hospital
Equipment & Technology Medical Management
Volume 37
March - April 2011 Weekly news updates on www.ihe-online.com
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
hospital
Contents Rue Royale 326
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FRONT COVER PRODUCTS Fax: +32-2-240 26 18
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[35] P
rinters for high [36] Software to cus- [37] Adhesive for use
quality medical tomise QA in the with neonates Managing Editors
images X-ray room Alan Barclay, Ph.D.
a.barclay@panglobal.be
Frances Bushrod, Ph.D.
Circulation Manager
Arthur Léger
Publisher/Editor in Chief
Bernard Léger, M.D.
ISSN 0306-7904
[16 - 18] Molecular imaging-based ultrasound for assessment of inflammation
[20 - 22] Optimised imaging protocols for enhanced contrast in FMISO PET Coming
Coming upMay/JUne
up in in JUNE2011
2010
Anaesthesiology special
Cardiology special
Ultrasound
Pediatrics
[24 - 33] Women’s Health Special Health IT
Ultrasound
[26 - 28] Early identification of pre-eclampsia For submission of editorial material, contact Alan
Barclay at a.barclay@panglobal.be
[30 - 31] The success of a multidisciplinary breast and breast screening clinic
For advertising information, go online to
[32 - 33] Laser computed tomography of the breast www.ihe-online.com, simply click on ‘Magazine’
and ‘Media Information’ or contact
Astrid Wydouw at a.wydouw@panglobal.be
to 85.3 in women – a drop of of the adrenal cortex. A joint Laguna Hills, CA 92653 USA
12179
7% in men and 6% in women – Swedish-American research TEL: 949-582-0313
since 2007. effort has now uncovered a FAX: 949-582-3747
Medcorpint@cox.net
However, the number of women genetic cause behind the occur- www. Neotechproducts.com
dying from lung cancer is rence of such tumours.
www.ihe-online.com & search 45756
– March/April 2011 6 emergency medicine
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.
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
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
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
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 51 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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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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Diagnostics, LLC, a subsidiary of General Electric T: 49-212-28 02-0, F: 49-212-28 02-28 gehealthcare.com
Company, doing business as GE Healthcare.
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.
Symposia
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Amsterdam_IHES.indd 2 20/05/10 14:58
Waterproof 12-crystal ultrasound transducer
Twelve-crystal transducer diffuse as the depth increases In addition to its ability to offer higher accuracy even without
technology was initially intro- [Figure 1]. The more homog- a more homogenous coverage touching the patient.
duced in 2007 for foetal mon- enous the signal, the greater and a larger focal area than
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-
ultrasound transducer attains tal transducer must be reposi- 12-crystal transducer’s larger essary for clinicians to locate
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.
ing increased sensitivity and signals to be detected with
higher clinical confidence.
Monitor
ducers.as has been shown
by a comparative analysis of
the sound field distribution of
EDAN has a long and proud history in obstetrical care technologies –
12-crystal and 8-crystal ultra- offering fetal and maternal monitors, obstetrical information system, and
sound transducers at differ- measurements used during routine and high-risk deliveries.
ent depths of 6 cm, 9 cm and
12 cm. It was found that the
beam area became larger as
the depth increased, and that F9 Express
the beam area of the 12-crys-
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ensures that the foetal heart
was within the ultrasound
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nal movement [Figure 1].
appears rectangular and 12.1” high resolution, color TFT-LCD touch screen
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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
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
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.
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
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
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
No Compression
No Contrast Agent
No Ionizing Radiation
Not Affected by Breast Density
Live
at
Demos 1
01
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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IMA
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laser based imaging device that reveals the distribution of angiogenesis
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AG ST
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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
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