be the primary medical procedure for the
evaluation of women for signs suggesting breast cancer. While mammog-
raphy screening has been credited with saving lives, the modality may miss
as many as 10% to 15 % of breast cancers. Multimodality breast cancer
detection technologies are being applied to improve detection methods, to
compensate for inherent reader variation errors and to find safer methods
for screening younger women and those with dense breasts. Despite such
efforts, current modalities have yet to show improvement in outcomes. In
addition, negative biopsy rates can be as high as 60 - 80 % showing
that many women are being subjected to unnecessary and traumatic pro-
Figure 2. Absorption of light (vertical axis) in hae-
cedures. All this points to the need for adjunctive breast cancer detection moglobin, water and fat at various wavelengths
technologies. This article describes the promise of the computed tomogra- (horizontal axis). CTLM uses a wavelength of
phy laser mammography (CTLM) technique, which uses non-ionising laser 808nm, the point at which both oxy- and deoxy-
haemoglobin absorb the near infra red light but
radiation to detect angiogenesis associated with tumours in the breast. water and fat absorb virtually none.

solving such problems and has been shown


Breast cancer is the most frequently diag- 1990s are most likely the result of changes in to increase sensitivity to about 95%, but
nosed cancer and the leading cause of can- reproductive factors (including the increased with a specificity that is lower than that
cer death in females worldwide, accounting use of postmenopausal hormone therapy) as of mammography [3]. For these reasons,
for 23% (1.38 million) of the total new can- well as an increased screening intensity [1]. it is desirable to have a different approach
cer cases and 14% (458,400) of total cancer Incidence rates in some countries, including to breast imaging, such as the use of addi-
deaths in 2008 which is the latest year for the United States, United Kingdom, France tional techniques that could act as adjuncts
which data have been collected [1]. In gen- and Australia, sharply decreased from the to mammography. One such technique that
eral, incidence rates are high in Western and beginning of the millennium, partly due is showing considerable promise is that of
Northern Europe, Australia/New Zealand to lower use of combined postmenopausal computed tomography using near infra-
and North America; intermediate in South hormone therapy. Breast cancer death rates red laser (CTLM) of the breast.
America, the Caribbean, and Northern Africa; have been decreasing in North America and
and low in sub-Saharan Africa and Asia. The several European countries over the past Computed Tomography Laser
factors that contribute to the international 25 years, largely as a result of early detec- Mammography
variation in incidence rates largely stem from tion through mammography and improved CTLM is based on the detection of neovas-
differences in reproductive and hormonal treatment [1]. cularisation and the angiogenesis that is asso-
factors and the availability of early detection ciated with the growth of tumour cells. It has
services. Reproductive factors that increase Mammography been shown that tumours are unable to grow
risk include a long menstrual history, recent Diagnostic mammography has been shown larger than approximately 1 mm3 without
use of postmenopausal hormone therapy or to have an average sensitivity for the detec- developing a new, hypoxia-triggered blood
oral contraceptives, and nulliparity or late age tion of cancer of 75%, and 60% to 80% of supply [4], [Figure 1]. A CTLM instrument
at first birth. The increases in the incidence all subsequent biopsies are negative for has been developed to detect such angiogen-
of breast cancer that have been observed in cancer [2]. In some cases magnetic reso- esis. The system uses a laser of wavelength
many Western countries in the late 1980s and nance imaging (MRI) can contribute to 808nm in the NIR region of the spectrum

Figure 1. The angiogenesis process. Images Figure 3. Correlation between mammography, CTLM and magentic resonance imaging in a 28-year old
created for National Cancer Institute. woman with an invasive ductal carcinoma and cutal carcinoma in situ (high grade) in her left breast.
33 – March/April 2011

that matches the crossover point of absorp- CTLM [2]. Seventy-nine patients were biop-
tion of both oxygenated and deoxygenated sied after their NIR scans were performed. Practical application of CTLM
haemoglobin [Figure 2]. The laser in the The results of this study showed that the
CTLM device is tuned specifically to this combination of the commercially available
intersection to produce images showing an continuous-wave NIR laser mammographic
attenuation absorption difference between system, (CTLM) plus mammography was
haemoglobin and water or fat molecules. more accurate than mammography alone,
This principle enables the CTLM device to with a statistically significant increase in the
produce a 3D image of the haemoglobin area under the curve (AUC) for mammogra-
distribution in the breast while tissues rich phy plus CTLM compared with mammog-
in fat and water appear transparent. At the raphy alone [2]. Of particular interest was
particular wavelength chosen, blood absorbs the observed correlation between CTLM,
most of the light, providing excellent 3D and not only with mammography but also with The CTLM system functions like a
tomographic images of the entire breast from MRI [Figure 3]. Although this preliminary conventional CT scanner in that an
the chest wall to the nipple. study was limited by several factors includ- energy source, in this case a Near-
ing the relatively small numbers of patients Infrared (NIR) laser, scans the breast;
There are several theoretical advantages to studied, the results were promising enough computed algorithms reconstruct
such optical methods based on near-infra to justify further investigation. cross-sectional images based on the
red imaging of the breast [2]. First, the breast measured optical data. The measured
is fully accessible for imaging with optical Women with dense breasts optical values are directly related to the
methods because of its surface location, rel- It is well-known that mammography has low optical effective transport coefficient of
atively small size and absence of bone struc- accuracy in women with dense breasts, who the breast tissue. Like CT, the images
tures. Secondly, at 800 nm it is possible to constitute 40% of the at-risk population. A may be viewed as single slices or as 3D
exploit the difference in absorption between study involving 155 women (23 - 74 years of volumes. The patient lies face down in a
total haemoglobin and water or fat as an age, median 41 years of age) was carried out comfortable position so that the breast to
intrinsic contrast. Haemoglobin thus acts as to compare CTLM and mammography [5]. be examined is suspended through the
a natural contrast medium and computed All the women who had undergone mam- circular aperture within the scanning
laser tomography produces a “haemoglobin mography were classified according to the bed. Nothing touches the breast; there
angiogram” that reveals the normal vascular Breast Imaging Reporting and Data System is no compression and there is no
structures of the breast [Figure 3]. Because (BI-RADS) into a heterogeneously dense ionising radiation since a laser is used
all tumours require neoangiogensis to sur- breast (BI-RADS 3) or an extremely dense as the energy source instead of the usual
vive and grow, NIR tomographic imaging breast group (BI-RADS 4). The data from X-ray tube. The CTLM system produces
can detect tumours within the breast. Other this trial indicated that the CTLM evaluation 3-dimensional coronal, sagittal and
advantages of the technique are that no ion- was not affected by tissue density in breasts axial cross-sectional images that
ising radiation is needed and that it is rela- and could provide information about angio- display the distribution of haemoglobin
tively inexpensive and easy to use. A com- genesis in most malignant and a few benign within the internal structures of the
mercially available CTLM system has been breast lesions. When CTLM was used as an breast. When interpreted by a trained
produced by Imaging Diagnostic Systems adjunct to mammography in heterogene- and certified physician, the images
Inc, Plantation, FL, USA and been evaluated ously dense and extremely dense breasts the provide images of high value in
in several cohorts of patients with breast sensitivity increased significantly. diagnostic determination.
cancer. The system is approved for sale in all
international markets. References
1. Jemal A et al Global Cancer statistics CA Cancer J mammography. CA Cancer J Clin 2007; 57: 75.
Clinical evaluation of CTLM Clin 2011 Feb 4. 4. Van de Wiele et al. Tumor angiogenesis pathways:
A study of 82 patients, of whom 79 had 2. Poellinger A et al. Near-Infrared laser computed tom- related clinical issues and implications for nuclear
unclear lesions on mammography, ultra- ography of the breast. Acad Radiol 2008; 15:1545. medicine imaging. Eur J Nucl. Med 2002; 29: 699.
sound or MRI, or had palpable masses on 3. Saslow D et al. American Cancer society guide- 5. J in Qi, Zhao Xu-iang Ye, Run Xiao Bao & Milne
physical examination, were studied using lines for breast screening with MRI as an adjunct to ENC, personal communication

Carestream Health offers free hands-on mammography experience at ECR 2011


Carestream Health is running a series of free Digital Mammog- session starts with a short introduction that includes the learning
raphy self-assessment workshops to help healthcare professionals objectives, the method of soft-copy reading and self-assessment,
acquaint and train themselves in digital mammography reading. and instruction on how to use the system. Participants will have 45
Held on Saturday 5th and Sunday 6th March in the Austria Centre, minutes to read the cases, then assess their own performance. Cases
the workshops will be facilitated by eminent clinicians Professor may be discussed in detail with the medical experts. Each module
Roland Holland from the National Expert and Training Centre contains 30 selected screening mammography cases with a mix of
for Breast Cancer Screening, Radboud University Medical Cen- biopsy proven positives and negatives. The modules are independ-
tre, Nijmegen, the Netherlands and Professor Ulrich Bick, MD, ent of each other and do not need to be completed sequentially.
Department of Radiology, CCM, Charité-Universitätsmedizin, Participation is limited and early registration is advised.
Berlin, Germany. Visit www.carestreamhealth.com/ecr
Participants may register for up to seven one-hour sessions. Each for details of how to register on-line.
– March/April 2011
34 PRODUCT NEWS

Vital signs monitor curved neck, which allows the user to reach
With simple, push-button programming all areas of the oropharynx. The brush is
and a large digital display, the YM1000 is ideal for paediatrics and those with chal-
an easy to use vital signs monitor. It enables lenging oropharyngeal situations.
both spot checks or continuous monitor- OroClean Complete is a convenient pack
ing of NIBP, SpO2, pulse rate and tempera- designed for use on those requiring a lit-
ture. A night panel allows the light inten- tle more attention, such as elderly patients,
sityof the display to be adjusted so that the patients in longer term care or patients with
patient can sleep and power saved. The specific requirements.
loudness of the alarm can also be adjusted
to reduce noise levels when patients are
resting. Patient data can be stored and
reviewed on the monitor or as a print- by user; AED allowing semi-automated
out. After 24 hours, data are automatically defibrillation after detection of VF/VT
deleted. Powered from either mains or bat- ECG rhythm; Cardioversion allowing syn-
tery allowing four hours continuous use, chronic defibrillation; monitoring, allow-
batteries allowing longer use are optional. ing long-term monitoring of ECG, SpO2
Other options include a rolling stand and and NIBP and Pacer (Pacemaker) working
built-in printer. in asynchronous (fixed) mode or synchro-
nous (on demand) mode. Both adult and
paediatric defibrillation is possible using
hard paddles and disposable electrodes. OroCare 2 has a product handle that acts as
a reservoir for the separately available anti-
Emtel bacterial mouthwash vials. The mouthwash
Zabrze, Poland is released by gently squeezing the handle
www.ihe-online.com & search 45793 whilst carefully brushing the patient’s teeth
with the soft atraumatic bristles. Standard
suction tubing may be attached to the end of
Oral care range to protect the handle and can be controlled by a com-
against VAP fortably located thumb hole.
Ventilator Associated Pneumonia (VAP) OroCath is a single use oropharyngeal cathe-
Mediana is a growing concern in modern hospital ter for oral suctioning during and in-between
Seoul, South Korea environments. Many recent studies suggest treatments. The flexible catheter extends all
www.ihe-online.com & search 45792 that it is possible to significantly reduce the the way to the ET tube cuff and allows for
risk of aspiration pneumonia by perform- oral hygiene in hard-to-reach places.
ing basic patient oral hygiene. An extended Finally OroCare tooth gel is available in
Defibrillator range of oral care products is now available single doses for use with any Oral Care
A modern, professional defibrillator with from Intersurgical to target VAP. These toothbrush systems.
a large, colour screen, the DefiMax bipha- include OroCare Mini, an extra small
sic can be powered from either mains or toothbrush for targeted cleaning. Designed Intersurgical
battery. Different modes include: manual with a small atraumatic brush head and Wokingham, Berks, UK
where energy for defibrillation is set for soft bristles, this brush also features a long www.ihe-online.com & search 45786

an event of the
PRODUCT NEWS 35 – March/April 2011

Oral and nasal suction device evaluated quickly and accurately. Two or
three waveforms can be displayed with
simultaneous multi-lead ECG monitor-
ing. The monitor allows advanced ST and Printers for high-quality
arrhythmia detection and quick BP read- medical images
ings recall. Graphical and tabular trend-
ing is enabled, and audible and visual
alarms are provided. A number of avail-
able options include EtCO2 and optional
printer. A battery back-up is provided.

Infinium Medical, Inc


Largo, FL, USA
www.ihe-online.com & search 45783
Developed for neonatal and paediatric
patients, the Neotech Little Sucker is one Carestream Health has launched new
of the most efficient oral and nasal suc- Electrical safety analyser printers that address the diverse printing
tion devices available. With its soft, flexible needs of healthcare providers across the
tip, it is extremely gentle, and the thumb globe. Showcased as a work-in-progress, the
port allows for intermittent, single-handed CARESTREAM DRYVIEW CHROMA
suctioning. The product is ideal for use in Imager is a general purpose device that
NICU, PICU, respiratory and L&D depart- will enable facilities to print high quality,
ments. Available in four sizes to accommo- low cost greyscale and colour images from
date different sizes of patients, the small- a variety of modalities to paper or medi-
est size is suitable for very tiny premature cal film. The device can be linked to PACS
babies. The device is ideal for oral and and to image-enabled EMR systems and
nasal suctioning in the nursery (labour and provides outputs of up to 200 prints an
delivery), neonatal intensive care, paediat- hour to film at a resolution of 650 pixels-
ric intensive care and emergency depart- per-inch for every image. This high reso-
ments. The clear handle allows visualisa- lution output meets the requirements for
tion of secretions, and the large opening digital mammography (CR or FFDM) as
allows suction of very thick secretions. The ESA620 Electrical Safety Analyzer, well as traditional modalities.The compact
featuring smart technology to enhance device delivers desktop output of CR, DR,
Medcorp International productivity under any standard, is a port- MRI and CT exams onto medical film,
Laguna Hills, CA, USA able electrical safety tester. With selections and combines high quality and reliability
www.ihe-online.com & search 45782 of three test loads, two protective earth test with low operating costs.
currents and two insulation test voltages,
this versatile device performs all primary Carestream Health
Patient monitors electrical safety tests as well as several addi- Rochester, NY, USA
tional leakage tests for premium standards www.ihe-online.com & search 45781
compliance worldwide. A convenient 20
A device receptacle broadens the range
of equipment that can be tested. Standard
2-wire and optional 4-wire protective earth DISTRIBUTORS WANTED
measurement capabilities offer first-rate
time savings, while DSP technology offers
AUSTRALIAN MADE ECG
better accuracy of leakage measurements
throughout specified ranges. Equipped with
ten unique safety-enhanced ECG posts,
the safety analyser offers simulation of
ECG and performance waveforms so both
electrical safety and basic tests on patient
monitors can be performed with a single
connection. When combined with optional
Featuring cutting-edge innovations and Ansur computer-based software, the safety
impeccable craftsmanship, Omni Express analyser allows for test procedure automa- USB - PC Based ECG
patient monitors are the perfect choice tion, the capture of results and comparison
> 12 Lead Real Time Display
for healthcare professionals who demand to standard limits, printed reports, and
> Reports and Diagnostics
precision, performance and afford- total digital data management. > Special Introductory Price
ability. Enabling effective monitoring of > Small & Compact
ECG, respiration, SpO2, NIBP and tem- Fluke biomedical > Free Worldwide Shipping
perature, the monitors provide for better Everett, WA, USA
patient care by allowing conditions to be www.ihe-online.com & search 45784
sales@machealth.com.au
www.ihe-online.com & search 45698
– March/April 2011
36 PRODUCT NEWS

Patient beside terminal Digital detector


The all-in-one interactive Designed to be cost-effec-
Infotainment bedside ter- tive and with high perform-
minal makes hospital stays ance, the Pixium RAD 4143
easier by providing the is a large-format, flat-panel
same multimedia enter- digital detector that gen-
tainment and commu- erates high quality X-ray
nication choices patients images in real time and
would enjoy at home, such with low exposure, for immediate diagnosis. The detector is available
as telephone, TV, radio, with either caesium iodide (Pixium CsI) or Gadox X-ray detection
movies, games and the internet. The patient experience is enhanced technology. Its simplified design greatly facilitates its integration in
by intranet access, providing them with access to relevant education X-ray systems. The detector is supplied either in an Ethernet compat-
on their condition, information on their care-giver team, and hospital ible version, including preprocessing, or as part of a complete turnkey
information, as well as helping them keep in touch with family and imaging sub-system, the PrestoDR, which provides clinical quality
friends through video-conferencing, Skype, and instant messaging. images. Comprising one or two detectors, a digital imaging worksta-
The patient terminal also benefits medical staff by providing secure tion and interfaces with generator, collimator and dose management
access to electronic patient data with an optimised hospital work- module, PrestoDR delivers outstanding quality images within a few
flow. As an aid to professional diagnosis, the terminal can remotely seconds to significantly improve productivity in any radiology room.
retrieve electronic patient records, access databases from the bedside DICOM compatibility ensures easy integration in a PACS network.
and comply with Hospital Information Systems (HIS) requirements.
Hospital administrators will see increases in operational efficiencies, Thales
increased patient and visitor satisfaction, and improved quality of Velizy, France
care, while boosting profitability. www.ihe-online.com & search 45774

Advantech Europe
Feldkirchen, Germany Foetal monitor
www.ihe-online.com & search 45778 With its brand new design, colour screen
and enhanced functionality, the F3 foetal
monitor reliably addresses the needs of
obstetric departments in doctors’ offices,
Software to customise QA clinics and hospitals. Offering an exten-
sive set of external fetal care monitoring
parameters such as FHR, TOCO as well
as foetal movement, the instrument is
compact, portable and easy to use with
enhanced user functionality. A powerful backup memory and long
lasting rechargeable battery facilitate use. The start button on the front
panel can be configured to integrate patient information and enable
printing, simplifying the workflow. Three different display modes
allow the selection of the one most appropriate for clinical needs. The
The development goal in the creation of Ocean QA software, a 12 hours data storage, rechargeable battery allowing seven hours use
powerful tool that allows users to customise their Quality Assur- and the Insight data management software enable the monitor to be
ance, was to create a smart and quick product incorporating the used in outpatient departments and during house calls.
best features of existing software as well as new features. The new
software creates a solid foundation for organising user and equip- EDAN Instruments
ment information, measured data and test analyses. It provides an Shenzhen, China
easy-to-view interface on the user’s laptop or netbook. Standard- www.ihe-online.com & search 45775
ised measurements are easily created, not only for X-ray equip-
ment, but also for the complete X-ray room. Attachments can be
added, set-ups can be shared and global reports can be sent. The Breast angiography
flexibility of the software allows the interface to be arranged as the GE Healthcare’s new SenoBright1 Contrast Enhanced Spectral
user wishes, and the templates provided can be edited to include Mammography (CESM) technology is designed to allow physi-
new columns, rows or analyses. The main templates can be saved cians to image blood flow through angiography of the breast using
as ”favourites”. Measured data and waveforms are easily stored for a contrast agent and a dual energy acquisition technique. Con-
later viewing and it is always possible to make additional expo- trast agents can be used to highlight angiogenesis, the growth of
sures. The software is specifically designed to faciliate use of RTI’s small blood vessels potentially related to the presence of cancer.
Piranha or Barracuda X-ray multi-meters, giving users access to In addition to typical mammography images that show breast tis-
the full power of these instruments in a very intuitive way. sue density, CESM technology is designed to provide doctors with
images of contrast uptake, which may indicate angiogenesis.
RTI Electronics SenoBright uses X-rays at multiple energies to create two separate
Mölndal, Sweden exposures. These resulting images specifically illuminate and high-
www.ihe-online.com & search 45773 light areas where there is contrast uptake and potentially angiogen-
esis. As mammography mainly images tissue densities, SenoBright
PRODUCT NEWS 37 – March/April 2011

has been designed to produce an image that


maps contrast uptake, adding the functional
information to the conventional standard Adhesive for use with neonates
tissue density information of mammog-
raphy. Doctors can highlight the prolif-
eration of small blood vessels, potentially
associated with cancerous tumour growth.
Patients receive an intravenous injection
of standard iodine contrast agent, and after
two minutes undergo a five-minute digital mammography exam.
CESM images are acquired in familiar mammography views so that
they can be correlated with standard results, facilitating interpretation
by other specialists like surgeons or oncologists. CESM technology is
intended to work as an upgrade to GE Healthcare’s Senographe DS
and Senographe Essential digital mammography equipment.

GE Healthcare
Buc, France A flexible, new alternative to harmful tape on fragile neona-
www.ihe-online.com & search 45796 tal skin, NeoFlex Silicone Adhesive Roll is a unique adhesive,
being easy to apply, adjust, remove as well as being an ideal
skin barrier. The product can be used to secure limb boards
Integrated MR/PET system and for a variety of other uses. The product is ideal for very
Until now, it was nearly small premature babies as well as older babies with sensitive
impossible to integrate skin. Conveniently packaged as a roll for single patient use,
MR and PET technolo- NeoFlex, like all of Neotech’s products, is latex and phthalate
gies: the conventional (DEHP) free.
PET detectors, which
use photomultiplier Neotech products, Inc.
tubes, could not be used Valencia, CA, USA
in the strong magnetic www.ihe-online.com & search 45777
field generated by an MR system. Integration was further limited
by the lack of space inside the MR device. For this reason, MR-PET
imaging has to be the result of two separate scans (MR and PET) with
a significant time lag. The Biograph mMR whole-body integrated MR
and PET system allows simultaneous data acquisition. This revolu-
tionary system comprises a MR scanner and an integrated PET detec-
tion system with an architecture that performs as one. The new 3-Tesla Summer Conference
hybrid system simultaneously captures MR and PET data with a
whole-body system. With the simultaneous acquisition of MR and
PET data, this system is designed to provide new opportunities for
7-9 July 2011
imaging. While MR provides exquisite morphological and functional Budapest, Hungary
details in human tissue, PET goes further to investigate the human
body at the level of cellular activity and metabolism. The innovative
system has the potential to be a particularly valuable tool for identify-
ing neurological, oncological and cardiac conditions of disease and in
Perioperative Management
supporting the planning of appropriate therapies. Since MRI does not State of the Art
emit ionising radiation, Biograph mMR may provide an added bene-
fit with lower-dose imaging. The system also opens new opportunities
for research, such as the development of new biomarkers or new ther-
apeutic approaches. MR and PET have become an established part of
everyday healthcare routines. The integration of these two technolo-
gies into a single system capable of simultaneous acquisition brings
the potential to revolutionise the diagnosis of many conditions. Initial
research suggests that with this system, Molecular MR can scan the Join us !
entire body in as little as 30 minutes for the combined exams, com-
pared to one hour or more for sequential MR and PET examinations. Joint with For more information contact
European Society of Intensive Care Medicine
A wide range of clinical applications is envisioned for molecular MR Rue Belliard 19
including the early identification and staging of malignancies, therapy 1040 Brussels, Belgium
Tel: +32 2 559 03 71
planning (including surgery planning) and therapy control. Fax: +32 2 559 03 79
Email: Budapest2011@esicm.org
Internet: www.esicm.org
Siemens
Erlangen, Germany
www.ihe-online.com & search 45776
– March/April 2011
38 PRODUCT NEWS

Flat panel DR cassette


Ideal for any clinical environment, the- Calendar of events
FDR D-EVO flat panel DR cassette uses an
March 17-20, 2011 June 15-17, 2011
innovative technology to provide clinicians KIMES 2011 IMDM (International Medical
with excellent image quality and outstand- Coex, Seoul, Korea Distributor Meeting) - Cardiovas-
Tel. +82 2 551 0102 cular & Surgery
ing flexibility. The cassette enables users Fax +82 2 551 0103 Berlin, Germany
to transition to DR without modification e-mail: kimes@kimes.kr Tel. +33 970 449564
www.kimes.kr e-mail: meetings@imdmeeting.org
to the exam room. The lightest weight DR www.imdmeeting.org
March 22-25, 2011
cassette of its size available, with a weight 31st International Symposium on June 22 - 25, 2011
of only 2.8 kg, the 384 x 460 mm x 14 mm Intensive Care and Emergency CARS 2011 - Computer Assisted
Medicine (ISICEM) Radiology and Surgery
flat panel DR cassette provides portability Brussels, Belgium Berlin, Germany
to address lateral or other cassette-based is prevented, and the antibacterial surface Tel. +32 2 555 36 31
Fax +32 2 555 45 55
Tel: +49-7742-922 434
e-mail: office@cars-int.org
also facilitates infection control. e-mail: sympicu@ulb.ac.be www.cars-int.org
www.intensive.org
June 23-25 2011
Britplas Commercial Windows March 29-31, 2011 ESICM Summer Conference,:
14th SE-Asian Healthcare Show & Mechanical Ventilation – an Update
Warrington, Cheshire Conferences Turin, Italy
www.ihe-online.com & search 45732 Kuala Lumpur, Malaysia e-mail: turin2011@esicm.org
Tel +603 79 54 65 88 www.esicm.org
Fax +603 79 54 23 52
e-mail: sales@abcex.com July 7-9, 2011
www.abcex.com ESICM Summer Conference: Periop-
Ultrasound system erative Management. State of Art
April 4-6, 2011 Budapest, Hungary
Offering superior Hospital Build Europe 2011 e-mail: budapest2011@esicm.org
images of a con- Nürnbergmesse, Germany
Tel. +49 211 9686 3756
www.esicm.org

exams as needed, even in existing DR sistent and uni- Fax +49 211 9686 4756 August 26-29, 2011
www.hospitalbuildeurope.com 13th World Congress of the World
rooms. Another distinct advantage over form quality, the Federation for Ultrasound in Medi-
competitive solutions includes a detach- E-CUBE 9 can April 6-8, 2011 cine and Biology (WFUMB 2011)
Med-e-Tel 2011 Vienna, Austria
able power supply, which eliminates the allow accurate Luxembourg, Luxembourg Tel. +43 1 535 13 05
potential hazards of a tethered cord or diagnosis, even Tel. +32 2 269 84 56
Fax +32 2 269 79 53
Fax +43 1 535 70 37
e-mail: office@wfumb2011.org
concerns about battery life. The cassette on obese patients, e-mail: info@medetel.eu www.wfumb2011.org
www.medetel.lu
represents the latest addition to Fujifilm’s providing fine and August 27-31, 2011
impressive line-up of groundbreaking DR detailed image res- April 13-14, 2011 ESC Congress 2011
The 7th Annual World Health Paris, France
products. Featuring secure network con- olution as well as Care Congress Europe 2011 Tel. +33.4.92.94.76.00
nectivity, images are transmitted to the superior penetra- Innovations and Best Practices to
Improve European Health Care
www.escardio.org/congresses/
esc-2011
technologist workstation in only five sec- tion. Single-crystal Brussels, Belgium
Tel. +1 781-939-2559 September 14-16, 2011
onds and cycle times are only nine second. transducers are www.worldcongress.com/europe Medical Fair Thailand 2011
The cassette uses the company’s patented now applied to three types of transducer: Bangkok, Thailand
May 10-13, 2011 Tel. +65 6332 9620
ISS (Irradiation Side Sampling) to improve the single-crystal convex array (the larg- World of Health IT 2011 Fax +65 6332 9655
DQE (detective quantum efficiency) for est radius of curvature), the single-crystal Budapest, Hungary
e-mail: customerservice@worldof-
e-mail: medicalfair-thailand@mda.com.sg
www.medicalfair-thailand.com
outstanding image quality. This patented phased array and the innovative single- healthit.org
www.worldofhealthit.org September 24-28, 2011
technology reduces the distance for light crystal 3D volume convex transducer. ERS Annual Congress
signals reaching the sensor, mitigating dif- These transducers offer wide bandwidth May 9-13, 2011 Amsterdam, The Netherlands
4th International Congress of Tel. +49 30 246 032 20
fusion and attenuation for enhanced image and higher resolution images. The imaging Myology Fax +49 30 246 033 99
sharpness and reduced noise. The result is technology of the ultrasound system offers Lille, France
Tel. +33 4 78 176 276
e-mail: ers2011registration@
kit-group.org
FDR images with consistently high quality excellent 2D images that are substantially http://myology2011.org/ www.erscongress2011.org
index_us.html
and increased diagnostic confidence. enhanced through FleXcan (Flexible Scan October 1-5, 2011
architecture), a unique hardware structure May 24-27, 2011 ESICM LIVES 2011 24th Annual
Hospitalar 2011 Congress
FUJIFILM Europe and wide-bandwidth imaging technology, São Paulo, Brazil ICC-Berlin, Germany
Düesseldorf, Germany and FullSRI, an advanced image process- www.hospitalar.com/ingles/ Tel. +32 2 559 03 71
Fax +32 2 559 03 79
www.ihe-online.com & search ing technology. June 6-8, 2011 e-mail: berlin2011@esicm.org
UKRC 2011 www.esicm.org
Core features that optimise the workflow of Manchester, UK
the ultrasound system include a unique 17” Tel. +44 20 7307 1406 / 11 November 16-19, 2011
e-mail : exhibition@ukrc.org.uk MEDICA
Windows developed for use in wide LCD monitor that provides thumbnail www.ukrc.org.uk Düsseldorf, Germany
hospitals images for instant review, a zoom reference June 7-9, 2011
e-mail: info@medica.de
www.medica.de
Specifically developed for use in hospitals, view, an image parameter adjustment con- Medifest South Africa
Cape Town, South Africa November 27 –
Safevent windows allow unrestricted natu- text menu to optimise the image quality www.vantagemedifest.com December 2, 2011
ral ventilation, reducing or eradicating the and a user interface (UI) that is efficiently RSNA 2011
June 11-14, 2011 Chicago, IL, USA
need for mechanical ventilation. The open- reinforced. For the convenience of both Euroanaesthesia 2011 Tel. +1 630 571 2670
Amsterdam, The Netherlands www.rsna.org
ing system is safe and secure, preventing users and patients, the system provides an Tel. +32 2 743 3290
access of intruders without the necessity integrated gel warmer and anti-dust trans- www.euroanesthesia.org

for locks or keys. The anti-ligature locks ducer connector door.


prevent opening by patients if this is unde- For more events see
sirable. They have easily cleaned rounded Alpion Medical Systems www.ihe-online.com/events/
edges, and cannot be pulled off the win- Seoul, The Republic of South Korea Dates and descriptions of future events have been obtained from
usually reliable official industrial sources. IHE cannot be held
dow. The entry of flies, wasps and vermin www.ihe-online.com & search responsible for errors, changes or cancellations.
CT L a s e r
Br easT ImagIng

No Compression
No Contrast Agent
No Ionizing Radiation
Not Affected by Breast Density

Live
at
Demos 1
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ECR 2
Stand FDA 510(k)
113 APPLICATION UNDER REVIEW

N G F OR
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CTLM ® 1020
SCAN

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The Computed Tomography Laser Mammography system is a non-invasive


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laser based imaging device that reveals the distribution of angiogenesis
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often associated with breast cancer.


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FORT LAUDERDALE, FLORIDA

Imaging Diagnostic Systems, Inc. • 5307 NW 35th Terrace • Fort Lauderdale, FL 33309 U.S.A.
Tel: (1) 954 - 581- 9800 • Fax: (1) 954 - 581- 0555 • www.imds.com • info@imds.com
CAUTION: Investigational device. Limited by US Federal Law to investigational use. 820001.ECR

www.ihe-online.com & search 45772


We image-enable Regional Care.

Where?
In Utopia?
Well, not in Utopia, but all over the world we actually live in. We call it regional health imaging – market-proven
image and information management systems that implement multi-site integration up to the regional level.
Consolidating radiology, cardiology, nuclear medicine ... any department that produces images – so that you can
stay ahead of hospital and governmental requirements for sharing data and infrastructure. We offer a complete,
configurable, single-source solution that helps standardize disparate IT infrastructures and consolidate patient
records. Optimizing clinical resources, workflow and load balancing, reducing waiting times, and, ultimately,
saving costs. To everyone’s benefit. So, even though Utopia is not yet on our list, our integrated regional health
program has your current world covered.

We invite you to visit our booth at ECR 2011 for a demo! - EXPO A: BOOTH # 103
www.agfahealthcare.com/ecr2011

Imaging Excellence, Clinical Confidence. We’ll take you there.


HealthCare
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