International

hospital
Equipment & Technology Medical Management
Volume 36
November 2010 Weekly news updates on www.ihe-online.com

PET/CT in ovarian cancer

Also in this issue

Susceptibility weighted imaging

in neurosurgery

Focused Assessment with Sonography

in Trauma (FAST)

Robot-Assisted Radical Prostatectomy (RARP)

HIgh performance US also Advanced SPECT/CT system Magnetically-guided

usable at point-of-care Page 36 capsule endoscope
Page 34 Page 37

The Magazine for Healthcare decision Makers

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 Publisher’s Letter 3 – November 2010

Bernard Léger, M.D.

Technology will remain a key driver

of improved healthcare in the next decade
It will surely not have escaped staff to record their observations in making hospitals more efficient : generally agree that healthcare
the notice of regular readers that and treatment prescriptions. Next its contribution will be positively improves when the people making
International Hospital has finally in line are Clinical Decision Support complemented by developments decisions on care have the latest,
adopted the A4 standard European Systems (CDS) and Health Informa- in medical instrumentation tech- reliable information.
size, and that it is now printed on tion Exchanges (HIE), the informa- nology and in energy-saving Now in its 36th year of existence,
heavier paper stock. These moves tion networks that encompass entire technologies. International Hospital looks forward
reflect the magazine’s position- health regions or countries. Quality medical magazines can to its continuing and renewed role in
ing in the last couple of years as a Of course, IT is not by any means also be considered as part of this providing such essential information
quality, editorially-led publication the only technology to be involved overall equation as health experts to healthcare decision makers.
covering the whole spectrum of
technological and clinical advances
relevant to the modern hospital.
So that this repositioning be
directly recognisable on the front
page, International Hospital’s sub-
title has also been changed, replac-
ing the much used (and sometimes
abused) word ‘Solutions’ with the
universally understood ‘Technol-
ogy’ and, more importantly, add-
ing the second subtitle ‘Medical
Management’ to highlight the
vital link between technologi-
cal and instrumentation innova-
tions on the one hand and better
patient outcomes on the other.
The term medical management is
used here in its broad meaning of
a healthcare organisation’s systems
and programmes designed to sup-
port diagnosis, manage disease,
prevent illness and, in general,
improve health, rather than in a
restricted sense of medical costs
management.
Not that containing costs is not one
of the major issues facing health-
care systems today. Indeed, it is
estimated that by 2015, healthcare
costs will account for nearly 20% of
the U.S. economy and close to 15%
of GDP in the larger EU countries.
Expectations are high that health IT
will enable healthcare organisations
not only to curtail operational costs
but also improve their performance
and reduce the number of medical
errors. Foremost among health IT
tools are Electronic Medical Records
(EMR), giving clinicians ready
access to complete, accurate and leg-
ible patient data and the Computer-
ised Physician Order Entry System
(CPOE) enabling physicians to order
tests and diagnostic procedures elec-
tronically. These devices can now be
deployed via handheld wireless com-
puting tablets that also allow medical
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 International

Contents
FRONT COVER PRODUCTS
[34] High performance
US also usable at
point-of-care
hospital
Rue Royale 326
1030 Brussels, Belgium
Tel. +32-2-240 26 11
Fax: +32-2-240 26 18
[36] A
 dvanced SPECT/ [37] Magnetically- www.ihe-online.com
CT system guided capsule
endoscope Managing Editors
Alan Barclay, Ph.D.
a.barclay@panglobal.be
Frances Bushrod, Ph.D.

Editorial & Advertising Coordinator

Anna Hyrkäs, M.Sc.

Circulation Manager
Arthur Léger

Publisher/Editor in Chief
Bernard Léger, M.D.

Advertising Sales Manager

Astrid Wydouw
FEATURES a.wydouw@panglobal.be
[6 - 8] Cardiovascular Medicine Webmaster
Calcium supplements and cardiovascular disease Damien Noël de Burlin

©2010 by PanGlobal Media bvba-sprl. Production &

[10 -12] Point-Of-Care Lay-out by Studiopress Communication, Brussels.

Focused Assessment with Sonography in Trauma (FAST) Circulation Controlled by Business of

Performing Audits, Shelton, CT, USA.

[16 - 19] Surgery The publisher assumes no responsibility for opinions or state-
ments expressed in advertisements or product news items.
Robot-Assisted Radical Prostatectomy (RARP) The opinions expressed in by-lined articles are those of the
author and do not necessarily reflect those of the publisher. No
conclusion can be drawn from the use of trade marks in this
[20 - 32] Medical Imaging Special publication as to whether they are registered or not.

[20] Scientific literature on medical imaging

ISSN 0306-7904

[22 - 27] The role of PET/CT in the imaging of ovarian cancer

Comingupup
Coming inin
DECJUNE
/Jan2010
2011
Telemedicine special
Cardiology special
[28 - 29] High field strength SWI of cerebral cavernous malformations: the MRI update
neurosurgeon’s perspective Pediatrics
Image-guided surgery
Ultrasound
[30 -32] Utility of point-of-care sonography in distinguishing soft tissue
For submission of editorial material, contact Alan
from joint effusions
Barclay at a.barclay@panglobal.be

For advertising information, go online to

www.ihe-online.com, simply click on ‘Magazine’
REGULARS and ‘Media Information’ or contact
[3] Publisher’s letter Astrid Wydouw at a.wydouw@panglobal.be

[14 - 15] News in brief Free Subscription for

Healthcare professionals
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[38] Product news next 12 months completely free of charge. To
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 – November 2010 6 CArdiovascular MEDICINE

Calcium supplements and cardiovascular

disease
Calcium supplements have been a mainstay of treat- all incident events, suggested events that occurred during the
ment to promote skeletal health for many years. Recent that calcium supplements might study. Where such data were
evidence, however, suggests that they may cause increase the risk of myocardial not available, trial-level sum-
infarction (MI) by 49%, and of mary data were requested. A
increased risk of cardiovascular disease, in particular
stroke by 37% [7]. While these draft protocol was circulated to
myocardial infarction. These data should prompt a results were not definitive, they all the authors of the 15 stud-
re-evaluation of the use of calcium supplements for mandated further investigation, ies eligible for inclusion, with
skeletal health in older people. because of the very widespread a request for comments. Sug-
use of calcium supplements in gested amendments were incor-
by Dr Andrew Grey, Dr Mark Bolland and Dr Ian Reid older people, in whom cardio- porated into the protocol, which
vascular risk is often high. was reviewed and approved by
all investigators participating
Calcium supplements have long populations at low risk of frac- Meta-analysis of cardio- in the patient-level meta-anal-
been recommended for improv- ture if it was inexpensive and vascular events in trials ysis before data collation and
ing skeletal health, initially on safe, or it conferred non-skeletal of calcium supplements analysis commenced.
the basis of metabolic balance health benefits. The ideal mechanism to deter-
studies. In the era of clinical mine whether calcium supple- Of the fifteen trials eligible for
trials, however, it has become There has long been interest in ments increase the risk of car- inclusion, cardiovascular data
apparent that supplemental the possibility that calcium sup- diovascular disease would be to were not collected in four trials,
calcium has modest effects on plements impact favourably on conduct an adequately powered patient-level data were available
bone metabolism, producing cardiovascular disease, as some randomised clinical trial. Such from five (8,151 participants,
decreases in biochemical mark- observational studies have a study is, however, unlikely median follow-up 3.6y) and
ers of bone resorption of 15-20% reported lower rates of vascular to take place, given that exclu- trial-level data were available
[1]. Bone loss is slowed, but not events in participants ingesting sion of a 20% increase in risk of from eleven (11,921 partici-
halted, by calcium supplements greater amounts of calcium [5], MI would require a trial with pants, median follow-up 4y).
[2], and fracture risk is reduced and RCTs have variably demon- > 100,000 participant-years In 10 of the 11 trials provid-
by about 10% in meta-analysis strated small improvements in of follow-up, and the ethical, ing data from analysis, calcium
of randomised controlled trials some cardiovascular risk factors funding and recruitment dif- supplements were studied at a
(RCTs) involving 6,560 partici- in those assigned to calcium [6]. ficulties inherent in prosecut- dose of at least 1000mg daily.
pants [3]. Co-administration of To address the important possi- ing a trial which hypothesises The average age of participants
calcium and vitamin D sup- bility that calcium supplements harm. We therefore conducted was 73y, and 83% were women.
plements produces a similarly improve cardiovascular health, a meta-analysis of cardiovascu- Thus, the participants were
modest (13%) reduction in frac- we pre-specified cardiovascular lar events in existing RCTs of similar demographically to the
ture risk, based on meta-analysis events as secondary endpoints in calcium supplements (see Table group within the general popu-
of RCTs involving 55,756 par- a 5y randomised controlled trial 1 for details of trial eligibility lation which is most commonly
ticipants [4]. Thus, calcium sup- of calcium supplements (1g daily) criteria). We contacted the prin- prescribed calcium supple-
plements, with or without vita- in older women. The results of cipal investigators of eligible ments. Cardiovascular disease
min D, are weak anti-resorptive this analysis, which involved a trials and invited them to par- was not a primary endpoint
agents. Such a therapy might be comprehensive search for, and ticipate by providing patient- of any of the trials, and events
an acceptable intervention in independent adjudication of, level data on cardiovascular were ascertained by participant
self-reports, hospital admis-
sion data and death certificates.
The pre-specified primary end-
points of the analysis were time
to first MI, time to first stroke,
and time to first event for the
composite endpoint of MI,
stroke or sudden death.

The results of the meta-analysis

of both individual patient-level
and trial-level data are sum-
marised in Table 2. In both
analyses, allocation to calcium
supplements conferred a sig-
Table 1. Eligibility criteria for meta-analysis of cardiovascular effects of calcium supplements. nificant, approximately 30%,

Endpoint Individual patient-
level analysis
(5 trials, 8,151
participants)
MI 1.31 (1.02-1.67)
Stroke 1.20 (0.96-1.50)
MI, stroke 1.18 (1.00-1.39)
and sudden
death
Table 2. Results of meta-analysis of cardiovascular events in trials of
calcium supplements. Data are hazard ratio/relative risk (95% CI).
increase in the risk of MI,
and smaller, non-significant
increases in the risks of stroke,
the composite of MI, stroke and
sudden death, and total mortal-
ity. The individual-patient level
analysis provides an insight
into the timing of the onset of
the adverse effect of calcium
supplements, and suggests that
the increase in risk of MI begins
soon after commencing treat-
ment [Figure 1A]. The results of
the trial-level analysis, incorpo-
rating data from 11 trials, dem-
onstrate a striking consistency
of the increased risk between
trials that contained a substan-
tial number of events [Figure
1B]. In additional analyses,
calcium supplementation also
increased the risk of all events
(both first and recurrent), for
each of the primary endpoints,
by 24-32%.
Limitations
Our study has some limitations.
In none of the trials were car-
diovascular outcomes the pri-
mary endpoints; consequently,
data on cardiovascular events
were gathered by a variety of
mechanisms, including par-
ticipant self-reports, hospital
admission data, death certifi-
cates and adjudicated medical
records. However, unless there
was systematic differential mis-
classification or misreporting of
cardiovascular events by treat-
ment allocation in this data-
set, this is unlikely to alter the
results, because the data came
from blinded, placebo-control-
led trials. In addition, the results
were similar across trials that
used different methods of event
7 – November 2010
Trial-level analysis potent therapies for fracture response to treatment with
11 trials (11,921 prevention, such as bisphos- zoledronate and calcium and
participants) phonates, it is not proven that vitamin D [11, 12].
this practice is necessary for the
anti-fracture efficacy of the lat- Implications for future
1.27 (1.01-1.59) ter agents. In fact, there is clini- research
cal trial evidence of anti-frac- The current results suggest
1.12 (0.92-1.36) ture efficacy of both clodronate some important directions
and oestrogen in the absence of for future research efforts. At
1.12 (0.97-1.30) calcium and vitamin D admin- present, the mechanism(s) by
istration [8, 9], of similar effects which calcium supplements
of alendronate vs alendronate increase risk of cardiovascular
plus calcium on bone mineral events is not known. A com-
density (BMD) and markers prehensive discussion of poten-
of bone turnover [10], and of tial mechanisms is beyond the
ascertainment. No or incom- changes in BMD and markers scope of this paper, but has
plete cardiovascular data were of bone turnover in response been published elsewhere [13].
available in seven trials, com- to intravenous zoledronate Possible ways by which calcium
prising 15% of the total number administered alone that are supplements might adversely
of potential participants. How- similar to those observed in affect vascular health include
ever, the consistency of the
findings in the other eight
larger trials suggests that
this small amount of miss-
ing data is unlikely to have
substantially affected the
results. Finally, our analysis
was restricted to trials of cal-
cium monotherapy, because
the original signal of cardio-
vascular harm came from a
trial of such treatment. It
is currently uncertain as to
whether combined therapy
with calcium and vitamin D
alters cardiovascular risk.
Implications for clini-
cal practice
The finding that calcium sup-
plements modestly increase
the risk of MI has important
implications for pharma-
cological management of
skeletal health. At an indi-
vidual patient level, the 30%
increase in relative risk of MI
is likely to negate the skeletal
benefit (10% relative reduc-
tion in risk of fracture) in a
great many older individu-
als, in whom use of calcium
supplements is currently
widely recommended. At a
population level, the find-
ings raise significant doubt
as to whether calcium sup-
plements should be included
in guidelines for manage-
ment of skeletal health.
Although calcium is often
co-prescribed (with or with-
out vitamin D) with more
www.ihe-online.com & search 45643
 – November 2010
Figure 1A & B. Effect of calcium supplements on the incidence of myocardial infarction. A. Time to first event analysis of individual patient data from 5
placebo-controlled RCTs of calcium supplements B. Random effects models of trial-level data from 8 placebo-controlled RCTs of calcium supplements
Adapted by permission from BMJ Publishing Group Limited. [BMJ, Bolland et al, 341, c3691, 2010]
acceleration of vascular calcification,
increased arterial plaque instability, altered
vascular tone and increased coagulabil-
ity. Laboratory and clinical studies should
focus on these possibilities.
There is urgent need for investigation of
the cardiovascular effects of combina-
tion therapy with calcium and vitamin D,
which is commonly prescribed for skeletal
health even though the anti-fracture effi-
cacy is comparable to that of calcium alone.
Although no effect of calcium and vitamin
D on risk of cardiovascular disease was
reported in the Women’s Health Initiative
trial, more than half of the participants in
that trial were taking non-protocol calcium
supplements [14], which potentially could
obscure adverse effects of the intervention.
The current findings apply to calcium
taken as a supplemental medication. It is
ISO 9001
ISOVersion
9001 Version
2000 2000
ISO 13485
ISO 13485
VersionVersion
2003 2003
CE 0197
CE 0197
www.ihe-online.com & search 45690
8 CArdiovascular MEDICINE
uncertain whether taking additional cal- Horne A, Ames R, et al. BMJ 2008; 336: 262-6.
cium in food has an effect on cardiovas- 8. M
 cCloskey EV, Beneton M, Charlesworth
cular risk. The biochemical effects of cal- D, Kayan K, deTakats D, Dey A, et al. J Bone
cium ingested as a supplement differ from Miner Res 2007; 22: 135-41.
those induced by calcium taken as a food, 9. W
 riting Group for the Women’s Health Initia-
including changes in serum calcium [15], tive. Risks and benefits of estrogen plus pro-
gestin in healthy postmenopausal women:
principal results from the Women’s Health
“... the findings raise significant Initiative randomised controlled trial. JAMA
doubt as to whether caclium 2002; 288: 321-33.
10. B onnick S, Broy S, Kaiser F, Teutsch C,
supplements
1 should be Rosenberg E, DeLucca P, et al. Curr Med Res
Opin 2007; 23: 1341-9.
incuded for the management 11. B lack DM, Delmas PD, Eastell R, Reid IR,
of skeletal health ....” Boonen S, Cauley JA, et al. N Engl J Med
2007; 356: 1809-22.
12. G rey A, Bolland MJ, Wattie D, Horne A,
suggesting that the two forms of calcium Gamble G, Reid IR. J Clin Endocrinol Metab
might differ in their effects on tissues 2009; 94: 538-44.
such as the vasculature and the skeleton. 13. R eid IR, Bolland MJ, Grey A. Clin Endocri-
Given that many authorities recommend nol (Oxf). 2010: published online 23 Feb.
minimum levels of daily calcium intake in 14. H sia J, Heiss G, Ren H, Allison M, Dolan
excess of 1000mg, it is important to deter- NC, Greenland P, et al. Circulation 2007;
mine whether altering intake of calcium in 115: 846-54.
the diet affects risk of vascular disease. 15. G reen JH, Booth C, Bunning R. Asia Pac J
Clin Nutr 2003; 12: 109-19.
References
1. Reid IR, Mason B, Horne A, Ames R, Reid HE, The authors
Bava U, et al. Am J Med 2006; 119: 777-85. Andrew Grey,*
2. Reid IR, Ames RW, Evans MC, Gamble GD, Mark Bolland and Ian Reid,
Sharpe SJ. N Engl J Med 1993; 328: 460-4. Department of Medicine,
3. Tang BMP, Eslick GD, Nowson C, Smith C, University of Auckland.
Bensoussan A. Lancet 2007; 370: 657-66.
4. The DIPART Group. Patient level pooled analy- *Corresponding author:
sis of 68 500 patients from seven major vita- Dr A Grey
min D fracture trials in US and Europe. BMJ Department of Medicine
2010;340:b5463-. University of Auckland
5. Bostick RM, Kushi LH, Wu Y, Meyer KA, Sell- Private Bag 92019
ers TA, Folsom AR. Am J Epidemiol 1999; 149: Auckland,
151-61. New Zealand
6. Reid IR, Mason B, Horne A, Ames R, Clearwa- Tel. 64-9-3737599
ter J, Bava U, et al. Am J Med 2002; 112: 343-7. Fax 64-9-3737677
7. Bolland MJ, Barber PA, Doughty RN, Mason B, Email a.grey@auckland.ac.nz
1
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 – November 2010 10 POint-of-care

Focused Assessment with Sonography in

Trauma (FAST). Can it be justified ?
Focused Assessment with Sonography in Trauma (FAST) is a limited ultra- Furthermore, it is not possible to con-
sound technique, usually performed by the emergency physician, in cases fidently exclude the presence of fluid on
of blunt abdominal trauma (BAT). It is designed to quickly identify free a normal FAST scan. Although as lit-
tle as 200 mL of fluid is sonographically
fluid, which would imply the presence of blood in the peritoneum, i.e.
demonstrable by a competent operator
haemoperitoneum. with appropriate equipment, bowel gas
The technique has been widely adopted throughout the world, and is now and artefact may obscure the fluid. Addi-
considered by many trauma departments to be an essential triage tool for tionally, the scan may be performed too
BAT patients. However, subsequent improvements in both quality and avail- early, before haemoperitoneum is estab-
lished, resulting in a false negative exami-
ability of radiological imaging and in patient management should now
nation. In such cases a prompt FAST scan
prompt us to re-evaluate the usefulness of the technique. may actively mislead the clinician, with
a consequent loss of time in treating the
by Jane Smith patient. (This may be a particular problem
if the technique is used by paramedics, for
example to triage patients prior to A&E
Blunt abdominal trauma (BAT) is a lead- FAST was adopted worldwide by the 1990s, admission.) Inadequate equipment and/
ing cause of morbidity and mortality, and came to be considered a vital tool in
with prompt diagnosis considered vital in BAT management, as the presence of hae-
improving the patient’s prognosis. FAST moperitoneum supported the case for A
was one of the first Point of Care Ultra- immediate CT analysis and/or surgery. The
sound (POCUS) techniques, introduced implementation of FAST has been facili-
in the 1980s to allow the emergency phy- tated by the introduction of hand-held
sician to establish the presence of free ultrasound equipment, which is easy to use,
intraperitoneal and/or pericardial fluid. relatively low in cost and easily accessible.
A positive finding implied haemoperito-
neum, and thus potentially accelerated Issues & limitations associated
appropriate patient management. with the performance of FAST
The technique involved in this limited
The FAST technique images four depend- ultrasound scan is relatively simple for the B
ent points where blood is most likely to emergency physician to learn, and high sen-
pool; the hepatorenal fossa, the sub- sitivities and specificities for demonstrating
xyphoid view, (to detect pericardial fluid), free fluid are possible [Figure 1]. However,
the left upper quadrant and the pelvis. the success of FAST is entirely dependent
upon the operator’s ability to perform the
scan and interpret the findings. The phy-
sician must obtain appropriate training in
both technique and image optimisation
and should be deemed competent to prac-
tise by someone experienced in ultrasound
scanning. In addition, the physician should
Figure 2. Technique is an important factor in
maintain this level of competence by reg- FAST sensitivity.
ular practice. The equipment used must a) A small haemoperitoneum anterior to the
be adequate for the purpose, and results liver (arrow) is difficult to see when the settings
should be audited on a regular basis. If or technique are not optimum. In this case the
these conditions are respected, FAST is focal zone, where the beam is narrowest and
the image clearest, (represented by the horizontal
both sensitive and specific for demonstrat-
arrow) is set at the depth of Morison’s pouch
ing the presence of fluid. (arrowheads.) Fluid anterior to the liver (arrow) is
therefore not well seen as the acoustic beam is
Unfortunately, training and competency unfocused at this level, degrading the image.
assessment are not universally available, b) In the same patient, the fluid is easily identi-
leading to poor results, and low sensitiv- fied once the focal zone (represented by the
horizontal arrow) is placed against the anterior
ity rates [Figure 2]. Low cost or elderly
Figure 1. Free fluid is present inferior to the left aspect of the liver. The beam is now narrow at
lobe of liver in a longitudinal section through the equipment may limit image quality, mak- this point, affording a high resolution view of the
epigastric region. Image courtesy of PostGrad ing diagnosis challenging or impossible in liver capsule and free fluid. Image courtesy of
Med J [1]. some patients. PostGrad Med J [1].
 11 – November 2010

or poor image optimisation operating theatre and reduced FAST in the ‘80s and ‘90s. In to link FAST to any reduction
techniques are also the cause number of diagnostic perito- some cases the patient is better in death rates from BAT.
of false negative scans. False neal lavage (DPL) procedures served by an accurate diagno-
positive results are obtained [4,5,6], but has not been shown sis, rather than by a hasty jour- Summary
from patients with cyst acci- to have had any recognisable ney to theatre. In the context of patient man-
dents, those on dialysis and impact on the length of hospi- agement, FAST can no longer
those with pre-existing ascites. tal stay [7]. No association has been estab- be considered as it was in the
lished between the use of FAST 1980s and 1990s. Since then,
CT or ultrasound? Although minimising the delay and reduced rates of laparotomy. accessibility to MDCT has
The advantages of ultrasound in getting patients to theatre Furthermore, there is insuf- improved, with BAT patients
(US) imaging are well docu- seems beneficial, BAT manage- ficient information to support able to speedily be defini-
mented. US is a non-inva- ment has become less depend- FAST on the grounds of reduc- tively diagnosed. Rather than
sive, non-radiation modality ent upon surgical interven- tion in mortality and/or mor- a FAST scan, the performance
which is accessible enough to tion since the introduction of bidity [7] and no information of a comprehensive ultrasound
be performed immediately,
at the bedside, without mov-
ing the patient. Ultrasound
has limitations, however, and
for example is usually unable
to demonstrate injuries of the
bowel, mesentery or bladder.
In addition, the technique has
low sensitivities for pancreatic
and renal injury. Multidetector
CT (MDCT) analysis, which is
now available in most trauma
centres, can deliver a swift and
all-inclusive evaluation of the
patient, in terms of soft organ
and skeletal damage. However,
patients should not be submit-
ted lightly to the radiation dose
from a CT scan, and its use
should therefore be reserved for
those who are likely to benefit.
A comprehensive ultrasound
scan by a qualified experienced
practitioner, especially with the

concept: www.glamlab.it
addition of a contrast agent, can
be a useful diagnostic tool, par- Visit us at Medica 2010
ticularly in the unstable patient Hall 9 - Stand C41

who is too ill to be moved to

Anywhere,
CT. Contrast enhanced ultra-
sound (CEUS) is able to safely
demonstrate organ rupture,
even before haemoperitoneum
[2,3], [Figure 3].

A FAST scan, however, is not

to be confused with a com-
prehensive ultrasound exami-
nation. Identifying the pres-
ence of fluid is still a long way
from establishing the origins
of the bleeding, and is in no
when (you) need.
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in the presence of a witness. Today the defibrillator is one of the
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Evidence for FAST

FAST has been associated with www.progettimedical.com
reduced time to initial diag-
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emergency department to the
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 – November 2010 12 POint-of-care

Eye Protection examination in skilled hands (especially

A
when using a contrast agent to identify
EyeGard™ organ rupture), is able to contribute mean-
is the safe, ingfully to patient management, especially
effective way in the unstable patient. Conservative man-
agement is able to replace surgical interven-
to protect tion in an increasing number of cases, and
the eyes from having the appropriate imaging may obvi-
corneal ate the need to take the patient to theatre.
abrasions.
The association between FAST and posi-
tive outcomes in BAT is tenuous at best.
Protect your
(Reducing the time taken to get a patient
patient’s eyes to theatre is not, in itself an outcome,
during general especially if that patient would have either
anesthesia benefited from conservative management,
with the or actually spends longer in theatre as a
Bat Mask result of not having a definitive diagno-
sis.) At worst FAST can be misleading
eye cover. (false negative results,) poorly performed B
and interpreted, and/or delay the patient’s
journey to CT. The emphasis on reducing
radiation dose from CT should prompt
further investigation into the role of com-
prehensive, good quality ultrasound in
U.S.A. 813-889-9614 • Fax 813-886-2701 BAT, and the role for CEUS in BAT has
yet to be established.

see us at MEDICA - Hall 16, E06 FAST continues because it has become
part of the “trauma culture”, but data on
www.ihe-online.com & search 45631 patient outcomes, in terms of reduced
morbidity and mortality, have yet to be
established. FAST represents an invest-
ment in staff time, equipment and train-
ing which could arguably be otherwise
employed more effectively. Figure 3.
The greatest meeting point A) a liver rupture post trauma prior to any visible
of the healthcare sector References haemoperitoneum on ultrasound, appears as a
textural change in the right lobe of liver.
of the Americas 1. Smith J, Focused Assessment with Sonog-
B) Following administration of contrast , the
raphy in Trauma (FAST). Should its role rupture is clearly seen as a perfusion defect.
be reconsidered?, Postgrad Med J 2010; 86:
years

Fair Forum 18 Image courtesy of PostGrad Med J [1].

Hospitalar 285-291.
2. Correas, Tranquar & Claudon. Guidelines for
CEUS – update 2008 J Radiol 2008; 90(1 Pt
2):123-38.
3. Valentino M. CEUS for BAT. Semin Ultra-
sound CT MR 2007; 28(2):130-40.
4. Arrillaga A, Graham R, York JW & Miller RS.
Increased efficiency and cost-effectiveness in
MAY 24 - 27 2011 the evaluation of the blunt abdominal trauma
São Paulo - BRAZIL
patient with the use of ultrasound. The Amer-
ican Surgeon 1999; 65:31-5
1,250 exhibitors from 36 countries 5. Boulanger BR, McLellan BA, Brenneman
89,000 visitors from 60 countries
FD, Ochoa J & Kirkpatrick AW. Prospective
evidence of the superiority of a sonography-
Owned by Management In Cooperation with based algorithm in the assessment of blunt
Hospitalar
Fair and Congress
abdominal injury. Journal of Trauma 1999;
47:632-7
6. Melniker LA, Leibner E, McKenney MG,
Tel: (5511) 3897-6199 • Fax: (5511) 3897-6191 Lopez P, Briggs WM and Mancuso CA. Ran-
international@hospitalar.com.br domized controlled clinical trial of point-
www.hospitalar.com
of-care, limited ultrasonography for trauma
in the emergency department: the first
sonography outcomes assessment program
trial. Ann Emerg Med 2006; 48(3):227-35.
7. S tengel D. Emergency US-based algorithms
for diagnosing blunt abdominal trauma.
Cochrane Database of Systematic Reviews
2005, Issue 2. Art. No.: CD004446. DOI:
10.1002/14651858.CD004446.pub2. (Last
assessed Feb. 2008)
The author
Jane Smith (née Bates) MPhil, DMU, DCR
Consultant Ultrasound Practitioner
Ultrasound Dept, Lincoln Wing,
St James’s University Hospital
Leeds Teaching Hospitals NHS Trust
LS9 7TF, UK
& Leeds & West Yorkshire Radiology
Academy
B Floor
Clarendon Wing Leeds General Infirmary,
LTHT.
Technology breakthroughs
trigger new developments for
Medical Devices and Drug Delivery

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 – November 2010 14 News in brief
Glucosamine may increase rare disease with a high mortality rate.
diabetes risk (and may not anyway Sixty-two patients were scanned using the
be effective in joint stiffness) method, which represents the largest sam-
High doses or prolonged use of glucosamine
cause the death of pancreatic cells and could
increase the risk of developing diabetes,
according to a team of researchers lead by
Prof. F Picard at Faculty of Pharmacy, Uni-
versité Laval, Canada. In vitro tests revealed
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rate increases with glucosamine dose and
exposure time. The research showed that glu-
cosamine triggers a mechanism intended to
U.S.A. 813-889-9614 • Fax 813-886-2701 lower very high blood sugar levels. However,
this reaction negatively affects SIRT1, a pro-
tein critical to cell survival. A high concen-
see us at MEDICA - Hall 16, E06 tration of glucosamine diminishes the level
of SIRT1, leading to cell death in the tissues
www.ihe-online.com & search 45632 where this protein is abundant, such as the
pancreas.
Individuals who use large amounts of glu-
cosamine, those who consume it for long
periods, and those with little SIRT1 in their
ISO 9001 Version 2000
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Manufacturer risk of developing diabetes. In a number of
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mammal species, SIRT1 level diminishes
with age. This phenomenon has not been
shown in humans but if it were the case, the
elderly—who constitute the target market for
glucosamine—would be even more vulner-
able. The results obtained by Picard and his
team coincide with recent studies that any-
way cast serious doubt on the effectiveness of
glucosamine in treating joint problems.
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TM Flowmeter & Pressure regulator
with pre-adjusted flowrates FDG-PET allows accurate diagnosis
The DEBSON TM2 flowmeter and the REGSON TM2 pressure regulator are used
to set the flow of a gas (either oxygen or medical air) that is to be delivered to of gall bladder cancer
patients through the respiratory tract. The pre-adjusted flowrates enable to use
both devices in any position thus making them perfectly aimed at emergency care
and intensive care. They are suitable for every patient – from adults to paediatric
patients – thanks to a wide range of versions: 1 - 5 - 15 - 25 - 50 l/min, each
version being set up with 9 different flowrates. The control knob with a new wide
transparent window enables to read the selected flowrate as well as the previous
and the next ones. The new FLUSH system option also makes it possible to instantly
deliver a 30 l/min gas flow by simply pressing on the control knob. This new
system can be used for very specific applications within recovery rooms.
Visit us at Medica “Hall 11 Booth E40”
TECHNOLOGIE MEDICALE S.A.S. Researchers at the University of Granada
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Spain have found that FDG PET allows early
diagnosis of gall bladder cancer, a relatively
www.ihe-online.com & search 45692
ple of patients with gall bladder cancer ever
studied by FDG-PET. The results were sig-
nificantly better than other structural imag-
ing methods, and enabled more accurate
and appropriate diagnosis and treatment of
patients, allowing unnecessary procedures to
be avoided.
The high mortality rate among patients with
gall bladder cancer results from the lack of
clinical data enabling early diagnosis of this
type of tumour. Once a diagnosis has been
made, accurate staging allows the most
appropriate treatment to be delivered.
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HRT associated with an increased
risk of death from breast cancer
A new Women’s Health Initiative (WHI)
report shows that hormone therapy is asso-
ciated with an increased risk of death from
breast cancer, as well as an increased risk
of developing invasive breast cancer in
postmenopausal women. Jean Wactawski-
Wende, PhD, professor of social and pre-
ventive medicine at the University at Buf-
falo, USA reports that the breast cancers
found in these women also tended to have
more lymph node involvement, indicating a
poorer prognosis.
Prof. Wactawski-Wende was co-Principal
Investigator at UB’s WHI Vanguard Center,
one of 16 centers that helped develop the
initial protocols for the study, which began
in 1993 and eventually included 40 clinical
centers across the US. Initially planned to
continue until 2005, the hormone trial was
halted in 2002 because preliminary analysis
of the data showed oestrogen plus proges-
tin increased the risk of heart disease, stroke
and invasive breast cancer. Prior to WHI,
scientists speculated that hormone therapy
reduced heart disease risk.The WHI contin-
ued to follow these women after the main
trial ended.
The current report gives the results of research
conducted during this WHI extension phase.
Most of the earlier observational studies,
which follow participants over time and col-
lect health information at specific intervals,
 News in brief 15 – November 2010

had suggested that breast cancers that develop in women taking hor-
mone therapy were less advanced and had a lower risk of death. How-
ever, the WHI researchers note that the influence of oestrogen plus
progestin on breast cancer mortality had not been addressed in the
context of a randomised clinical trial, prior to WHI.
Their current study to answer that question was based on 12,788
surviving postmenopausal women who took part in the initial trial.
Results showed that combined hormone therapy increases the inci-
dence of invasive breast cancer and that, more commonly, the cancers
had spread to the lymph nodes. There also were more deaths attrib-
uted to breast cancer in those taking hormone therapy — 2.6 versus
1.3 per 10,000 women. There also were more deaths from all causes
in the women who had been diagnosed with breast cancer who were
on hormone therapy — 5.3 versus 3.4 per 10,000. The trial also found
that hormone therapy interfered with detection of breast cancer, lead-
ing to cancers being diagnosed at a more advanced stage.
http://www.buffalo.edu/
Revising the time-line in pancreatic cancer
Pancreatic tumors are one
of the most lethal cancers,
with fewer than five per-
cent of patients surviving
five years after diagno-
sis. But a new study lead
by Bert Vogelstein of the
Howard Hughes Medical
Institute, USA could pro-
vide an opportunity for
Extracting and archiving patient radiation dose info
An efficient method for extracting and
archiving CT radiation dose informa-
tion to keep track of estimated radiation
dose delivered to each patient has been
developed. Researchers at the Hospi-
tal of the University of Pennsylvania
in Philadelphia, PA, designed, imple-
mented and validated RADIANCE,
an automated extraction “pipeline” to
query their institutional PACS and extract radiation dose data stored
in the dose report image of every CT examination performed. The
“pipeline” can process both retrospective and prospective CT studies,
in order to make dose information available for all CT examinations
at the institution, said Tessa S. Cook, MD, lead author of the study.
The goal of extracting and analyzing radiation dose information was
to assess patient exposure to radiation from CT. Dose report cards
can be generated showing patients’ estimated lifetime radiation dose.
enabling clinicans to be more cognizant of radiation dose to patients.
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Dmed® oculux Dmed® oculux

early diagnosis. This is particularly important since in general

there are no clinical symptoms until the cancer has metasta-
sized. His findings show that, in contrast to earlier predictions,
many pancreatic tumors are, in fact, slow growing, taking
nearly 20 years to become lethal after the first genetic perturba-
tions appear.
Vogelstein and co-workers obtained samples of primary
pancreatic tumors from seven autopsied patients, as well as
metastatic lesions. Their team sequenced the DNA of every
gene in each metastatic tumor as well as in the primary
tumor. These genetic read-outs provided data to compare
the genetic mutations found in each patient’s metastatic
lesions with the mutations found in the primary tumor. The
investigators found that each metastatic lesion contained, on
average across all patients, 61 cancer-related genetic muta-
tions. Further, the majority of these mutations – 64 percent
on average – were also present in the primary tumor. Using
a “molecular clock” technique commonly used in evolution-
ary biology, it is possible to generate a hypothesis about
when a mutation occurred. Because such mutations accu- LED Light - REaDy to mEEt aLL ChaLLEngES
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www.ihe-online.com & search 45633
 – November 2010 16 Surgery

Robot-assisted radical prostatectomy

Technology plays an ever increasing role in the care of the surgical patient. scissors, monopolar and bipolar cautery
In an effort to make surgery more minimally invasive, robotics has come instruments, needle drivers, forceps, etc.
to the fore in certain specialty areas. Although originally conceived for However, the differentiating feature of the
robotic instruments is a hinged wrist near
heart surgery, the daVinci Surgical System is now being used for radical
the instrument tip [Figure 2]. This robotic
prostatectomy to such an extent that this is the application in which robotic wrist mirrors the flexibility of the human
surgery is most used. In fact the widespread use of robot assisted radical wrist. However, because this wrist is minia-
prostatectomy has driven the proliferation of robotic surgery in general. This turized, it allows exceptional mobility deep
article describe the current status of robot prostatectomy. within the operative field thereby facilitat-
ing dissection and suturing.
by Dr David I. Lee
The robot interface also provides several
advantages to the surgeon. The console
Prostate cancer is the most commonly diag- portion of the sewing together of the blad- is very ergonomic allowing the operating
nosed cancer in men in the United States. It der to the urethra, which is a mandatory surgeon to be seated with arms supported.
is estimated that nearly 200,000 men were part of the procedure. This greatly reduces fatigue, allowing for
diagnosed and nearly 28,000 men died improved surgery and perhaps longer
because of prostate cancer in the United The seminal work of Menon and col- surgeon life span. When performing sur-
States in 2009. Similar data on the incidence leagues showed that the use of the daVinci gery, the hand controls or ‘masters’ have
of prostate cancer exist in Europe. While a Surgical System (Intuitive Surgical, Sun- the ability to filter hand tremor. With the
myriad of treatments exists for prostate can- nyvale, CA) could benefit the surgeon in additional ability to scale the motion of the
cer including open surgery, external mean allowing a difficult laparoscopic procedure robot instruments, incredibly delicate and
radiation, brachytherapy, proton radiation to be performed with the advantages that fine work can be performed. Such dexterity
therapy, high intensity focused ultrasound, the robotic platform provides [Figure 1]. allows even very complex skills like lapar-
cryosurgery and active surveillance, many The benefits of the robotic surgical system oscopic suturing to be performed with
men opt for surgical removal. Radical pros- include a visual system that can provide amazing ease. With these multiple benefits
tatectomy has been shown to reduce the 3-D vision. Unlike standard laparoscopic provided by the robotic platform, the appli-
incidence of distant metastasis and death systems where the image is sent to a video cation of laparoscopy to prostatectomy
from prostate cancer as compared to active monitor, the camera system transmits a become a much more feasible option.
surveillance. However, open surgery has dual image captured by a dual lens and
always involved significant side effects and dual camera head. When seated at the con- There are however some limitations to the
morbidity including incontinence, impo- sole, the surgeon views each image with a ability of the robot. For example, there is
tence, pain, significant blood loss and a different eye and thus can see in 3 dimen- no tactile feedback to the robotic instru-
lengthy recovery process. sions inside the patient. Additionally, the ment. This can be a considerable hurdle
image is magnified tenfold. This 3-D mag-
Robotics nified image provides a visual picture that
The minimally invasive laparoscopic is superior to any other surgical working
approache to radical prostatectomy was environment.
very difficult due to challenges with visu-
alisation and limited instrumentation. The robotic instruments are available in a
Especially difficult was the reconstruction variety of shapes and functions including

Figure 2. The underlying concept of the system is

that the robot instruments move in response to the
motions that the surgeon performs while seated
Figure 1. The new daVinci Si robotic system showing the latest platform, which has updated computer at the robotic console.  The robot is thus simply a
integration and future add-on tools. master - slave robotic control manipulator.
 17 – November 2010

for experienced open surgeons benefit both in worker produc- patients undergoing open radi- of the specialised robotic ports
when they first try to adapt to tivity and overall costs due to cal prostatectomy. and the camera port is a stand-
the robotic approach. Many the shortened recovery period. ard laparoscopic 12 mm port.
steps of radical prostatectomy In addition, there is increasing The Penn technique Two of the ports used are for
are facilitated by feel, so the evidence that there are fewer With a few modifications, our the table-side assistant; this
improved visualisation that the medical and surgical complica- technique (known as the Penn person in our operating room
robot provides must be used to tions after robot prostatectomy; technique) for performing is a very experienced physi-
compensate for this. This, how- this should further drive down robot prostatectomy is broadly cian’s assistant. The importance
ever, represents a significant overall costs. For example, similar to many other centres. of this assistant cannot be over-
learning curve. bleeding that requires transfu- We utilise a 6 port transperi- stated as it can make or break
sion occurs in fewer than 1% toneal approach. The ports are the success of the procedure.
Robotic versus open rad- of the cases with robot prosta- placed in the usual technique
ical prostatectomy tectomy but has been recorded for a laparoscopic case. The By using a transperitoneal
The gold standard for treatment as being as high as 25% of robot is then docked to three approach, the peritoneum must
of early stage prostate cancer
has been open radical prosta-
tectomy. However, in 2009 it
was estimated that more than
80% of all radical prostatec-
tomy cases in the United States
were performed with robotic
assistance. In the early days
of the use of the technique, its
popularity was patient-driven;
now many studies show at least
equivalence with open radical
prostatectomy and in experi-
enced centres the results are
actually superior. Stress urinary
incontinence and erectile dys-
function can result in consider-
able decrease in the quality of
life. However, with increasing
experience outcomes are being
improved. Data from centres of
excellence with radical prosta-
tectomy demonstrate excellent
results in regard to maintaining
continence and potency. Gen-
erally, large studies report that
90% of cases are pad-free rate
after 12 months; after complete
nerve sparing procedures in
robotic prostatectomy and open
radical prostatectomy, 80% of
cases have potency. However,
the clear benefit of robot pros-
tatectomy is the convalescence
period. Ninety-six percent of
our patients at the University of
Pennsylvania leave the hospital
on day one, whereas hospital
stay after open radical pros-
tatectomy is two to four days.
We tell our robotic surgery
patients that they may walk as
much as they want right away
after the operation, and may
resume full activities within
three weeks. For open radical
prostatectomy, this is likely to
take six to eight weeks. There is
thus likely to be a large societal
www.ihe-online.com & search 45548
 – November 2010 18 Surgery

Figure 4. An intraoperative view of the male pelvis in which the prostate was removed and in
which the neurovascular bundles can be seen. The reconstruction of the bladder to the urethra is
just being begun.

Figure 3. The advantages of the robotic instru-
mentation are that the instruments have articulat-
ing wrists designed very much in the same way
as the human wrist is constructed.
be incised to gain access to the bladder and
prostate and this is performed over the
anterior abdominal wall. With the bladder
dropped, the endopelvic fascia is visualised
and incised to mobilise the prostate from
the surrounding levator muscles. We then
use a laparoscopic stapler to ligate the dor-
sal venous complex. The bladder is then
divided away from the prostate and the
seminal vesicles and vasa are divided next.
The rectum is then mobilised away from
the prostate and the nerve sparing can then
be performed. We do this with an athermal
technique, which avoids any heat sources
such as cautery since this can cause addi-
tional injury to the neurovascular bundles.
The urethra is then divided, freeing the
prostate and also leaving a long urethral
stump to increase the chances for conti-
nence return. The prostate is placed into a
laparoscopic entrapment sac until the rest
of the case is completed. A lymph node dis-
section can be easily performed if indicated.
The reconstruction is then performed. We
utilise a running stitch anastomosis, called
the vanVelthoven technique, that expedites
the process and provides a watertight clo-
sure. Our technique has pioneered the use
of an anterior plication stitch. This helps to
take tension off the anastomosis and per-
haps to increase the functional length of
the urethra. We have noted that since we
have been using this stitch, continence has
on average returned earlier than before
we started using the stitch. The bladder is
irrigated with saline to ensure a watertight
anastomosis and the prostate is retrieved.
Indications
We have found that we can perform the
robotic operation for most men with pre-
vious abdominal surgery and regardless of
their body habitus or size of the prostate.
We have performed this in men as heavy as
360 pounds and with a prostate as heavy as
250g (the normal mass is about 30g). Many
surgeons have worried about previous her-
nia repairs as a potential contraindication
for open radical prostatectomy. However,
we have experienced little difficulty even
in cases where patients have had previous
laparoscopic hernia repairs with mesh.

an event of the
 19 – November 2010

Therefore virtually all men who are candidates for open

radical prostatectomy may be candidates for robot prosta-
tectomy as long as they have what appears to be localised
prostate cancer.

Oncologic outcomes
Positive surgical margins
A positive surgical margin is defined as the presence
of tumour cells adjacent to the inked surgical margin.
Increasing experience has been shown to be a large deter-
mining factor for the incidence of positive margins in the
setting of open prostatectomy. This is likely to be true for
surgeons performing robot prostatectomy as well. Our
margin rates have steadily improved to the point where we
have seen rates of 4 to 5 % for organ confined disease and
11-12% overall.

PSA recurrence
The true benchmark for prostate cancer control/cure is an
undetectable PSA level post treatment. Ten year results for www.ihe-online.com & search 45637
PSA recurrence after open radical prostatectomy show rates
of about 20-25% overall. Equivalent data for PSA recurrence 5
B0

do not yet exist for robot prostatectomy; so far however the

d
an

data accrued over a shorter 3 to 5 year follow-up show that

St
ll 9

similar numbers are being reported.

Ha

Conclusion
Robot prostatectomy is the new preferred method of per-
forming radical prostatectomy. Patients convalesce more
quickly and experience fewer complications. Functional out-
comes seem equivalent and may even be improved compared
to open radical prostatectomy. Cancer control in the form of
margin rates and early PSA recurrence is also comparable
between the two techniques. Future improvements should
allow improved prostatectomy results and wider application
of the robotic platform to other procedures and specialties.

Further reading
1. Ahlering TE, Skarecky D, Lee D & Clayman RV. Successful
transfer of open surgical skills to a laparoscopic environment
using a robotic interface: initial experience with laparoscopic
radical prostatectomy. J Urol 2003;170(5):1738-41.
2. Badani KK, Kaul S, Menon M. Evolution of robotic radical
prostatectomy: assessment after 2766 procedures. Cancer 2007;
110(9):1951-8.
3. Khatlani K, Sharma S, Mendoza PJ, Lee DI. The current state of
robot assisted radical prostatectomy. Minerva Urol Nefrol 2010;
62(2):193-201.

The author
David I. Lee, MD, FACS
University of Pennsylvania School of Medicine
Philadelphia, PA, USA
Corresponding address:
David I Lee, MD
51 North 39th Street
Medical Office Building Suite 300
Penn Presbyterian Medical Center
University of Pennsylvania Division of Urology
Philadelphia PA, 19104, USA
Tel. +1-215-662-8699
Fax +1-215-243-2060
e-mail: david.lee@uphs.upenn.edu
www.ihe-online.com & search 45616
Imaging Special
Selection of peer-reviewed
literature on medical imaging
The number of peer-reviewed papers covering the vast field of medical
imaging is huge, to such an extent that it is frequently difficult for health-
care professionals to keep up with the literature. As a special service to its
readers, International Hospital presents a few key literature abstracts from
the clinical and scientific literature chosen by our editorial board as being
particularly worthy of attention.
Emerging role of ImmunoPET in
receptor-targeted cancer therapy
Marik J & Junutula JR. Curr Drug Deliv. 2010 Nov
1. [Epub ahead of print]
ImmunoPET is a non-invasive imag-
ing technology based on tracking and
quantification of radiolabelled mono-
clonal antibodies, antibody fragments
and peptides in vivo. The knowledge
of distribution and expression levels of
a given receptor is a key for successful
receptor-targeted cancer therapy. Immu-
noPET performed with probes with high
affinity and specificity to a given recep-
tor aspires to be a method for obtaining
comprehensive information about cur-
rent in vivo status of the targeted recep-
tor. This review describes methods for
radiolabelling of peptides, monoclonal
antibodies and antibody fragments for
immunoPET, and highlights the recently
reported pre-clinical and clinical appli-
cations of immunoPET in receptor-tar-
geted therapy.
Acute abdominal pain: is there a
potential role for MRI in the set-
ting of the emergency department
in patients with renal calculi?
Kalb et al. J Magn Reson Imaging. 2010 Nov;
32: 1012.
Acute flank pain is a frequent clinical
presentation encountered in emergency
departments, and a work-up for obstruc-
tive urolithiasis in this setting is a common
indication for computed tomography (CT).
However, imaging alternatives to CT for
the evaluation of renal colic are warranted
in some clinical situations, such as with
younger patients, pregnancy, patients that
have undergone multiple prior CT exams
and also patients with vague clinical presen-
tations. MRI, although relatively insensitive
for the direct detection of urinary calculi, has
the ability to detect the secondary effects of
International
hospital
November
2010
Medical
Imaging
obstructive urolithiasis. Using rapid, single
shot T2-weighted sequences with and with-
out fat saturation provides an abdominopel-
vic MR examination that can detect the
Special
sequelae of clinically active stone disease,
in addition to alternate inflammatory proc-
esses that may mimic the symptoms of renal
colic. In addition, MR nephro-urography
(MRNU) has the ability to provide quanti-
tative analysis of renal function, which has
the potential to direct clinical management
in the setting of obstructing calculi. This
review describes the potential utility and The role of PET/CT in
limitations of MRI in the emergency setting
for diagnosing causes of flank pain and renal
the imaging of ovarian
colic, particularly in patients with unusual cancer
presentations or when an alternative to CT
may be warranted. Page 22 - 27
Clinical utility of intravascular
ultrasound in the assessment of
coronary allograft vasculopathy: High field strength SWI
a review.
Logani S et al. J Interv Cardiol. 2010 Oct 4 of cerebral cavern-
[Epub ahead of print]
Coronary artery vasculopathy (CAV) is
ous malformations:
one of the major factors that limit the long- the neurosurgeon’s
term survival of heart transplant recipients. perspective
Current literature suggests that intravas-
cular ultrasound (IVUS) is a safe imaging
technique that is beneficial for the early Page 28 - 29
diagnosis of CAV; IVUS with virtual histol-
ogy (IVUS-VH) is an even more promising
diagnostic utility. Despite its advantages,
IVUS is currently not routinely utilised for The utility of point-of-
CAV in heart transplant recipients. This
review, summarises the clinical utility of care sonography in
IVUS in the early diagnosis of CAV, includ- distinguishing soft tis-
ing its utility for assessing vessel remodel-
ling, plaque composition and prognostic
sue from joint effusions
value, morphometric analysis and guiding
therapy. After reviewing the relevant pub- Page 30 - 32
lished literature, the authors recommend
that the use of IVUS be considered in all
post-transplant CAV screening.
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 – November 2010 22 MEDICAL IMAGING

The role of PET/CT in the imaging of

ovarian cancer
Ovarian cancer is the leading cause of death among patients with gynae- abdominal CT examination with intrave-
cologic cancer. This article reviews the role of fluorodeoxyglucose positron nous administration of 120 mL of iodi-
emission tomography/computed tomography (FDG PET/CT) in the imaging nated contrast medium (iopamidol 370
mg) is also usually performed.
of ovarian cancer. Specifically, we discuss and demonstrate how FDG PET/CT
can substantially alter the clinical management of patients with primary and FDG PET/CT images
recurrent ovarian cancer. As a result, FDG PET/CT is considered a critical tool Distinguishing physiologic from
for the preoperative evaluation of women with primary ovarian cancer and for pathologic increased FDG uptake
postoperative assessment for evidence of recurrence in these patients. This arti- In premenopausal women, ovarian FDG
cle reviews the current role of FDG PET/CT in the imaging of ovarian cancer. uptake varies with the phase of the men-
strual cycle. For example, physiologic
uptake is particularly pronounced in
by Dr O.J. O’Connor, Dr P. Prakash, Dr C. G. Cronin and Dr M. A. Blake the early luteal phase [Figure 1]. Physi-
ologic ovarian uptake can be minimised
by imaging immediately following men-
The leading cause of death among The technique of FDG PET/CT struation, thus avoiding potential diag-
women with gynaecologic cancers, ovar- At our institution, PET/CT examinations nostic uncertainty. Typically, physiologic
ian cancer accounts for 3% of new cases are performed on an integrated PET/CT ovarian FDG uptake appears spherical
of female malignancies and 5% of can- unit composed of a multidetector CT or discoid in shape with smooth margins
cer-related deaths in 2009 in the United (MDCT) and a PET system using 3D lute- and is usually located above the urinary
States, according to data from the Ameri- tium oxyorthosilicate crystals. Patients bladder or around the uterus. Concurrent
can Cancer Society [1]. Similar levels of fast for a minimum of four hours before PET/CT imaging can further help distin-
the incidence of ovarian cancer are found scanning; blood glucose should be less guish physiologic from pathologic uptake
in Europe. Imaging, especially ultra- than 200 mg/dL before FDG adminis- by allowing correlation of uptake site
sound and computed tomography (CT), tration. FDG is administered according with the CT features. Characteristic CT
has become a critical part of the evalu- to patient weight within the dose range appearances of normal benign ovarian
ation of patients with ovarian cancer. As of 10–20 mCi (370–740 MBq). Approxi- tissue include the observance of a small
in many other malignancies, the roles of mately one hour after FDG administration, rim-enhancing cyst, the absence of any
fluorodeoxyglucose positron emission an attenuation-correction CT is acquired lymph nodes and concordance with the
tomography (FDG PET) and PET/CT are from the skull base to mid-thigh for FDG appropriate stage of menstrual cycle [3].
being extensively studied for the evalu- localisation and attenuation-correction Any ovarian FDG uptake in a post-men-
ation of ovarian malignancy. According purposes. PET images are then immedi- opausal patient is considered pathologic,
to the American College of Radiology ately acquired in 2D or 3D mode from the whether benign or malignant.
guidelines, the goals of oncologic imag- skull base to mid thigh and these images
ing with PET/CT are: to help differentiate are fused with attenuation-corrected CT Distinguishing benign and
benign from malignant disease; to deter- images. The fused PET/CT is mainly used malignant lesions
mine the extent of malignant disease; to for visual interpretation and tumour vol- Studies evaluating the role of PET alone
detect residual and recurrent disease and ume measurements. In addition, a diag- for early diagnosis of ovarian cancer
to monitor and guide therapy [2]. nostic contrast-enhanced, neck, chest and have reported a low sensitivity (58%)

A B C

Figure 1. Distinguishing physiologic from pathologic increased FDG uptake

Transverse PET, intravenous contrast enhanced CT, and fused PET/CT images in a 43-year-old premenopausal woman with normal ovarian uptake.
A. There are two spherical areas of increased FDG uptake (one shown by the arrow) in the right adnexal region on PET imaging.
B. A normal right ovary (arrow) containing two corpus luteal cysts which have peripheral enhancement is seen on CT.
C. Fused images confirm increased FDG uptake correlates with normal right ovarian tissue (arrow) containing two corpus luteal cysts
which have peripheral enhancement.
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 – November 2010 24 MEDICAL IMAGING

and specificity (76%) [4]. The advent of
combined structural and metabolic data
acquired contiguously with PET/CT helps
to precisely localise suspicious areas of
increased FDG uptake and assess inciden-
tal ovarian findings. A more recent study
of combined PET/CT has demonstrated a
sensitivity of 87% and specificity of 100%
for differentiating benign from malignant
ovarian cancer [5]. These results were
achieved in part by characterising a focal
increased standardised uptake value (SUV)
of 3 or higher in the ovary as positive for
ovarian malignancy, whereas an SUV of 2.7
or less was considered benign. Benign and
malignant ovarian FDG uptake on PET
were also differentiated using contempora-
neously acquired CT, the pattern of FDG
uptake and the absence of lymphadenopa-
thy in patients with benign lesions.
than that of sonography for the assess-
ment of small (<5mm) lesions. Hence,
PET/CT has not replaced sonography for
the screening of ovarian cancer. However,
given its high specificity, FDG PET/CT is
used to assess for occult metastases before
patients undergo surgical treatment.
“.... PET/CT has not replaced
sonography for screening for
ovarian cancer but, given its
high specificity, FDG PET/
CT is used to assess for occult
metastases prior to surgery....”
in conjugation with CT, FDG PET is ben-
eficial in evaluating distant metastases and
equivocal lesions [5, 6]. PET/CT had high
sensitivity in identifying peritoneal depos-
its larger than 1 cm and lymph nodes larger
than 7 mm. Compared to CT alone, PET/
CT increases the pretreatment staging
accuracy from 53–55% to 69–75% [Figures
2 and 3] [5]. Studies also suggest that PET/
CT helps distinguish stage I–IIIB (oper-
able) cancer from stage III C–IV (inop-
erable) cancer. For this classification, the
specificity, sensitivity and accuracy of FDG
PET/CT were respectively 91%, 100%, and
98%, in comparison to 64%, 97%, and 88%
respectively for CT alone [6]. Thus, PET/
CT may help to better identify patients
for whom optimal debulking is not pos-
sible and who, more importantly, need to
undergo preoperative chemotherapy.

In another study, PET/CT was found to
have a sensitivity of 80% and specificity
of 97% for the diagnosis of synchronous
malignancy in the contralateral ovary in
patients with primary ovarian cancer [6].
Although PET/CT has a high specificity
for the assessment of lesions greater than
5 mm in size, its sensitivity is much lower
Staging of ovarian cancer
Ovarian cancer is surgically staged accord-
ing to the Federation International of
Gynecology and Obstetrics TNM staging
system [7]. Traditionally, CT has been the
preferred imaging modality for primary
preoperative staging of ovarian cancer.
Recent studies have shown that, when used
Detection of recurrent disease
Approximately 75% of patients with ovar-
ian cancer suffer from disease recurrence
[8]. Early diagnosis and accurate localisa-
tion of recurrence and of metastases are
essential for clinical decision-making pur-
poses. For example, the number of sites of
recurrence has prognostic significance

A B C

Figure 2. Staging of ovarian cancer.

Transverse PET, intravenous contrast enhanced CT and fused PET/CT images in a 48-year-old post menopausal woman with ovarian cancer.
A. There are non-focal linear areas of increased FDG uptake in the pelvis on PET (arrows).
B. There is abnormal soft tissue on CT in the adnexal regions (arrows). There is stranding of the surrounding fat and ascites (arrowhead).
C. Fused images help localize the local extent of tumour within the pelvis (arrows) which is of assistance to the surgeon if surgical treatment is to be attempted.

A B C

Figure 3. Staging of ovarian cancer.

Transverse PET, intravenous contrast enhanced CT, and fused PET/CT images in a 48-year-old post menopausal woman
with ovarian cancer and peritoneal metastases (same patient as Figure 2).
A. On PET, it can be seen that there is a crescent-shaped area of in FDG uptake in the left side of the abdomen (arrow).
B. On CT, there is abnormal soft tissue in the omentum with associated ascites and inflammatory fat stranding (arrow). Due to the close proximity between
bowel, fat standing and peritoneal disease, the soft tissue planes are indistinct and the tumour extent is uncertain.
C. Fused images again help localise the local extent of tumour (arrow) within the abdomen. This is important information for oncology follow-up.
 25 – November 2010

A B C

Figure 4. Recurrent disease.

Transverse PET, intravenous contrast enhanced CT, and fused images in a 62-year-old-woman with metastatic ovarian cancer to the liver.
A. On PET imaging, it can be seen that there is an increased FDG uptake in the segment 4B of the liver (arrow) adjacent to the falciform ligament.
Increased FDG accumulation is also noted in the region of the right kidney (arrowhead).
B. A metastatic deposit in segment 4B is confirmed on CT (arrow). No mass is seen in the upper pole of the right kidney (arrowhead).
C. Fused images confirm increased FDG uptake in the liver lesion identified on CT (arrow). No other foci of abnormal increased uptake were seen within
the liver. Increased FDG uptake in the region of the kidney is confirmed to lie within the collecting system and is due to normal urinary excretion of FDG.

following cytoreductive surgery for recur- [11]. Recently, PET/CT has been shown to
rent ovarian cancer [9]. Even though the increase the accuracy of diagnosing recur-
serological tumour marker CA-125 has rence [Figures 4, 5A & 6]. FDG PET/CT
a high sensitivity for early detection of is considered appropriate by the Ameri-
recurrence, it does not quantify tumour can College of Radiology for the imaging
extent or indicate the location of recur- of patients with suspected recurrence and
rence. Moreover, it has a poor negative a negative CT, and also for the assessment
predictive value [10]. of patients with oligometastatic disease on
CT as part of treatment planning [12]. The
CT has been the standard imaging tech- patient-based sensitivity, specificity and
nique for evaluation of suspected recur- accuracy of PET/CT ranges from 53% to
rence of ovarian cancer. The accuracy 97%, 80% to 97% and 68% to 92%, respec-
of CT however varies from 38% to 88% tively [11, 13-14]. The lowest sensitivity
of 53% was reported in a study where the
lesions that were FDG negative were less
than 5 mm in size, i.e. below the resolution
of PET/CT and essentially all other cur-
rently available imaging techniques [11].
PET/CT has a high positive predictive
value of 89%–98% for recurrence of ovar-
ian cancer. Iagaru et al. [15] classified the
lesions of recurrent ovarian malignancy
into pelvic and extra-pelvic lesions and
found that PET/CT is much more sensi-
tive for extra-pelvic lesions than for pelvic
lesions. This is partly because physiologic

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 – November 2010 26 MEDICAL IMAGING

bladder uptake can obscure pathologic pel-
vic uptake. Additionally, postsurgical pel-
vic inflammatory changes can create false-
positive areas of FDG uptake on PET/CT.
The ability to accurately localise lesions
and quantify the extent of recurrence and
metastases has raised the profile of PET/CT
for restaging recurrent ovarian cancer. The
ability of PET/CT to predict the likelihood
A B
of optimal cytoreduction in recurrent
ovarian cancer has a reported accuracy
of 79%, sensitivity of 93%, specificity of
56%, positive predictive value of 77% and
negative predictive value of 83% [16]. This
shows that FDG PET/CT is an efficient
tool in the planning of surgical treatment
of patients with recurrent ovarian cancer
[16]. For this purpose, it was found to be
comparable to staging laparoscopy. Again,
the false-negative results on PET/CT in
that study were due to small peritoneal
implants < 7 mm in size. Mangili et al. [17]
not only reported a much higher sensitiv-
ity of PET/CT (91%) in comparison with
contrast-enhanced CT alone (62%) for the
detection of recurrent ovarian cancer, but
also showed that the use of information
gained from PET/CT resulted in a change
in treatment techniques in 44% of patients.
In another, similar study, PET/CT findings
were found to result in significant changes
to the management of recurrent ovarian
cancer in 57% of patients studied [18].

Potential limitations
Accurate characterisation of calcified
lesions or lesions measuring less than 0.5cm
in diameter can be challenging with FDG
PET/CT. This has important implications
for the detection of small peritoneal depos-
its. In one study, 41 malignant deposits
were identified at surgery (including lymph
C D nodes and peritoneal deposits) but nine
lesions were falsely negative at PET/CT, and
all of these measured less than 0.5 cm in size
[11]. The presence of bowel peristalsis in the
abdomen and pelvis combined with physi-
ological bowel and bladder uptake can cre-
ate misregistration of PET and CT data and
interfere with interpretation. Usually an
awareness of this phenomenon and care-
ful image review are sufficient for accurate
Figure 5. Potential limitations of PET/CT. interpretation. Similarly, the use of PET/
Transverse PET, intravenous contrast enhanced CT, and fused PET/CT images with soft tissue and CT for the detection of recurrent ovarian
bone windows in a 72-year-old-woman with metastatic ovarian cancer to the retroperitoneum. cancer can be limited by the difficulty of
A. On PET, it can be seen that there is a small focus of avid FDG uptake in the retroperitoneum distinguishing postoperative inflammatory
(arrow). It is not possible to differentiate between normal ureteric or metastatic uptake based on PET
alone. A second focus of increased FDG uptake is seen in a vertebra at this level (arrowhead).
changes from tumour recurrence or per-
B. There is a small linear soft tissue lesion posterior to the right ureter on CT (arrow). sistence [Figure 5], [11]. Often, correlation
C. Fused images confirm increased FDG uptake in the retroperitoneum lies within the soft tissue lesion with prior imaging, clinical and biochemi-
posterior to the right ureter (arrow) rather than in the ureter itself. This uptake is therefore highly suspi- cal examinations helps determine the sig-
cious for metastatic disease. nificance of abnormal FDG uptake and
D. On bone windows, it can be seen that increased FDG uptake in the spine at the level is due to
helps guide appropriate management.
degenerative spinal changes with facet joint hypertrophy rather than malignancy (arrowhead).

A B C

Figure 6. Detection of recurrent disease.

Transverse PET, intravenous contrast enhanced CT, and fused PET/CT images in a 59-year-old-woman with recurrent ovarian cancer in the pelvis
previously treated with hysterectomy and bilateral salpingo-oophrectomy.
A. On PET, it can be seen that there are focal areas of increased FDG uptake in the pelvis (arrows). Based on the PET images alone it is difficult to
accurately differentiate this mild uptake from normal bowel uptake. Incidental note is made of increased FDG uptake in the upper right thigh (arrowhead).
B. On CT, it can be seen that there are soft tissue lesions in the pelvis (arrow).
C. Fused images confirm increased FDG uptake in the soft tissue lesions rather than in bowel and therefore these deposits are likely metastases (arrows).
Upper right thigh FDG uptake is again noted (arrowhead) without a mass on CT. This increased FDG uptake is due to muscle activity
and is not due to metastatic disease.
 27 – November 2010

A B C

Figure 7. Transverse PET, intravenous contrast enhanced CT, and fused PET/CT images in a 59-year-old-woman (same case as in Figure 6)
with recurrent ovarian cancer at site of previous surgery.
A. On PET it can be seen that there is abnormal FDG uptake in the anterior abdominal wall (arrow).
B. There is subtle increased soft tissue thickening in the region of the surgical clips (arrow) in the anterior abdominal wall that may be post surgical in nature.
C. Fused images confirm increased FDG uptake in the anterior abdominal wall at the level of the surgical clips (arrow). The prior surgery was two years prior to
the PET/CT and therefore this uptake is abnormal and highly suspicious for metastatic disease.

Conclusion 233: 433.

FDG PET/CT is an impor-
tant tool for the preoperative
evaluation of women with pri-
mary ovarian cancer and also
for postoperative surveillance.
FDG PET/CT substantially
helps physicians to assess the
extent of primary and recurrent
ovarian cancer and, hence, often
appropriately alters patient
management [Figure 7].
References
1. Jemal A et al. CA Cancer J Clin
2009; 59: 225.
2. ACR practice guideline for
performing FDG-PET/CT in
oncology. http://www.acr.org/
S econdar yMainMenuCate-
gories/quality_safety/guide-
lines/nuc_med.aspx. Accessed
August 20, 2010.
3. Liu Y. Ann Nucl Med 2009; 23:
107.
4. Fenchel S et al. Radiology 2002;
223: 780.
5. Castellucci P et al. Nucl Med
Commun2007; 28: 589.
6. Kitajima K et al. Eur J Nucl
Med Mol Imaging 2008; 35:
1912.
7. Mironov S et al. Radiol Clin
North Am 2007; 45: 149–166.
8. Greenlee RT et al. CA Cancer J
Clin 2001; 51: 15.
9. Biliatis I et al. J Surg Oncol.
2010 Aug 18. pubmed ahead
of print.
10. Rustin GJ et al. Ann Oncol
1996; 7: 361.
11. Sironi S et al. Radiology 2004;
12. A
 CR Appropriateness Cri-
teria October 2008. http://
www.acr.org/secondarymain-
m e nu c at e g o r i e s / q u a l i t y _
safety/app_criteria.aspx 2008.
Accessed August 20, 2010.
 hung HH et al. Eur J Nucl
13. C
Med Mol Imaging 2007; 34:
480.
14. S ebastian S et al. Abdom
Imaging 2008; 33: 112.
15. I agaru AH et al. Nucl Med
Commun 2008; 29: 1046.
16. F agotti A et al. Oncology
2008; 75: 152.
17. M angili G et al. Eur J Nucl
Med Mol Imaging 2007; 34:
658.
18. S imcock B et al. Gynecol
Oncol 2006; 103: 271.
19. D e Iaco P et al. Eur J Radiol.
2010 Aug 3 pubmed ahead of
print. The Intelligent Solution from ICU to MRI
The authors The HAMILTON-MR1 ventilator is designed to ventilate
Owen J O’Connor , Priyanka 1 the adult or paediatric ICU patient within the vicinity
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Prakash2, Carmel G. Cronin1
and Michael A. Blake1* With its compact design, built in batteries and turbine,
1
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*Corresponding author: Switzerland
Dr Michael A Blake MD (+41) 81 660 60 10
Tel. +1-617-726-8396 (+41) 81 660 60 20
e-mail: mblake2@partners.org
www.ihe-online.com & search 45624
 – November 2010 28 medical imaging

High field strength SWI of cerebral

cavernous malformations:
the neurosurgeon’s perspective
Susceptibility weighted imaging (SWI) is a relatively drawbacks can be overcome. simple endothelium and filled
new magnetic resonance imaging (MRI) technique utilis- The increased signal-to-noise- with blood at different stages
ing changes in local magnetic susceptibility to create a ratio (SNR) and susceptibility of thrombosis. Typically no
sensitivity and the deceased brain parenchyma intervene
unique image contrast. It allows high-resolution depiction
T2* relaxation times at higher in the lesion. CCMs are com-
of venous structures, blood products and iron deposits, field strengths [2] result in monly found in the cerebral
making it, in addition to other applications, a prom- improved conditions for SWI, hemispheres and, more rarely,
ising complementary imaging tool for the visualisation allowing high-resolution, infratentorially. Recurrent
of cerebral cavernous malformations (CCMs). Although whole-brain coverage in just microbleedings and second-
the technique was first introduced as early as 1997 and several minutes scan time. ary iron deposit determine
With the growing availability the patients´ symptoms,
has been constantly improved since then, it is not yet in
of higher field strength MRI which are mainly seizures or
routine use in many neuroimaging protocols. systems and the improvement neurological deficits due to
of SWI sequences and post mass effects [5]. Depending
by Dr Philipp Dammann, Dr Mark E. Ladd and Dr Ulrich Sure processing software, this imag- on the balance of the level of
ing modality has become a risk as shown by the analysis
powerful tool to study diverse of the patient’s anamnesis,
Principles and technical paramagnetic substances such pathological conditions [3]. compared to surgery-related
background as deoxygenated haemoglobin, risks, some of the lesions may
SWI is a high-resolution, haemosiderin or ferritin. These A detailed explanation of require surgical treatment.
3-dimensional (3D) gradient substances produce a strong the underlying physical and
echo imaging technique that is hypointense signal in the proc- mathematical principles of Currently gradient echo (GE)
extremely sensitive to suscepti- essed images. This “native” SWI is beyond the scope of T2* weighted imaging is con-
bility changes in the local mag- contrast allows high-resolu- this review, but can be found sidered as the gold standard
netic field [1]. It provides infor- tion depiction of e.g. venous elsewhere [4]. in detection of CCMs, which
mation from both the so-called vessel structures, iron depos- can occur either as sporadic
magnitude and phase images, its or blood products [Fig- SWI in imaging of or hereditary forms. The
either separately or combined, ure 1]. At lower field strength CCMs potential of SWI in imaging
although the combination is MRI, the requirements for a Cerebral cavernous malfor- of such lesions is obvious and
actually referred to as SWI. long echo time and high spa- mation (CCMs) are low-flow has been suggested relatively
In brain imaging, image con- tial resolution, which lead to vascular lesions affecting 0.4 early by different authors.
trast in SWI is predominately unreasonably long measure- – 0.9 % of the population. His- Several recent studies [6, 7]
created by the phase changes ment times, compromise the tologically, these lesions are reported a higher sensitivity
between the diamagnetic full application of SWI. At defined as dilated thin-walled of SWI in identifying CCMs
brain tissue and surrounding higher field strengths, these vascular channels lined by compared to conventional GE

Figure 1. SWI of the brain. Axial slices (1 mm). 0.25 * 0.25 mm²
in-plane resolution. Note the excellent depiction of the deep brain nuclei
(Putamen, Globus pallidus) and the venous vessel system. Images in MIP
(minimum initensity projection). Arrows showing signal cancellations
caused by the frontal sinus.
Figure 2. (A) Typical impression of a CCM, located in this case in the area
of the left trigonum. Axial slices of SWI. The patient presented with a his-
tory of recurrent seizures. Note the typical “popcorn“-like configuration. (B)
Patient with multiple cavernomas after radiotherapy. Acute bleeding
in a left parietal lesion. Several CCMs are marked by arrows.

Figure 3. Frames A-C show multiple slices obtained by SWI in Minimum
intensity projection (mIP) of a right frontal developmental venous anomaly
(DVA) not associated with a CCM. Note that no contrast agent was used
in this sequence. Frames D-F show CCM with associated venous
anomalies. (D) brainstem, (E) right temporal, (F) left frontal.
T2* weighted imaging. SWI
therefore may help to con-
firm the diagnosis of a CCM
in patients with “cryptogenic”
epilepsy or atypical bleeding,
where conventional imaging
fails. At our institute, we also
perform SWI for screening or
follow-up imaging in patients
with familial CCMs or multi-
ple CCMs, for example after
radiation therapy [Figure 2].
Once a decision is taken on the
surgical treatment to be carried
out, preoperative and postop-
erative imaging is crucial. In
particular, whenever surgery
is performed to achieve seizure
control, a postoperative assess-
ment of residual haemosiderin
deposits is necessary since
these residues have been found
to be associated with impaired
postoperative seizure control
[8]. The high sensitivity of SWI
for local susceptibility changes
as caused by haemosiderin may
be very helpful in postoperative
detection of even the small-
est amounts of these residual
blood products.
Another important feature in
the imaging of CCMs is the
depiction of CCM-associated
venous anomalies. Whether
these are involved in the patho-
genesis of the diseases and
how they should be treated is
still a subject of controversy
[9]. Such lesions are often
occult in preoperative conven-
tional imaging or angiography.
Reports from single cases [10,
11] and our own preliminary
series show that SWI may
improve the visualisation of
these important findings [Fig-
ure 3]. A more circumstantial
description of these issues can
be found elsewhere [12].
Future prospects
As shown above, higher field
strength MRI improves the
conditions for SWI. As part
of our fundamental research,
we carry out SWI at field
strengths as high as 7 Tesla
using a Magnetom 7T, Sie-
mens Healthcare, Erlangen,
Germany. The standard sus-
ceptibility weighted imaging
sequence parameters are as
follows: TE 15 msec, TR 27
msec, flip angle 14° , in-plane
resolution 250 × 250 μm2, slice
thickness 1 mm, bandwidth
140 Hz/pixel. All images pre-
sented in this review were
acquired using these param-
eters. The local ethics com-
mittee authorised the patient
examinations, and written
consent was obtained from all
patients before imaging.
While on the one hand higher
field strengths provide higher
signal-to noise ratios (SNR)
and decreased T2* relaxation
time, allowing optimal sus-
ceptibility effects at shorter
29 – November 2010
measurement times, there are 2002; 25: 1-53; discussion 4-5.
pronounced imaging artefacts  e Souza DR et al. J Appl Oral
6. d
which may compromise image Sci 2008; 16: 226-31.
quality. In particular, sus-  inker K et al. Invest Radiol
7. P
ceptibility artefacts, e.g. the 2007; 42: 346-51.
so-called “blooming effect” 8. Baumann CR et al. Epilepsia
and signal drop-outs at the 2006; 47: 563-6.
air-tissue boundaries, such as 9. Perrini P & Lanzino G. Neuro-
the frontal sinus or the rostral surg Focus 2006; 21: e5.
skull base, can cause severe 10. Amemiya S, Aoki S, Takao H. J
image disturbances [Figure Magn Reson Imaging 2008; 28:
1]. Further reduction in SWI 1506-9.
artefacts are urgently needed 11. F ushimi Y et al. AJNR Am J
to realise the full poten- Neuroradiol 2008; 29: E56.
tial of SWI in clinical rou- 12. D ammann P et al. Neurosurg
tine protocols, especially at Focus; 29: E5.
ultra-high field strength, but
even now the promise of the The authors
technique in neurosurgery Philipp Dammann1 MD, Mark
is unmistakable. E. Ladd2 PhD and Ulrich Sure3
MD
References 1
Department of Neurosurgery,
1. Reichenbach JR et al. Radiology University Hospital Essen,
1997; 204: 272-7. Germany
2. Ladd ME. Top Magn Reson 2Erwin L. Hahn Institute for
Imaging 2007; 18: 139-52. Magnetic Resonance Imaging,
3. Mittal S et al. AJNR Am J Neu- University of Duisburg-Essen,
roradiol 2009; 30: 232-52. Germany
4. Haacke EM et al. Am J Neurora- 3Department of Neurosurgery,
92diolX 2009; 30: 19-30. EXAGO:Mise University
132 IMAGYNE en page 1Hospital Essen, 17:41 Page
28/10/10
5. Bertalanffy H et al. Neurosurg Rev Germany
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 – November 2010 30 MEDICAL imaging

Utility of point-of-care sonography in

distinguishing soft tissue from joint effusions
Joint pain is an increasingly common emergent presentation that can have physician visits, hospitalisations, and possi-
a variety of underlying aetiologies ranging from benign inflammatory ble progression of the infection. If not diag-
processes to potentially limb and life threatening infections. Differentiating nosed and treated in a timely fashion, the
sequelae of septic arthritis can be devastating.
between infectious and inflammatory processes is often left up to blind joint
Current evidence suggests that synovial fluid
aspiration. Point-of-care ultrasound is ideal for differentiation of joint effu- analysis is the most useful diagnostic tool in
sion from soft tissue swelling and may help avoid unnecessary aspiration the evaluation of these patients [2]. Unfortu-
attempts. nately patients with soft tissue abnormalities,
but no effusion, are often subjected to inva-
sive procedures, only to receive antibiotics or
by Dr Michael Blaivas analgesics or other conservative measures.
Additionally, severe dermatitis or cellulitis
overlying a joint is a contraindication to joint
Scope of the problem Unfortunately, the diagnosis of a patient aspiration. Patients receiving anticoagulants
Patients with musculoskeletal symptoms with joint swelling is not always clear and or those with a bleeding diathesis are not can-
comprise a significant portion of patients the evaluation can be a significant challenge. didates for joint aspiration. Ideally, a physi-
seen in emergency departments (EDs) in Clinical criteria alone are inadequate to dif- cian should know if a joint effusion is present
United States. Roughly similar numbers of ferentiate patients with simple arthritis from before introducing a needle into the joint
cases occur in Europe. A study in 2004 by those with soft tissue abnormalities. Physi- space. This would avoid subjecting patients to
the US National Hospital Ambulatory Med- cal examination and laboratory data are also a potentially futile invasive procedure, but is
ical Care Survey showed 13.8% of the 110 not definitive. Cellulitic changes such as ery- surprisingly difficulty to accomplish in many
million ED visits during 2004 were attribut- thema, induration and swelling overlying a settings if ultrasound is not available.
able to musculoskeletal symptoms [1]. Rapid joint can mimic a septic joint with effusion.
and appropriate evaluation and treatment Traditionally, physicians perform blind joint Compared to the physical examination
of these patients can help limit symptoms, aspiration to identify the presence of a joint point-of-care ultrasound has been shown
speed recovery, prevent complications, and effusion. This approach subjects the patients to be both more accurate and sensitive in
improve outcomes. Emergency patients to a painful, invasive procedure. Further- identifying a joint effusion [3,4]. It pro-
can have a vast spectrum of joint disorders more, small joint effusions can potentially vides the most efficient and rapid method
and be virtually of any age. The differential be missed with the blind technique and to evaluate a patient with a suspected joint
diagnosis in a patient with a swollen pain- multiple attempts may be needed to confirm infection [5]. The superiority of ultrasound
ful joint includes septic arthritis, crystal the absence of an effusion. over X-rays in identifying a joint effu-
arthropathy, haemarthosis, cellulitis, abscess sion has also been well established [6,7].
as well as soft tissue haematoma. Physicians Alternatively, empiric treatment with antibi- In addition to its diagnostic capabilities,
have to rapidly differentiate between con- otics or analgesics can be instituted, but this ultrasound offers real-time guidance of
ditions requiring immediate therapy from approach may delay or confuse the diagno- joint fluid aspiration when necessary and
those that need less urgent intervention. sis of a septic joint. This can lead to repeat reduces potential complications associated
with contaminating other anatomic com-
partments and injury to adjacent nerves
and vessels [8-11]. The accuracy and man-
agement impact of point-of-care ultrasound
in differentiating cellulitis from abscess
compared to clinical evaluation has been
well studied [12,13]. Tayal et al. found that
point-of-care ultrasound identified occult
abscess, prevented invasive procedures and
provided guidance for further imaging and
consultation [14]. In the recent years point-
of-care ultrasound has also been utilised by
physicians to diagnose fractures and guide
fracture reduction [15-21].

Our study design

We performed a retrospective review
of emergency patients presenting with
Figure 1. In this study to determine the usefulness of POC US in determining the presence of joint joint symptoms over a one-year period at
effusions, patients were included if they presented with joint pain, erythema or swelling. two urban EDs with an annual census of
 31 – November 2010

approximately 45,000 patients. Patients

were included in the study if they presented
with joint pain, erythema and swelling, and
received a point-of-care ultrasound exami-
nation [Figure 1]. All patients included in
the study underwent a physical examina-
tion by an emergency medicine staff phy-
sician prior to receiving an ultrasound.
The treating physician’s opinions regard-
ing the probability of joint effusion and
need for aspiration were documented prior
to performing ultrasound examination.
Point-of-care ultrasound examinations of
the joints were performed using either a
Philips EnVisor system with a 12-5 MHz
broadband linear transducer or a SonoSite
M-Turbo device with a 13-6 MHz lin-
ear transducer. Researchers recorded the
effect on management as either no effect,
new aspiration procedure or elimination of Figure 2. Ultrasound analysis showed that there was joint effusion, not only in patients who had been
considered by physicians to need joint aspiration, but also in patients where joint aspiration was
aspiration procedure. Ultrasound guidance thought unnecessary.
was allowed for the aspiration of the joint.
hypothesis, ultrasound interpretations and physicians believed that joint aspiration
The ultrasound protocol specified scanning clinical information. We used descriptive was necessary and not necessary [Figure
the effected joint and surrounding soft tis- statistics to summarise the data. The pro- 2]. Point-of-care ultrasound altered man-
sues in two orthogonal planes. Graded portion of patients whose primary treat- agement in 35 out of 54 (65%, 95% CI
compression was used to differentiate effu- ment plan was altered, and if there was a 52%-77.5%) patients. Prior to point-of-
sion from cartilage, and the anechoic or significant change in the management by care, joint aspiration was planned in 39 out
hypo-echoic area was followed along the the addition of point-of-care ultrasound, of 54 patients (72.2%, 95% CI 60.2-84.1).
entire length of the bone. Power Doppler was determined. After point-of-care ultrasound, only 20
was used as needed to evaluate the joint (37%, 95% CI 24.1-49.9) of these patients
and adjacent tissues. Ultrasound interroga- Summary of findings underwent joint aspiration. We found a
tion of the contralateral joint was also per- A total of 54 patients were identified over statistically significant difference in treat-
formed for comparison as needed. Chart a one-year period. The mean age of the ment plan after the addition of point-of-
reviewers performed data abstraction for patients was 41 years +/- 19 (standard care ultrasound results (p<0.01).
information about ultrasound findings, deviation). The symptomatic joints in our
final interpretation, clinical assessment, study subjects included knee, elbow, ankle In the group where treating physi-
hospital course, outcome and final diagno- and finger joint in decreasing frequency. cians believed that joint aspiration was
sis. The point-of-care ultrasound images of Of the patients 22 out of 54 (40.7%, 95% required, ultrasound changed manage-
all patients included in this study were also CI 27.6%-53.8%) were found to have joint ment in 27 out of 39 patients (69.2%,
reviewed for accuracy by an emergency effusions on ultrasound. Joint effusions 95% CI 54.7% to 83.7%) cases, with 12
sonologist who was blinded to the study were found both in patients in whom patients given antibiotics for cellulitis
 – November 2010
and 15 patients being treated with other
conservative measures. In the patient
group where physicians believed joint
aspiration was unnecessary, ultrasound
changed the management in eight out
of 15 cases (53.3%, 95% CI 28%-78.5%).
Four patients were hospitalised for sep-
tic arthritis with intravenous antibiot-
ics and orthopedic consultation, four
other patients were found to have crys-
tal arthropathy. No subsequent change
in management occurred during hospi-
talisation or follow-up. There was 100%
agreement in the interpretation of ultra-
sound images between the clinicians and
the blinded investigator.
In our study, more than 50% of planned
aspirations would have been futile and
were avoided. Conversely, ultrasound
detected joint effusions in approximately
50% of patients in whom aspiration was
not planned by the treating emergency
physicians. This led to accurate diagno-
sis, appropriate consultation and ther-
apy. Misdiagnoses of septic arthritis in
this group of patients would have led to
potentially serious complications. Our
study indicates that ultrasound is supe-
rior to clinical judgment in determining
the presence or absence of a joint effusion.
It must be noted that ultrasound findings
do not distinguish between infectious and
inflammatory effusions and septic arthritis
has a wide spectrum of imaging findings.
Absence of a joint effusion doesn’t neces-
sarily completely exclude septic arthritis.
However, it at least makes it extremely
unlikely. Overall our study results suggest
that ultrasound is a reliable way of identi-
fying a joint effusion and determining if
an aspiration is needed.
Amsterdam, the Netherlands
2011
Euroanaesthesia
The European Anaesthesiology Congress
Symposia
Refresher Courses
Workshops
Industrial Symposia & Exhibition
Abstract Presentations Deadline abstracts:
December 15th 2010
CME Accreditation Online submission:
EACCME - UEMS www.euroanaesthesia.org
Amsterdam_IHES.indd 2
32 MEDICAL imaging
Future developments
There are several constant trends in the
development of point-of-care ultrasound
development. Equipment is becoming
smaller, image quality is steadily improv-
ing and the technology is findings its way
to more and more patient bedsides. This
combination will likely lead to its routine
“.... the study showed that
ultrasound is superior to clinical
judgment in determining
the absence or presence
of joint effusion....”
use for evaluation of any joint prior to
consideration of aspiration. In addition,
since trauma precedes many joint pain
complaints with redness and swelling on
presentation, we are likely to see consoli-
dation of imaging use since ultrasound
may provide superior evaluation of bone
surface irregularity over plain X-rays.
Such a trend will also be reinforced by
escalating health care costs and increased
scrutiny of overuse of expensive imaging
modalities such as MRI and their clinical
impact over other imaging techniques.
As hand-held ultrasound units enter the
market at costs around €3,500 we are only
several years away for pocket ultrasound
devices being a common aid carried by
most clinicians involved in the evaluation
of patients with joint pain. Technological
developments such as real-time three-
dimensional ultrasound imaging may
provide for more complex evaluation of
June 11-14
ESA Secretariat
Phone +32 (0)2 743 32 90
Fax +32 (0)2 743 32 98
E-mail: registration@euroanaesthesia.org
20/05/10 14:58
internal joint surfaces allowing for grad-
ing of severity of inflammatory effects on
the joint.
References
1. McCaig LF & Nawar EW. Adv Data 2006;
372:1.
2. Li SF et al. Emerg Med J 2007; 24:75.
3. Hauzeur JP et al. J Rheumatol 1999; 26:2681.
4. Spadaro A et al.. Ann Rheum Dis 2009;
68:1559.
5. Cardinal E et al. Radiol Clin North Am 2001;
39:191-201.
6. Bickerstaff DR et al. JBJS 1990; 72: 549.
7. Volberg FM et al. Pediatric s 1984; 74:118-
120.
8. Fessell DP et al. AJR Am J Roentgenol 2000;
174:1353.
9. Craig JG. Radiol Clin North Am 1999;
37:669.
10. Widman DS et al. Skeletal Radiol 2001;
30:388.
11. Punzi L & Oliviero F. Ann N Y Acad Sci
2009; 1154:152.
12. Chao HC et al. J Ultrasound Med 2000;
19:743.
13. Sivitz AB et al. J Emerg Med 2010; 39:637.
14. Tayal VS et al. Acad Emerg Med 2006; 13: 384.
15. Tayal VS et al. J Ultrasound Med 2007; 26:
1143.
16. Chern TC. J Bone Joint Surg Am 2002;84-
A(2):194-203.
17. Chen L et al. Pediatr Emerg Care 2007;
23:528-531.
18. Durston W & Swartzentruber R. Am J
Emerg Med 2000; 18:72.
19. McManus J et al. Am J Disaster Med 2008;
3: 241.
20. Marshburn TH et al. J Trauma 2004;
57:329.
21. Hubner U et al. J Bone Joint Surg Br 2000;
82:1170.
The author
Michael Blaivas, MD
Professor of Emergency Medicine
Associate Professor of Internal Medicine
Vice President, Emergency Ultrasound
Consultants
Vice President, Society of Ultrasound in
Medical Education
Editor-in-Chief, Critical Ultrasound
Journal
Chair, AIUM Emergency and Critical Care
Ultrasound Section
President, WINFOCUS
Editorial Board, Journal of Ultrasound in
Medicine
Past Chair, ACEP Ultrasound Section
ACEP liaison for Critical Care Medicine
Department of Emergency Medicine
Northside Hospital Forsyth
Atlanta, Georgia, USA
 Register online
now at
myESR.org/registration2011
 – November 2010
34 Medica Highlights
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wice ultrasound of the control panel. The touch-screen
system is that, in allows all mode-dependent parameters
addition to the to be clearly visu-
premium per- alised and modi-
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central instru- touch. A further
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Sat ultrasound unit which can be unloaded Light, gives the
from the central device and used as a possibility to
point-of-care ultrasound system. Thanks control the light-
to the MyLabSat system, which with its ing room level
arm-held deign could be described as a directly from the
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Fukuda Denshi
Tokyo, Japan
www.ihe-online.com & search 45699
Medica Hall 09/E67
Autcoclavable SpO2 sensor
Designed to meet the highest hygiene
standards and requirements, the new, auto-
clavable SpO2 sensor from Med-Linket also
improves patient comfort, thanks to the use
of bio-compatible (latex-free) silicone rub-
ber. The autoclavability of the new system
reduces the risk of nosocomial infection
resulting from microorganisms remaining
on the sensor surface, and thus makes the
device suitable for use in harsh environ-
ments such as those of rescue services,
emergency care and busy hospital facilities.
The Med-Linket company also provides
highly cost-effective medical grade - cable,
sensors and probes. The company has been
ISO13485 certified since 2005, and has com-
prehensive in-house design and produc-
tion facilities so that the all functions, from
design, tooling/moulding, prototyping, test-
ing, certification, product modification and
mass production can be carried out to high
quality specifications. The company also
produces a wide range of medical acces-
sories compatible with virtually all patient
monitors on the market.
MED-LINKET
Shenzhen, China
www.ihe-online.com & search 45702
MEDICA Hall 8B/P19-4
Advanced acute hospital bed
The Independence Innov8 advanced acute
hospital bed combines practicality, world-
class infection control and advanced ergo-
nomics and has been designed exclusively to
meet the needs of hospital teams and patients
around the world. Each bed has a special Bio-
Cote antimicrobial coating, which reduces
levels of bacteria by up to 99.9% over an 18
hour period, thus reducing the risk of cross
infection and facilitating cleaning. Being elec-
trically operated, the bed can be adjusted to a
low level for added patient safety and also has
additional functionalities to adjust the back-
rests and knee breaks. Separate patient handset
and nurse control panels are provided, which
means that, if needed, specific functions can
be locked out via the nurse control panel. The
bed is also easy to manoeuvre manually and
offers complete flexibility thus making it suit-
able for use in all hospital environments, from
general wards to high dependency units.
Sidhil
Halifax, Yorks, UK
www.ihe-online.com & search 45711
MEDICA Hall 16/G10
 Medica highlights
Magnetically guided capsule
endoscope system
Developed in a collaborative effort
between Siemens and Olympus, a new
magnetically guided capsule endoscope
(MGCE) system enables easy examina-
tion of the stomach while maintaining
maximum patient comfort. The MGCE
system consists of an innovative guid-
ance magnet, an image processing and
guidance information system as well as
the capsule endoscope itself. After swal-
lowing the capsule, the patient is posi-
tioned in the system so that his stomach
is located in the centre of an artificially
generated magnetic field whose inten-
sity and orientation can be varied in
real time. This enables the physician
to “steer” or navigate the capsule with
a joystick. The capsule wirelessly trans-
mits images from inside the stomach
to an image processing system where
the clinician can view the images. The
results of a first feasibility study pub-
lished in the recent issue of the journal
Endoscopy show that the innovative
method is effective and accurate. The
capsule is approximately 31 mm long
and 11 mm in diameter.
Siemens Healthcare
Erlangen, Germany
Sans
www.ihe-online.com & search 45706
Medica Hall 10/A20-1&2
Automated digital BP system
The Connex ProBP 3400 is a portable auto-
mated digital blood pressure device designed
to deliver accurate readings while held in
37 – November 2010
the palm of the hand. Incorporating Welch
Allyn’s SureBP technology from the com-
pany’s multiparameter vital signs devices, ISO 9001 Version 2000
ISO 9001
ISO 13485 Version 2003
the new system delivers fast, accurate blood
CE 0197
ISO 1348
pressure readings with the reliability of the CE 0197
well-established vital signs devices. Now
available in markets outside the United States
and Canada, the new device is easy to use
and provides a portable option for capturing
reliable blood pressure readings in virtually
any hospital or primary care environment.
Whether used as a reliable alternative to
traditional blood pressure gauges, as an
accurate alternative to home-grade digital
blood pressure devices, or as a hand-held
alternative to an electronic vital sign device,
the ProBP 3400 is suitable for just about any
healthcare setting.
Welch Allyn
Skaneateles Falls, NY, USA www.ihe-online.com & search 45691
www.ihe-online.com & search 45703
Medica Hall 09/E15
Patient trolley for use in MRI
The MR Elevating Trolley from Wardray is
easy-to-use, has an adjustable height to assist
in manual handling and has been fully tested
for safety up to 7 Tesla (which is a magnetic
field well above current routine clinical use).
It offers gas spring-assisted Trendelenburg
and backrest elevation as standard features,
together with a dual pedal arrangement
which
enables
titre-1.indd 1 the nurse to maintain eye
Sans titre-2 1
contact with the patient at all times. The fold-
down cot sides enable the trolley to be used
in the narrowest of areas; its ability to han-
dle patient loads of 220 kg means that this
is the most versatile and dependable trolley
of its kind in today’s market. The company
also produces an X-Ray Trolley that allows
clinicians to use either conventional or dig-
ital X-ray films. Ideal for accident and emer- www.ihe-online.com & search 45639
gency use, it has an adaptable Bucky assembly
that slides the full length of the table top and
can rotate through 360 degrees in 90 degree
increments for maximum versatility.
Wardray Premise HAVE YOU RENEWED YOUR
Thames Ditton, Surrey, UK
FREE SUBSCRIPTION ?
www.ihe-online.com & search 45710
Medica Hall 10/A62 www.ihe-online.com
 – November 2010
38 PRODUCT NEWS

Support tube and line structural heart disease assessment, as

visualisation by DR well as systolic and diastolic heart fail- Calendar of events
The Carestream ure and arrhythmia. Aimed at supporting November 19-20, 2010 March 3-7, 2011
3rd European Symposium on ECR 2011
DRX-Evolution workflow improvements as well as provid- Rare Anaemias Vienna, Austria
system will now ing clinical benefits, the iE33 xMATRIX Madrid, Spain Tel. +43 1 533 40 64 - 0
Tel. +34934515950 Fax +43 1 533 40 64 - 448
support tube cardiac ultrasound system  is designed www.enerca.org e-mail: communications@myESR.org
and line visuali- to give clinicians new diagnostic tools http://myESR.org
Nov 28 – Dec 3, 2010
sation and long and helps them examine patients more RSNA 2010 March 17-20, 2011
length imaging. quickly. In particular, clinicians who have Chicago, IL, USA KIMES 2011
Tel. +1 630 571 2670 Coex, Seoul, Korea
The company’s experienced scanning fatigue will appre- www.rsna.org Tel. +82 2 551 0102
innovative ciate that the X5-1 transducer combines Fax +82 2 551 0103
Nov 30 - Dec 2, 2010 e-mail: kimes@kimes.kr
v isu a l is at i on the ergonomics of 2D transducers with 16th Postgraduate Refresher www.kimes.kr
feature creates the three-dimensional technology they Course: “Cardiovascular and
Respiratory Physiology Applied to March 22-25, 2011
a companion need. Clinicians can more easily obtain Intensive Care Medicine” 31st International Symposium on
image from the challenging 2D views, such as apical two- Brussels, Belgium Intensive Care and Emergency
Tel. +32 2 555 36 31 Medicine (ISICEM)
original exposure that enhances the visibil- chamber. Rather than manually rotating Fax +32 2 555 45 55 Brussels, Belgium
ity of tubes and lines used in the treatment the transducer and searching for a win- e-mail: sympicu@ulb.ac.be Tel. +32 2 555 36 31
www.intensive.org Fax +32 2 555 45 55
of seriously ill or injured patients. Adding dow that isn’t obscured by ribs, rotation e-mail: sympicu@ulb.ac.be
long length imaging allows the automated is achieved electronically to maintain the Nov 30 – Dec 2, 2010 www.intensive.org
Clinical Excellence Asia
DR suite to support a variety of orthopaedic, best acoustical window. Marina Bay Sands, Singapore March 29-31, 2011
spine and other exams. The company’s tube www.iirme.com/clinicalasia 14th SE-Asian Healthcare Show
& Conferences
and line visualisation feature will be available Philips December 5-8, 2010 Kuala Lumpur, Malaysia
on all three DRX-1-based devices, namely Eindhoven, The Netherlands Respiratory Monitoring Tel +603 79 54 65 88
Rome, Italy Fax +603 79 54 23 52
the DRX-1 System itself, the DRX-Evolution www.ihe-online.com & search 45709 Tel. +32 2 555 36 31 e-mail: sales@abcex.com
and the DRX-Mobile Retrofit Kit. The Sys- Medica Hall 10/A21 & C23 Fax +32 2 555 45 55 www.abcex.com
e-mail: sympicu@ulb.ac.be
tem allows healthcare facilities to quickly www.intensive.org April 6-8, 2011
and cost-effectively upgrade existing rooms Med-e-Tel 2011

to DR technology by employing the wireless, Large format X-ray detector for DR December 13-15, 2010
Medifest India 2010
Luxembourg, Luxembourg
Tel. +32 2 269 84 56
cassette-size DRX-1 detector instead of a film New Delhi, India Fax +32 2 269 79 53
Tel. +91 11 30580444 e-mail: info@medetel.eu
or CR cassette, while the DRX-Mobile retrofit e-mail: info@vantagemedifest.com www.medetel.lu
kit enables users to upgrade selected mobile www.vantagemedifest.com
April 13-14, 2011
X-ray systems to wireless DRX-1 technology. January 13-14, 2011 The 7th Annual World Health
As for the DRX-Evolution, this is a fully auto- 2nd China International Medical Care Congress Europe 2011
Device Summit 2011 Innovations and Best Practices to
mated DR suite that delivers rapid patient Beijing, China Improve European Health Care
throughput with wireless DRX-1 detectors to Tel. +86 21 5258 8005 Brussels, Belgium
e-mail: info@duxes.cn Tel. +1 781-939-2559
provide the ultimate in positioning flexibil- www.duxes-events.com/md_2/ www.worldcongress.com/europe
ity. The company has also introduced a new
January 18-20, 2011 May 10-13, 2011
version of software for the complete DRX-1 Combat Trauma Innovation World of Health IT 2011
family. The new software offers an extended London, UK Budapest, Hungary
www.combat-trauma-innovation.com e-mail: customerservice@worldof-
exposure mode (up to three seconds) that The Pixium RAD 4143 from Thales is the healthit.org
can be helpful when imaging obese patients new large-format X-ray detector for dig- January 19-21, 2011 www.worldofhealthit.org
The International Medical
as well as for cross-table and mobile exams. ital radiography. To meet market demand, Distributor Meeting (IMDM): May 24-27, 2011
Thales offers equipment manufacturers a Cardiovascular Hospitalar 2011
Budapest, Hungary São Paulo, Brazil
Carestream HEALth choice between two versions of the new Tel: +41 22 533 0948 www.hospitalar.com/ingles/
Rochester, NY, USA detector, one with a caesium iodide (CsI) www.internationalmedicaldistribu-
tormeeting.org June 7-9, 2011
www.ihe-online.com & search 45714 scintillator, the other with a Gadox scin- Medifest South Africa
tillator, both of them delivering excellent January 24-27, 2011 Cape Town, South Africa
Arab Health 2011 www.vantagemedifest.com
quality for the price. As with all Thales Dubai, UAE
Cardiac ultrasound imaging detectors, the Pixium RAD 4143 gen- Tel. +971 4 336 5161 June 11-14, 2011
e-mail: info@iirme.com Euroanaesthesia 2011
The iE33 xMATRIX erates high quality images in real time, www.arabhealthonline.com Amsterdam, The Netherlands
cardiac ultrasound while reducing exposure to a minimum. Tel. +32 2 743 3290
February 24-27, 2011 www.euroanesthesia.org
system from Philips Easy to integrate in all types of X-ray sys- International Conference on Pre-
features a new ergo- tems, the flat-panel digital detector deliv- hypertension & Cardio Metabolic September 14-16, 2011
Syndrome Medical Fair Thailand 2011
nomic solution, the ers both quality images and fast exams Vienna, Austria Bangkok, Thailand
X5-1 transducer, for for high X-ray room productivity. Tel. +41 22 5330948 Tel. +65 6332 9620
Fax +41 22 5802953 Fax +65 6332 9655
more efficient adult The system can also be supplied as part e-mail: Secretariat@prehypertension.org e-mail: medicalfair-thailand@mda.com.sg
echocardiograms. of Thales PrestoDR, a complete turnkey www.prehypertension.org www.medicalfair-thailand.com

The new system imaging solution featuring clinical image For more events see
enables expanded acquisition, display and distribution. www.ihe-online.com/events/
cardiac-related diag- Dates and descriptions of future events have been obtained from
nostic capabilities Thales usually reliable official industrial sources. IHE cannot be held
responsible for errors, changes or cancellations.
related to ischaemic Vélizy-Villacoublay, France
disease detection, www.ihe-online.com & search 45717
 Productivity & Efficiency in Healthcare Models

27 January 2011
Dubai International Convention and Exhibition Centre, UAE

Confirmed for 2011, Leaders who raised the profile of their billion-dollar global institutions
Leong Yew-Meng
CEO, NHG Polyclinics, Singapore

Delos Cosgrove
CEO and President, Cleveland Clinic, USA

Philippa Robinson
Former Implementation Director, Department of Health, UK

Raj Raja Rayan OBE

Former Advisory Committee to the Secretary of Health, UK

Dr Nipit Piravej MD
CCO, Bangkok Chain Hospital PCL, Thailand

Dr Ali Parsa
CEO, Circle Group, UK

Kevin Davies
Author, The $1000 Genome, USA

Jim Roth
CEO, Huron Consulting, USA

Dr Michael Heuer
President EMEA and Latin America, Roche Diagnostics, Switzerland

John Bell
Renowned Healthcare Personality, UK

Book Your Place at Leaders In Healthcare Now

Call +971 4 336 7334 or Email ahcongress@iirme.com

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