who did not receive donated blood. The risks associated with blood

transfusion occurred regardless ofhaemoglobin levels, age, or level ofpatient disability at the time of trans-fusion, the researchers point out.The finding, which implicates thecause being lack of oxygen to keyorgans, has knocked the widespread

events. ‘The study demonstrates thecost implications of our current transfu-sion practice. This is important, partic-ularly in modern health systems whereresources are finite, and should encour-age the sort of research that willaddress the major health issues raisedin the study,’ said the study’s lead authorGavin Murphy of Walport ConsultantSenior Lecturer in Cardiac Surgery atthe University of Bristol.

The researchers aim to undertake alarger study to ascertain whether chang-ing transfusion guidelines couldimprove patient outcomes. Presentlythe suggestion is that surgeons shouldthink twice before giving blood transfu-sions.

In March, the New England Journal

of Medicine found that patients whoreceived blood that was more than twoweeks old were up to 70% more likely todie within a year than patients whoreceived fresher blood.

The question of how red cell transfu-sions may affect immunity or tissueoxygenation needs further study, asdoes the question of how the safety ofdonor blood storage could be improved.

Surgeons urged to ‘thinktwice’ before giving bloodtransfusions

A danger to patients’ security and privacy?

EUROPEAN HOSPITAL

News . . . . . . . . . . . . . . . . . 1-3Competition . . . . . . . . . . . .4Radiology . . . . . . . . . . . . 5-15Cardiology . . . . . . . . . . 16-21Surgery . . . . . . . . . . . . . 22-24IT & Telemed . . . . . . . . . . . 25Lab & Pharma . . . . . . . 26-29Russian pages . . . . . . . 30-35Diabetes & infections . . .36

contents

T H E E U R O P E A N F O R U M F O R T H O S E I N T H E B U S I N E S S O F M A K I N G H E A L T H C A R E W O R K4

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Hospitals are urged to tighten up onblood transfusions, following a grow-ing number of reports on unrecognisedrisks from blood transfusions – andthese are not the generally-knowninfection risks, such as HIV.Researchers point to risks presentedby the lack of oxygen delivered to keyorgans, which can result in stroke oradverse cardiac events.

It has now been suggested that per-haps up to 60% of blood transfusionsare not good for patients.

Although blood transfusions arecommonly given during various surgi-cal procedures, e.g. orthopaedic, con-cern about the risk in blood transfu-sions for cardiac surgery patients hasbeen particularly highlighted. In onestudy, published in November by thejournal Circulation, researchers atBristol University and the Bristol HeartInstitute, followed 8,500 cardiacsurgery patients for an eight-year peri-od and found that red blood cell trans-fusions increased the risks of heartattack or stroke three-fold – and, in themonth after surgery patients were sixtimes more likely to die than patients

Unexpected risks my result fromtoday’s medical devices, such asimplantable cardiac defibrillators andpacemakers, if they are equipped withwireless technology to enable remotedevice checks. According toresearchers Tadayoshi Kohno, assis-tant professor of computer scienceand engineering at WashingtonUniversity working with Kevin E Fu,assistant professor of computer sci-ence at UMass Amherst, and cardiolo-gist William H Maisel MD, director ofthe Medical Device Safety Institute atBeth Israel Deaconess Medical Centreand Harvard Medical School, patients’private medical data could be extract-ed and their devices reprogrammedwithout the patients’ authorisation orknowledge.

The study was designed to identifyand prevent future problems, theyemphasis; no case of a patient with animplantable cardiac defibrillator orpacemaker has been targeted by hack-ers. It was pointed out that the studyrequired a high level of technicalexpertise, and the published paperomits certain method details to pre-vent the findings being adversely used.‘One of the purposes of this research is

New research reveals potential harmBrenda Marsh reports

to encourage the medical device indus-try to think more carefully about thesecurity and privacy of patient infor-mation, particularly as wireless com-munication becomes more common.Dr Maisel explained: Fortunately,there are some safeguards already inplace, but device manufacturers cando better.’

The team expects this issue to takeon greater importance as implantablecardiac defibrillators operate wireless-ly at greater distances. These devicestypically receive short-range wirelesssignals over several feet, but new tech-nologies are expanding that reacheven farther, creating the potential forinformation to be intercepted en route.‘We hope our research is a wake-upcall for the industry,’ said TadayoshiKohno. ‘In the 1970s, the BionicWoman was a dream, but modern tech-nology is making it a reality. Peoplecontinued on page 2

V O L 1 7 I S S U E 2 / 0 8 A P R I L / M A Y 2 0 0 8

16-17Cardiology

● AAC reports● Stent developments● 1st biodegradable

implant for children● Russian auto-

transplantation

The Netherlands - The prosecutionof two doctors and a faith healer hasbeen ordered by the Dutch appealcourt, due to their treatment of apatient who died seven years ago. Thewoman, well-known actor/comedianSylvia Millecam, died of untreatedbreast cancer, having chosen alterna-tive medicine as a therapy, perhapspersuaded that her illness was due tobacterial infection. However, althoughthe public prosecution service had pre-viously dismissed the case againstthree of the people involved in hertreatment, a Dutch HealthcareInspectorate investigation found that‘various individual carers’ had offeredsuch irresponsible care, based on‘unfounded methods of treatment’,that disciplinary action or prosecutionwere likely.

The inspectorate now wants the lawchanged to ensure greater supervisionof alternative practitioners and that allsuch practitioners have to be regis-tered. It also wants it made illegal foranyone other than a trained doctor tobe allowed to make a medical diagno-sis. The Royal Dutch MedicalAssociation supports the proposals.(Full report: BMJ 2008;336:853(19 April), doi:10.1136/bmj.39549.636586.DB )* In many European countries, ‘alter-native’ medicine has increased in pop-ularity. When asked, for consumer sur-veys, about 60% of the public in theNetherlands and Belgium stated theywould pay extra health insurance pre-miums for complementary treatments,and 74% of the British public thoughtthey should be available from thecountry’s National Health Service. TheDutch population seeking treatmentsfrom alternative medicine practitionerswas reported to be 6.4% in 1981, butthis had increased to 15.7% in 1990and, in France, 16% of the populationvisited practitioners in 1982, but thefigure rose to 36% in 1992.

Demands for greatersupervision of alternativemedicine practitioners

Three types of human heart cellshave been grown from culturesderived from embryonic stem cells,by a team of Canadian, US and UKscientists. During the research,when a mix of the cells was trans-planted into mice with simulatedheart disease, the animals’ heartfunction was significantlyimproved, according to researchpublished in the journal Nature.

The embryonic stem cell cultureswere carefully supplied with astaged cocktail of growth factorsand other molecules involved indevelopment, and grew into imma-ture versions of cardiomyocytes,endothelial cells and vascularsmooth muscle cells, each impor-tant constituents of heart muscle.‘This development means that wecan efficiently and accurately makedifferent types of human heartcells for use in both basic and clin-ical research, said researcher DrGordon Keller, of the McEwenCentre for Regenerative Medicinein Toronto. ‘The immediate impactof this is significant, as we nowhave an unlimited supply of thesecells to study how they develop,how they function and how theyrespond to different drugs. In thefuture, the cells may also be veryeffective in developing new strate-gies for repairing damaged hearts,following a heart attack.’

LAB-CULTUREDCARDIAC CELLS

The USA’s National Institutesof Health aims to reviewblood transfusion safety

belief that red cell transfusionimproves oxygen delivery to tissues,and that surgical patients are helpedby a ‘top up’ of red cells.

In the UK, for example, over 50% ofall cardiac surgery patients receivetransfusions, yet only about 3% aregiven due to life-threatening bleeding.The rest are usually given on the basisof a low haemoglobin level, disregard-ing whether the patient has physicalsymptoms to suggest they need blood.

Along with danger to patients, hos-pital costs increase due to adverse

Implantable medical devices

Kevin E FuTadayoshi Kohno

22-24Surgery

● Moscow’smedical mighty

● Gastric polypsmorphology

● Wireless retina implants● Surgical lights and tables

5-15Radiology

● The end ofcontrast agents?

● Trends in image-guided therapy

● Image processing● ECR reports

2 EUROPEAN HOSPITAL Vol 17 Issue 2/08

N E W S & M A N A G E M E N T

will have sophisticated computerswith wireless capabilities in their bod-ies. Our goal is to make sure thosedevices are secure, private, safe andeffective.’

Kevin E Fu noted that the studydeveloped three prototype defencesthat require no battery power, makingthem potentially easy to incorporatein the devices without extensiveredesigning.

The researchers used animplantable cardiac defibrillator con-taining computers and radios thatallow healthcare practitioners to diag-nose patients, read and write privatemedical information and adjust thedevice’s therapy settings wirelessly.They also used an inexpensive soft-ware radio to intercept and capturesignals sent from the implantabledevice. Accordingly, they obtaineddetailed information about a hypo-thetical patient, including name, diag-nosis, date of birth and medical IDnumber. They also determined thedevice make and model, accessedreal-time electrocardiogram resultsand data on heart rate and cardiacactivity.

From 2000 to 2007, Israeli hospitals havetreated the victims of 148 terroristattacks. At ECR 2008, radiologist DrAhuva Engel described the protocoldeveloped to deal with such emergenciesat the Rambam Medical Centre in Haifa.

When a suicide bombing or other mul-tiple casualty incidents occur, more than50% of the injured arrive at the hospitalwithin five to 20 minutes. Immediately onnotification, the Ramban Medical Centrecancels all scheduled radiology proce-dures. Portable X-ray machines and ultra-sound machines are moved to the emer-gency department, as well as mobilePACS diagnostic workstations.

The medical staff identifies two distinctphases in dealing with victims. First, theemergency physicians and staff, radiolo-gists and surgeons identify the most crit-ically injured. Next, they treat non-lifethreatening injuries. Both stages requireheavy use of diagnostic imaging equip-ment.

At the Centre, at least two radiologistsgo to work within the emergency depart-ment, along with as many radiographersneeded to operate the portable diagnos-tic equipment.

All front-line staff and physicians usewalkie talkies for rapid communication.The objective is to determine who needsthe most urgent care – particularlysurgery. Chest radiography and focusedabdominal ultrasound are the most com-monly used imaging procedures in theemergency department. Computedtomography is also used to assess theabdominal injuries of more stable victimsand to evaluate shrapnel localisation anddetect unsuspected injuries. The most crit-ically injured patients bypass X-rays inlieu of CT examinations.

CT angiography (CTA) helps radiolo-gists and cardiologists to more accurate-ly evaluate the vessels. Approximately

They then mounted several attacks— and could turn off the therapy set-tings stored in the implantabledevice, rendering it incapable ofresponding to dangerous cardiacevents. Additional commands weredelivered, resulting in the delivery ofa shock that could induce ventricularfibrillation, a potentially lethalarrhythmia.

Because the team studied one com-mon model of implantable cardiacdefibrillator, the susceptibility of sim-ilar devices to privacy and securityrisks is uncertain. The team believesfuture studies are needed to assesspotential risks associated with otherimplantable devices equipped withwireless technology. They alsostrongly advise that nothing in theirreport should deter patients fromreceiving such life-saving deviceswhen medically recommended.

Their peer-reviewed report will bepresented in May and published at theInstitute of Electrical and Electronic

Engineers Symposium on Securityand Privacy in Oakland, California. Details: www.secure-medicine.orgSource: http://www.uwnews.org/

TopClinicaThe TopClinica, an international trade fair and congress focusedon medical equipment and solutions is a new event on the calendar.‘It was established with the Baden-Württemberg Ministry of EconomicAffairs and market leaders from the medical industry who no longer felt ade-quately represented at existing trade fairs,’ explained Ulrich Kromer, ManagingDirector of Messe Stuttgart. ‘This new platform for decision-makers in clinics wastherefore developed jointly by numerous partners and industry leaders, and willbe presented to international visitors at Europe’s most modern trade fair centre.These are outstanding conditions for a successful premiere.’

Focusing on what it calls the ‘Clinic Principle’, the organisers expect to draw inover 150 exhibitors and 7,500 visitors. Exhibitors include: Erbe Elektromedizin,

Gebrüder Martin, Karl Storz, RichardWolf, Rudolf Medical, Wilhelm JuliusTeufel, and Trumpf Kreuzer MedizinSysteme. Thieme Congress, a division ofThieme Publishing Group, will partnerthe congress, which will focus on man-agement and financial management,medicine, quality management, healthpolicy, e-health and marketing.Details: www.topclinica.de

In-patient with terminaland doctor. terminal andGerman electronic health card

Self-service can cut patientservices costs, saysAnne Warner, whoreports for the tradepublication Kiosk Europe.‘Self-service solutions arehelping to streamline customerservice and save costs wherevercustomer service is crucial. Airportshave installed check-in kiosks, super-markets are adding self-checkout termi-nals, and so on. How can self-servicehelp to provide better patient servicesin hospitals?

‘In an industry where confidentialityand trust is key, the self-service kioskcan play a major role in providing atrustworthy and highly secure means oftransmitting information between thepatient and their doctor or healthcareadvisor, without the need to go via athird party,’ she points out, adding thatit also enables patients to access infor-mation and that surgeries and hospitalscan have automated check-in proce-dures. ‘It even cuts down on the paper-work!’

Some examples of the solutionsoffered by kiosks for healthcare includeautomated arrival terminals, wherepatients can check in without queuingat reception; appointment bookingkiosks, where patients can makeappointments or view available times-lots; health check terminals providingbasic checks such as blood pressure,without seeing a nurse or doctor, andhealthcare information terminals tomake general health information avail-able on request, she points out.

‘In Germany, plans are in place toinstall kiosks that will provide functionsto holders of the new electronic healthcard. Soon, insured patients will be ableto look up health information and med-ical documents at kiosks installedthroughout the country. Though still on

Hospital IT director builds in-house HISTelemed system remarkably beats commercial IT pricesSpain - The Torrevieja Salud Hospital, insouthern Valencia, serves a populationof 200,000 – but this swells to 600,000in holiday periods. To meet demand LuisBarcia Albacar, General Director ofTorrevieja Salud UTE, faced the chal-lenge of creating a modern, versatileand efficient hospital that could alsoprovide the benefits of top technology.

In early planning, it was decided thatthe hospital would have its own com-puter platform, and would also becomepaper-less. The hospital’s in-house ITstaff subsequently built a robust, end-to-end hospital information systemusing commodity, off-the-shelf develop-er tools, software, and technologiesfrom Microsoft. The resulting systemhas been created for a fraction of whatmost hospitals spend on commerciallyproduced IT solutions.

‘Florence – the name of our process-ing and management tool – includeseverything,’ Luis Barcia Albacar pointedout. The system allows all of a patient’smedical care information to be seen bythe specialist and family doctor. Florenceis focused on three essential points,improved provision of medical care forpatients, as is the case of SMS with theword URGENCIAS, which offers patientsa waiting time according to differentemergencies; the SMS informs the userof a free appointment; or the day andtime of a test he has asked his doctorfor, or the automatic appointment read-

er, which reads the health card, informsthe doctor that the patient is waiting tobe seen.’

The system also enables teleradiologyand teledermatology. Physicians on dutyat home can receive urgent requestsand send back reports. ‘Recently wehave the surf-table – a mobile laptopcomputer with incorporated washableand resistant screen, which allowsaccess to data by a surgeon in the oper-ating theatre. It can also be used by apatient as an entertainment station. Thesame versatility is provided by the PCTablet, another innovative mobiledevice that is compact and light, wash-able and resistant to blows and which,in emergencies, means we can seepatients in different cubicles at thesame time, and check their clinic histo-ry, change it, ask for tests,and so on.’

‘Florence also brings potential forresources, throw the information at thecontrol panel about emergency waitingtimes, surgical rates, appointments,tests, entrees, discharges, medical stays,etc, all allows making decisions to keepimproving healthcare.’Our technology’s heartFlorence was born with the TorreviejaHospital, Luis Barcia Albacar proudlypoints out. ‘The computer system wascreated by our Systems Director, usingMicrosoft tools, at low cost, very belowother programmes on the market.Besides being created here, for total syn-chronization it is also constantly adapt-ed for organizational needs and the soft-ware of the other companies that pro-vide the hospital with equipment.’

ISRAELBy Cynthia E Keen

25% of the victims undergo this proce-dure, which reveals vessel stenosis, dila-tion, and pseudo-aneurysms. Con-ventional angiography is used ifendovascular treatment is necessary.

According to Dr Engel, the most com-mon injuries from explosions aredamage to air containing organs(lungs or bowels). Victims throwninto the air, or hit by debris, mayhave a variety of broken bones andother orthopaedic injuries, cervicalspinal injuries, or incur closed headinjuries.

Penetrating wounds from numer-ous fragments of shrapnel are imagedto determine which may be life-threaten-ing. For victims with numerous shrapnelpieces embedded, there is no way thatall can be surgically removed during theinitial frantic period. Their removal mayneed surgery over a period of weeks.

PACS workstations enable multiplephysicians to evaluate examinationresults. The simultaneous availability ofimages has expedited surgery and treat-ment, because radiologists and surgeonscan make their clinical assessmentssimultaneously. The use of 3-D recon-struction software helps surgeons todetermine life threatening fragments.

‘Planning and practice of protocols todeal with mass casualties are critical fora hospital to respond effectively,’ DrEngel emphasised. ‘No amount of med-ical experience prepares you for thechaos. Anticipating the worst case sce-narios will help all medical staff to pre-pare for the aftermath of terrorism.’

* A large number of X-rays and CT scansof victims of terrorist attacks, obtainedfrom two Jerusalem hospitals, have beencompiled as an art exhibition currentlytouring galleries in the USA. These may beviewed online at: www.x-rayproject.org

11-13 JuneStuttgart,Germany

6-8 MayEssen

Germany

continued from page 1A danger to patients’ security & privacy?

Olympus, which recently opened the global Research and Development Centrefor Life Science in Munich, will invest around €15m in this project. By 2009, thecentre will employ an estimated 450 people, bringing together a highly-qualified team from many fields for interdisciplinary work. Dr HelmutKöhler, Executive Managing Director of Olympus Life Science Europa GmbHand Olympus Life Science Research Europa GmbH, said that, in addition to earlydisease detection, the company’s objective is individualised disease prevention,analysis and prevention along with follow-up treatment. The Munich centre willfocus on taking in vitro diagnostics, laboratory automation, molecular biology,digital image processing and microscopy applications to the next level.

Over the last four years, in the European life sciences sector, Olympus hasachieved growth rates averaging 15.8% in microscopy and 10.4% indiagnostics, placing the firm as one of the leading companies in these markets.Tsuyoshi Kikukawa, President of the Olympus Corporation, added: ‘With ournew global Research and Development Centre in Munich we have created thefoundation for future sustained grown in this business segment.’

Kiosk EuropeExpo 2008-04-24

The global Researchand DevelopmentCentre for Life Science

The hospital protocol fordealing with terrorism

paper, prescriptions in Germany will becreated digitally in future, allowinginsurers to view them at an eKiosk thenrelease them to a pharmacy. Later on,patients will be actively involved inhandling their health data with a viewto increasing responsibility for theirown health.’ For this, eKiosks are envis-aged as the medium.

In the UK,’ she observes, ‘self-servicetouch screen kiosks are being providedto the medical industry to enhancemedical record access and surgerycheck-in procedures for patientsthroughout the country.’ Rather thanqueuing, on arrival, patients who regis-ter with the self-service system can scanin a fingerprint to check-in. ‘The kioskscan also be used by patients wishing tocheck their medical records, as well asallowing them to access patient infor-mation leaflets containing informationon commonly diagnosed illnesses.’

In summary, she concludes: ‘Kioskscan improve the patient’s experienceand help to reduce costs, while main-taining confidentiality at all times.’ Presentations on self-service for themedical sector will be held on 8 May.Details: www.kioskeurope-expo.com

* The hospital was built on public groundsby a Private Finance Initiative (PFI), whichwill also provide healthcare services to thearea for 15 years. However, after fiveyears, according to an administrativeconcession, the hospital will be owned bythe Health Department of the ValenciaCommunity Government, and the PFI willbe managing public funding.

EUROPEAN HOSPITAL Vol 17 Issue 2/08 3

N E W S

Despite Hurricane Amma storm-ing over Prague, hundreds ofmedical specialists paid little

attention when they attended the 1stInternational Conference on AdvancedTechnologists and Treatments forDiabetes (ATTD), observed ourRussian correspondent Olga

Ostrovskaya, reporting on theInternational Conference on AdvancedTechnologies & Treatments forDiabetes (ATTD) in Prague (ATTD)held in Prague.

‘Our meeting aims to bring togetherdevelopers of new technologies totreat diabetes, from the academicworld and industry, and diabetes pro-fessionals,’ said Professor Tadej

Battelino, renowned endocrinologistfrom Slovenia. He addedthat the conferencewould hopefully ac-quaint clinicians andresearchers working ondiabetes, endocrinologyand metabolism withtechniques for new treat-ments.

‘These technologies are used byAmerican specialists more widely thanEuropean,’ he said, and it’s not right.The conference was his idea, and hechaired it with Professor Moshe

Phillip (Israel).

is always top priority. ‘What may looklike a technical gadget can represent asignificant factor in making daily lifeeasier for diabetics. Take, for example,blood glucose meters such as ourContour or Breeze 2 with No Codingtechnology: a study conducted by Rainein the USA has shown that one in sixdiabetics codes his or her blood glucosemeter incorrectly. So something thatlooks like a small additional benefit canactually be of crucial importance forindividual patients when it comes toavoiding hypoglycaemia.’

Indeed, patient training was a bigtopic in Prague. ‘We [Bayer] are inten-

sively involved in patient training. Inthis, it is impossible to overstate theimportance of diabetes nurses. Theyare important contacts for diabeticsand are not only trained in the use ofmedical technology but also play a keyrole in motivation and compliance,which is why we support, for example,the Federation of European Nurses inDiabetes (FEND). ’ Bayer, he said, holdsdiscussion forums for an internationalexchange of information. The companyalso frequently establishes direct con-tact with diabetics to ensure its devel-opments actually meet their needs.

In his opinion, the development of

telemedicine for diabetics provides aninteresting additional benefit forpatients and doctors. ‘Real-time trans-fer of the measured data to a centralserver makes it possible for theattending doctor to adapt the treat-ment and provide better care forpatients. Interesting results from apilot project were presented inPrague.’ Home-caring offers manyoptions, he added, which is still inearly development. ‘What direction itwill take will naturally depend notonly on the technical possibilities butalso many other factors, includinghealthcare policies.’

Tadej Battellino

GLOBAL PERSPECTIVES ON DIABETES

Lectures on global perspectives oftechnology and nanomedicine in dia-betes research were aired to stimulatedebate about insulin analogues. Protheir use was Professor T Danne

(Hanover, Germany), who said thatshot-acting insulin analogues are safeand more comfortable for patients.Against, was Professor F Holleman

(The Netherlands), who, underlinedthe contra-indications. ‘Use ana-logues? Only incidentally!’ heexclaimed.

During our attendance, EuropeanHospital interviewed Dr Thorsten

Petruschke, Director of Medical,Clinical and ScientificAffairs, Bayer Health-Care Diabetes CareEurope, about thefirm’s latest develop-ments. He pointed outBayer’s Contour Link

blood glucose meterthat wirelessly transmits the patient’scurrent blood glucose data to aMedtronic insulin pump, which thencalculates the bolus insulin dose. Inaddition, the blood glucose values areused to calibrate continuous glucosemeasurement with the Medtronic sys-tem, which determines the glucosecontent in the intercellular fluid, headded. ‘Any system for blood glucosemeasuring has to meet extremely highsafety standards,’ he stressed. ‘BayerHealthcare invests over €30 million ayear in Diabetes Care research anddevelopment to further improve theprecision and safety of blood glucosemeasurement. Just a few months ago,our new R&D Centre, in Tarrytown,New York, came on stream, providingstate-of-the-art conditions to work onthese topics.’

Asked whether some developmentsare only technical gadgetry, DrPetruschke pointed out that, in themedical market the safety of diabetics

Dr ThorstenPetruschke

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Do you consider that your equipment isout-dated � Yes � Norelatively modern � Yes � Nostate-of-the-art � Yes � No

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EUROPEAN HOSPITALReader Survey

EH 2/08

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European Hospital Publisher,Theodor-Althoff-Str. 39, 45133 Essen, Germany

who did not receive donated blood.

The risks associated with blood

transfusion occurred regardless of

haemoglobin levels, age, or level of

patient disability at the time of trans-

fusion, the researchers point out.

The finding, which implicates the

cause being lack of oxygen to key

organs, has knocked the widespread

events. ‘The study demonstrates the

cost implications of our current transfu-

sion practice. This is important, partic-

ularly in modern health systems where

resources are finite, and should encour-

age the sort of research that will

address the major health issues raised

in the study,’ said the study’s lead author

Gavin Murphy of Walport Consultant

Senior Lecturer in Cardiac Surgery at

the University of Bristol.

The researchers aim to undertake a

larger study to ascertain whether chang-

ing transfusion guidelines could

improve patient outcomes. Presently

the suggestion is that surgeons should

think twice before giving blood transfu-

sions.

In March, the New England Journal

of Medicine found that patients who

received blood that was more than two

weeks old were up to 70% more likely to

die within a year than patients who

received fresher blood.

The question of how red cell transfu-

sions may affect immunity or tissue

oxygenation needs further study, as

does the question of how the safety of

donor blood storage could be improved.

Surgeons urged to ‘think

twice’ before giving blood

transfusions

A danger to patients’ security and privacy?

EUROPEAN HOSPITAL

News . . . . . . . . . . . .

. . . . . 1-3

Competition . . . . . . . . . . . .

4

Radiology . . . . . . . . . . . .

5-15

Cardiology . . . . . . . . . . 16-21

Surgery . . . . . . . . . . . .

. 22-24

IT & Telemed . . . . . . . . . . . 25

Lab & Pharma . . . . . . . 26-29

Russian pages . . . . . . . 30-35

Diabetes & infections . . .36

contents

T H E E U R O P E A N F O R U M F O R T H O S E I N T H E B U S I N E S S O F M A K I N G H E A L T H C A R E W O R K

4

Competition

● Enter today!

● Three prizes!

● You may win a

Philips Digital

Voice Trainer

Hospitals are urged to tighten up on

blood transfusions, following a grow-

ing number of reports on unrecognised

risks from blood transfusions – and

these are not the generally-known

infection risks, such as HIV.

Researchers point to risks presented

by the lack of oxygen delivered to key

organs, which can result in stroke or

adverse cardiac events.

It has now been suggested that per-

haps up to 60% of blood transfusions

are not good for patients.

Although blood transfusions are

commonly given during various surgi-

cal procedures, e.g. orthopaedic, con-

cern about the risk in blood transfu-

sions for cardiac surgery patients has

been particularly highlighted. In one

study, published in November by the

journal Circulation, researchers at

Bristol University and the Bristol Heart

Institute, followed 8,500 cardiac

surgery patients for an eight-year peri-

od and found that red blood cell trans-

fusions increased the risks of heart

attack or stroke three-fold – and, in the

month after surgery patients were six

times more likely to die than patients

Unexpected risks my result from

today’s medical devices, such as

implantable cardiac defibrillators and

pacemakers, if they are equipped with

wireless technology to enable remote

device checks. According to

researchers Tadayoshi Kohno, assis-

tant professor of computer science

and engineering at Washington

University working with Kevin E Fu,

assistant professor of computer sci-

ence at UMass Amherst, and cardiolo-

gist William H Maisel MD, director of

the Medical Device Safety Institute at

Beth Israel Deaconess Medical Centre

and Harvard Medical School, patients’

private medical data could be extract-

ed and their devices reprogrammed

without the patients’ authorisation or

knowledge.

The study was designed to identify

and prevent future problems, they

emphasis; no case of a patient with an

implantable cardiac defibrillator or

pacemaker has been targeted by hack-

ers. It was pointed out that the study

required a high level of technical

expertise, and the published paper

omits certain method details to pre-

vent the findings being adversely used.

‘One of the purposes of this research is

New research reveals potential harm

Brenda Marsh reports

to encourage the medical device indus-

try to think more carefully about the

security and privacy of patient infor-

mation, particularly as wireless com-

munication becomes more common.

Dr Maisel explained: Fortunately,

there are some safeguards already in

place, but device manufacturers can

do better.’

The team expects this issue to take

on greater importance as implantable

cardiac defibrillators operate wireless-

ly at greater distances. These devices

typically receive short-range wireless

signals over several feet, but new tech-

nologies are expanding that reach

even farther, creating the potential for

information to be intercepted en route.

‘We hope our research is a wake-up

call for the industry,’ said Tadayoshi

Kohno. ‘In the 1970s, the Bionic

Woman was a dream, but modern tech-

nology is making it a reality. People

continued on page 2

V O L 1 7 I S S U E 2 / 0 8

A P R I L / M A Y 2 0 0 8

16-17Cardiology

● AAC reports

● Stent developments

● 1st biodegradable

implant for children

● Russian auto-

transplantationThe Netherlands - The prosecution

of two doctors and a faith healer has

been ordered by the Dutch appeal

court, due to their treatment of a

patient who died seven years ago. The

woman, well-known actor/comedian

Sylvia Millecam, died of untreated

breast cancer, having chosen alterna-

tive medicine as a therapy, perhaps

persuaded that her illness was due to

bacterial infection. However, although

the public prosecution service had pre-

viously dismissed the case against

three of the people involved in her

treatment, a Dutch Healthcare

Inspectorate investigation found that

‘various individual carers’ had offered

such irresponsible care, based on

‘unfounded methods of treatment’,

that disciplinary action or prosecution

were likely.

The inspectorate now wants the law

changed to ensure greater supervision

of alternative practitioners and that all

such practitioners have to be regis-

tered. It also wants it made illegal for

anyone other than a trained doctor to

be allowed to make a medical diagno-

sis. The Royal Dutch Medical

Association supports the proposals.

(Full report: BMJ 2008;336:853

(19 April), doi:10.1136/bmj.39549.

636586.DB )

* In many European countries, ‘alter-

native’ medicine has increased in pop-

ularity. When asked, for consumer sur-

veys, about 60% of the public in the

Netherlands and Belgium stated they

would pay extra health insurance pre-

miums for complementary treatments,

and 74% of the British public thought

they should be available from the

country’s National Health Service. The

Dutch population seeking treatments

from alternative medicine practitioners

was reported to be 6.4% in 1981, but

this had increased to 15.7% in 1990

and, in France, 16% of the population

visited practitioners in 1982, but the

figure rose to 36% in 1992.

Demands for greater

supervision of alternative

medicine practitioners

Three types of human heart cells

have been grown from cultures

derived from embryonic stem cells,

by a team of Canadian, US and UK

scientists. During the research,

when a mix of the cells was trans-

planted into mice with simulated

heart disease, the animals’ heart

function was significantly

improved, according to research

published in the journal Nature.

The embryonic stem cell cultures

were carefully supplied with a

staged cocktail of growth factors

and other molecules involved in

development, and grew into imma-

ture versions of cardiomyocytes,

endothelial cells and vascular

smooth muscle cells, each impor-

tant constituents of heart muscle.

‘This development means that we

can efficiently and accurately make

different types of human heart

cells for use in both basic and clin-

ical research, said researcher Dr

Gordon Keller, of the McEwen

Centre for Regenerative Medicine

in Toronto. ‘The immediate impact

of this is significant, as we now

have an unlimited supply of these

cells to study how they develop,

how they function and how they

respond to different drugs. In the

future, the cells may also be very

effective in developing new strate-

gies for repairing damaged hearts,

following a heart attack.’

LAB-CULTURED

CARDIAC CELLS

The USA’s National Institutes

of Health aims to review

blood transfusion safety

belief that red cell transfusion

improves oxygen delivery to tissues,

and that surgical patients are helped

by a ‘top up’ of red cells.

In the UK, for example, over 50% of

all cardiac surgery patients receive

transfusions, yet only about 3% are

given due to life-threatening bleeding.

The rest are usually given on the basis

of a low haemoglobin level, disregard-

ing whether the patient has physical

symptoms to suggest they need blood.

Along with danger to patients, hos-

pital costs increase due to adverse

Implantable medical devices

Kevin E Fu

Tadayoshi Kohno

22-24Surgery

● Moscow’s

medical mighty

● Gastric polyps

morphology

● Wireless retina implants

● Surgical lights and tables5-15

Radiology

● The end of

contrast agents?

● Trends in image-

guided therapy

● Image processing

● ECR reports

PPPP llll eeee aaaa ssss eeee iiii nnnn ffffoooo rrrr mmmm mmmm eeee aaaa bbbb oooo uuuu tttt tttt hhhh eeee HHHH oooo ssss pppp iiii tttt aaaa llllAAAA dddd mmmm iiii nnnn iiii ssss tttt rrrraaaa tttt oooo rrrr FFFFoooo rrrr uuuu mmmm aaaatttt tttt hhhh eeee EEEE CCCC RRRR 2222 0000 0000 9999 ....

Signature Date

R A D I O L O G Y

EUROPEAN HOSPITAL Vol 17 Issue 2/08 5

Visage Imaging has launched itsCardiac Analysis software for theVisage CS Thin Client, which offers‘advanced visualisation andquantitative analysis for cardiac CTstudies, such as calcium scoring,coronary artery analysis and leftventricle analysis,’ the firm reports.‘The Visage CS Thin Client/Server isa scalable advanced visualisationsolution that provides fast andconsistent access to all patientimages, anywhere inside andoutside the hospital, acrossmultiple interconnected sites, andImage

processingSpeedy qualityimage accessibilityvia inter- or intranet

‘AxRecon leverages the processing power ofGPUs to speed-up CT scanner workflow’

dicomPACS, developed by theGerman manufacturer ORTechnology in partnership withmedical specialists, is now installedin 5,000 workstations globally,because, ‘It is set apart by a veryclear and user friendly structure,’OR points out. The company hasalso set up an internationalcompetence network fordicomPACS with over 30authorised, trained local partners tosupport users.

The solution has also been certifiedin accordance with the EU guideline93/42/EEC Annex II (CE 0482) and its510(k) (no. K070618) has been clearedby the FDA.

Along with features such as perfect

memory, parallel compilation ofdiagnostic reports and individualcustomisation of the user interface,the current version 5.2 includesseveral new features and modules.‘The newly developed web serverallows fast image accessibility inoriginal quality (DICOM) via internetor intranet and the new prosthesismodule documentation allows theplanning of operations with digitaltemplates. dicomPACS can beextended by a number of modules, e.g.patient CD module, report module,video module etc. Another option isthe processing of CT and MRT seriesincl. MIP and MPR functions.’

OR Technology, which has workedon imaging technology internationallyfor 16 years, deals exclusively withdigital image processing and iscertified according to the ISO 13485quality management norm. Thecompany provides system solutionsfor hospitals and specialists’ surgeries.Apart from its own productdicomPACS the solutions includedigital X-ray systems with CR and DR,conventional X-ray technology,portable and mobile X-ray technologyand computer systems for operatingtheatres.For a free dicomPACS 5.2 demo version, orfurther information, contact:info@or-technology.com Also: www.or-technology.com

Cardiac software launched for CS Thin Clientthrough the internet.’

The cardiac software tools arefully integrated into the workflowand technology platform so thatit can be accessed on all clientcomputers – a dedicated cardiacworkstation is not necessary.Visage CS Cardiac Analysis allowsviewing and post-processing ofeven the largest multi-phasecardiac CT studies at the click ofa mouse, Visage reports.

‘Visage Thin Client solutions,like the cardiac one, enhance theentire clinical workflow, with

advanced tools for 2-D, 3-D and 4-Dimage review and interpretation,post-processing, data managementand image distribution. The originalCT and cardiac CT data frommultiple potential sources can bemanaged and archived consistentlyin a single system across the entirehospital enterprise. That is why weare talking about a cost-effectivevisualisation tool that optimisesworkflow not only within onedepartment but over the boundariese.g. of radiology and cardiology,’explained Colin Murphy, Vice

President of Sales & Marketing atVisage Imaging.

The new software provides, forexample for left ventricle analysis,automatic short/long axisreformatting, segmentation of leftventricle with a few clicks, a globaland by segment presented ejectionfraction and wall motion analysis bysegment. And, Visage adds, ‘Forcoronary artery analysis newfeatures include automatic tracingwith only a few clicks, a powerfulvessel visualisation, an easy to usecross-sectional measurement andstenosis calculation, as well as acurved reformatting for efficientassessment of vessel lumen andadjacent structures.’

To achieve victory, you must surround yourselfwith a strong team that works together as one.

KODAK CARESTREAM Solutions can make sure your team is powerful and united by creating a strong community among all

members. Our integrated lineup centres around the KODAK CARESTREAM RIS/PACS solution—allowing you to collaborate

with others to help improve diagnostic results, facilitate increased productivity, cut costs through improved workflow,

streamline reporting and enhance patient services. No matter how big your team is, or where they’re located,

Carestream Health has the strategy to bring them all together, allowing you to play as one powerful team. In our community—

strength comes in numbers. Start building your winning team at www.carestreamhealth.com

Consolidate. Unify. Enable. Experience the power of [community].

©Carestream Health, Inc. 2008. Carestream is a trade mark of Carestream Health. The Kodak trademark and trade dress are used under license from Kodak.

[community]

Visit us at DRKBerlin

30 April-3 May2008

6 EUROPEAN HOSPITAL Vol 17 Issue 2/08

R A D I O L O G Y

During ECR 2008, the Canada-basedAcceleware Corporation, which deve-lops acceleration solutions for high-performance computing, demonstratedits new AxRecon image reconstructionsolution for medical imaging, security,and non-destructive testing. ‘Imagereconstruction for computed tomogra-phy (CT) scanners often takes hours ofprocessing time and represents a majorbarrier to efficiency for many organisa-tions.Acceleware’s solution reduces thetime required to complete this workfrom hours to minutes,’ the firm report-ed. ‘AxRecon works with existing conebeam CT scanners to eliminate bottle-necks by significantly speeding up fil-tered back projection computations.This enables medical and commercialusers to accelerate the reconstructionof their data and improve the quality oftheir images without disrupting theircurrent workflow.’

ACCESSING AND MANIPULATINGPATIENT DATA The Digital Lightbox

Combining the advantages of atraditional hospital light box withthe features of computer worksta-tions, BrainLAB has produced theDigital Lightbox – which is certain-ly unlike the usual light box. TheDigital Lightbox integrates with ahospital’s Picture Archive andCommunications System (PACS)enabling physicians working inalmost any location to access MRI,CT, PET and X-ray images. Thedevice also provides a wide rangeof DICOM viewing functions andadvanced functionality, such asautomatic image fusion in combi-nation with an intuitive touchscreen, making image navigationand modification easy, the manu-facturer points out. ‘DigitalLightbox transforms traditional

Designed by a team of radiolo-gists, the latest release ofOsiriX 3.0.1 on the Mac Pro8-core was demonstrated for

the first time at the recent EuropeanCongress of Radiology (ECR). OsiriX– a powerful image processing soft-ware dedicated to DICOM images(.dcm / DCM extension) produced byimaging equipment (MRI, CT, PET,

SYSTEM SPEEDS UP CT RECONSTRUCTIONS

static images into detailed anddynamic views with its multimodali-ty image and data system, allowingusers to extract more value fromdata.’

The wall-mounted multi-touchcontrolled device not only connectsto PACS servers but also theBrainLAB treatment planning systemiPlan Net, for fast image and treat-ment plan review. ‘Treatment plansfor surgery and radiation therapycan easily be accessed, altered orconfirmed for treatment,’ the firmpoints out. ‘Data can be retrieved inmultiple formats including DICOM,jpg, bmp, tif, png, avi, wmv andBrainLAB proprietary image for-mats.’* FDA clearance pending. This productwill be available shortly.

Hospital of Geneva, Switzerland, heexplained that the idea to createOsiriX was born at UCLA in 2004,when he became annoyed that noknown industry software could han-dle the huge amount of data pro-duced by PET/CT scanners includ-ing 3-D dynamic images. He beganto develop an open-source softwarewith radiologist Antoine Rosset,

ally looking for a reason to use aMac. Hospitals may not want it, butthe physicians, the radiologists,want it. In many hospitals the Macplatform is slowly making its way inaddition to the existing Windowsmachine. The IT departments areusually very reluctant, and Apple isvery aware of that. Essentiallythere are no technical problems,especially now that Apple can runWindows applications at a muchbetter cost and much faster. Butyes, IT departments in hospitals arereluctant to integrate – I experi-enced this first hand when I washead of IT at UCLA, so I’ve beenstruggling to demonstrate that ahybrid environment is possible. Wereally see an advantage for users interms of rapid adoption. We havehad presentations at various hospi-tals, when OsiriX was integrated.The average training time is in therange of 60 to 90 minutes, then theusers are not heard from again;they don’t ask questions; they areusually capable of using the soft-ware by themselves. That’s usuallynot the case with other platforms.

‘We have identified 25,000 userswho use OsiriX on a regular base,and these numbers come frommachines that have visible uniqueIP addresses outside firewall andare visible. Other users are behindfirewalls in hospitals and we don’tknow about them. So we thinkthere is double this number ofusers out there. Also, there arecommercial companies that pro-vide FDA and CE certified versionsof the software.

‘In current multicore Applemachines, OsiriX provides real timerendering and visualisation of 3-Dand 4-D images dynamically withextremely high performance. Usersand radiologists can navigatethrough very large 3-D data sets inreal time with a performance thatmatches very high-end commercialworkstations.

‘There have been a lot of requestsand attempts to move the softwareon Windows platform. Since theprogramme is Open Source, thesource is available for free and canbe copied. However, the effort tomove to Windows platform is sig-nificant and to achieve the samegraphic performance is very chal-lenging. Several groups haveattempted to do it but so far there isno evidence that it is any closer tobeing done. In a large NationalCancer Institute (NCI) project adecision was made to integrateWindows applications with OsiriX

on the Mac platform instead of try-ing to import OsiriX to the Windowsplatform. Besides, OsiriX uses a lotof basic tools and core technologiesthat are imbedded in the Apple plat-form that don’t exist on theWindows platform. This includes allthe powerful graphic capabilities ofthe Mac platform that are the reasonfor the success of the Macs in thegraphic and editing industry, butalso core technologies such asiChat, embedded databases andcommunication tools.

‘The Open Source option that weadopted is a new challenge. Thereare thousand of Open Source pro-grammes out there, but only a feware successful. To be adopted by theuser community an Open Sourceprogramme must be good. It is notenough just to be free. A pro-gramme that does not provideadvanced tools and functions and isnot robust enough, or crashes allthe time, will be rapidly abandonedby users. The success of OsiriXresides in its design, done by radiol-ogists for radiologists, and therobustness of its code, which makesit a very stable product for use in

OSIRIX

who had a research grant to studyat UCLA at that time. Their inten-tion was for the free use of this newsoftware by anyone who mightneed to modify it, which, he pointedout, would also mean the solutioncould benefit from large contribu-tions. ‘That would be somethingway beyond what the industry hadmanaged to do. Four years later, itworked much better than anticipat-ed. 25,000 people around the worldnow use it. It has all the 3-D analy-sis and viewing tools that you canfind on any commercial platform.’

The team chose to create the soft-ware only for Apple Mac, due tothat system’s powerful graphicsabilities. ‘However, even Apple was-n’t good enough. We had to put insome special video boards. But, wemade that risky choice. We are veryhappy that Apple is now doing verywell in that field, because we bene-fit from it. The machines are now sopowerful that we don’t need anyspecial graphic boards anymore.The software runs on any Mac. Yes,the fact that there are not manyApple users is a problem, but itturns out to be an advantage,because many physicians are actu-

clinical and research applications. Itis also a good development platformfor programmers and researcherswho want to add their own tools forimage analysis.’

Indeed, OsiriX use has alreadybroadened into research in biology,astronomy, molecular imaging andarchaeology. It is a generic image dis-play and rendering that can be used inmany other areas than medicine.

‘Fully leveraging the Leopard oper-ating system and the Mac user inter-face, the 64-bit OsiriX programmeoffers functionality comparable with,or better than, the most advancedscanner consoles on the market. It’salso extremely fast and easy to use,’Professor Ratib concluded.

Radiologist Dr Will Adair, at theLeicester Royal Infirmary, UK, anoth-er user of OsiriX, on his MacBook,added: ‘The combined OsiriX and Macproposition has the potential to com-pletely change the way we work byproviding easy access to affordable,commercial-level image processingsolutions with exceptional 3-D and 4-D capabilities.’Further information:www.osirix-viewer.com/

AxRecon combines Acceleware’sproprietary software accelerationlibraries with the massive parallel pro-cessing power of NVIDIA GraphicProcessing Units (GPUs).

David Holdsworth of RobartsImaging, based in Canada, added: ‘Inbiomedical micro-computed tomogra-phy applications, the volume dimen-sions of our reconstructions haveincreased dramatically over the past

few years. During the same period, scantimes have also been reduced; thismakes cone-beam CT reconstructiontime the bottleneck that limits workflowin some situations. GPU-based recon-struction is a cost-effective solution forthis task, and we have found thatAcceleware’s AxRecon product can pro-vide 3-D reconstructions up to 50 timesfaster than a single-CPU.’

Acceleware also emphasised that thesoftware seamlessly integrates withexisting CT scanners with minimalsetup.

Sean Krakiwsky, CEO of Acceleware,added: ‘The benefits of higher through-put and image quality already beingrealised by early customers of AxReconwill help us drive adoption of this prod-uct within the broader imaging market.’Further details:www.acceleware.com/solutions/imaging/imagingintegrator.cfm.

THE 64-BIT MULTIMODALITY VIEWERON THE MAC PRO 8-CORE WORKSTATION

NEW

NEW

RadiologistsOsman Ratib(left) andAntoine Rosset

PET-CT etc.) and confocal micro-scopy (LSM and BioRAD-PIC for-mat) – a multidimensional imagedisplay and analysis platform thatsupports peer-to-peer communica-tion technology as an alternative toconventional PACS architecture,allowing wider access to imagesacross medical enterprises.

The 64-bit programme can han-dle new generation imaging modal-ities combining anatomical andmetabolic images (MRI, PET, CT,ultrasound, and angiographicimages). It also provides dynamicdisplay for time-varying imagessuch as cardiac motion or metabol-ic functional studies.

The OsiriX creators say it pro-vides an intuitive and user-friendlyuser interface tailored for physi-cians who are not familiar withcomplex image processing andmanipulation techniques.

When Meike Lerner, ofEuropean Hospital, spoke withone of its developers, Osman Ratib

MD PhD FAHA, Professor andChair of Radiology of the Dept. ofMedical Imaging and InformationSciences and Head of NuclearMedicine Division at the University

Visit us at DRK in BerlinHall 2.1 – Booth No. C30

M A R K E T I N G : A G F A H E A LT H C A R E

EUROPEAN HOSPITAL Vol 17 Issue 2/08 7

R A D I O L O G Y

Strengthening portfoliosand customer relationships

ChristianReinaudo,President of AgfaHealthCare,speaking withEuropeanHospitalrepresentativeGabriela Eriksen

After Agfa split its core businessunits to form three legal entitiesunder the Agfa-Gevaert Group, inJanuary this year, Christian

Reinaudo became President ofAgfa HealthCare. Speaking withEuropean Hospital representativeGabriela Eriksen, he explained theimplications of the business splitand future aims for the division henow heads. ‘We remain an integralpart of the Agfa-Gevaert Group,but have more legal independenceas a division, allowing theorganisation to take a number ofspecific decisions on a moreautonomous basis.’

For the future, Agfa Healthcareneeds to continue to fuel itsprofits, he pointed out. ‘The bestway to achieve that is to offerunique, modern and innovativeproducts that meet the demands ofthe market. Agfa has a goodrelationship with its customerswho appreciate and believe in oursolutions that clearly differentiatefrom those of our competitors. Wereally have all the ingredientsnecessary for success, includingthe know-how, image, reputation,the right people and excellentproducts and solutions. My targetnow is to strengthen certain areasthat I feel are most promising forthe future. One of those fields is,of course, IT. However, we mustalso ensure we maintain a strongfocus on our imaging capabilities,which form an integral and corepart of our business.’

In terms of strengths, he saidthat Agfa Healthcare has been anintegrator for the healthcareenvironment. ‘It is one of our coreskills and we apply these on twolevels. First, our solutions considerthe different requirements andexpectations of our customers.This is, for example, the conceptbehind our new series of IMPAXSuites that were launchedsuccessfully in Europe at thisyear’s ECR. Simply said, ourcustomers in orthopaedics havedifferent needs than those inradiology, so what IMPAX does isto provide the same platform, butfor different clinical use cases withdifferent key targets. One obviousbenefit is that, because they usethe same platform, differenthospital departments can work inan integrated manner.

‘This automatically leads me tothe second level of integration. Thechallenge is to connect differentusers, from a single department tomultiple departments, a hospital oreven a multi-site centre by bringingtogether different systems, oftenfrom diverse vendors, or maybeeven alternative PACS solutions.Our strengths in this field are wellknown, and we should, as AgfaHealthCare, ensure that wecontinue to build our business onthis expertise.

‘So the goal is to ensure wecontinue to deliver high qualityimaging solutions and at the sametime expand the IT front to meetthe needs of specific segments andreach a scalability of integration atdifferent levels.’

What of the need for consult-

ancy, to help hospitals to integratesystems? ‘Well we provide a kindof consultancy; years of experiencein healthcare play an importantrole in our daily work with clients.What our customers want is acomplete solution that fits in theirhealthcare surroundings. This

demands different needs andcapabilities, from country tocountry and hospital to hospital. Inthis business you need to be veryspecific. The delivery of state-of-the-art software and applicationsare only one part of the equation;being able to comply with national

organisation requirements andcustomer needs is often the corechallenge, and yes, our advice andknowledge do play a critical rolehere. We need to provide the bestsolution for each country and eachhospital, and our extensiveportfolio of solutions, from film,

print and CR to healthcareenterprise IT systems are verywell positioned to offer this.

‘Looking at geographicdifferences specifically, thereare countries like Germany,Switzerland and Austria wherecontinued pn page 8

GE Healthcare

GE imagination at work

© 2008 General Electric Company GE Medical Systems, a General Electric company, doing business as GE Healthcare.

The sooner the better. Never did that phrase ring more true thanwhen treating illness. From predicting and diagnosing to monitoring,treating and informing, GE Healthcare dedicates its resources to helphealthcare providers stay as many steps ahead of illness as possible.Because the earlier the detection, the sooner we just might bringdisease to an end. Healthcare Re-imagined.

To learn more visit www.gehealthcare.com

The end of diseasestarts at the beginning.

8 EUROPEAN HOSPITAL Vol 17 Issue 2/08

R A D I O L O G Y

Artiste is a linearaccelerator and CTscanner combined. At theGerman Cancer Research

Centre, a team of scientists led byProfessors Wolfgang Schlegeland Uwe Oelfke of the MedicalPhysics in Radiation Oncologydivision, contributed substantiallyto the technical development ofthe Artiste platform. They reportthat users will be able to observeand correct the actual position,extension and potentialmovements of a tumour duringradiation therapy.

The first Artiste system,produced and marketed bySiemens Healthcare, has now beeninstalled at the Centre and isready for its first actual cancertreatment. ‘The patient is sufferingfrom an inoperable oesophagustumour; the treatment demandsvery complicated radiotherapyapproach,’ explained ProfessorPeter Huber MD, head ofRadiation Oncology in the ClinicalCooperation Unit. ‘To achieve theclinically required accuracy wemust determine the actualposition of the tumour prior toeach of the 30 fractions with theutmost precision.’ Anatomicallythis is necessary because the

In recent years, intra-operative 3-D C-arm imaging hasrevolutionised orthopaedics andtrauma surgery. In particular

using the images created during anoperation, C-arms with 3-Dcapability can produce 3-D views ofa quality effectively on a par withthose of a CT scan. They allowimproved intra-operative monitoringfor the repositioning of complexfractures and insertion of implants.3-D C-arms with flat panel detectorsproviding highly dynamic, distortion-free imaging have been on themarket for barely two years. Theimage information is read outdirectly from the detector andbecomes available in digital formimmediately after acquisition. Theuse of digital flat panel detectors inmobile X-ray machines hassignificantly improved image qualityand is opening up new fields ofapplication in minimally invasivesurgery (MIS).

Ziehm Imaging reports that it isleading the way in flat paneltechnology for mobile C-arms. In2006, the company launched theVision FD, the world’s first mobileC-arm with fully digital imaging.Furthermore, Ziehm’s flat paneltechnology has been implementedwithin the Ziehm Vision RFD mobileIntervention Suite and the ZiehmVision FD Vario 3D. Vision RFD isparticularly suitable for proceduresin interventional radiology,neurosurgery, vascular surgery andcardiology, while Vision FD Vario

3D offers major advantages fortraumatology, orthopaedics andbrachytherapy. Using flat paneltechnology and a variable isocentre,the C-arm provides distortion-freeintra-operative 3-D imaging whichdelivers critical additionalinformation particularly forassessing complex fractures orduring spinal operations.

FUJIFILM’SDIGITALMAMMOGOES MOBILEFujifilm Medical Systems USA,based in Stamford,Connecticut, reports that it’sCR for mammography (FCRm),a full-field digitalmammography system, is nowavailable for use in mobilemammography environments.

The first two installations ofMobile FCRm systems were inmobile units operated by theHarris County Hospital Districtin Houston, Texas, and St.Joseph’s Hospital of Atlanta,Georgia.Fujifilm reports that more

than 400 mobilemammography units are inuse today throughout the US– and the majority useanalogue film systems; onlyabout 10-15% of existingmobile coaches haveconverted to digitalmammography. Thus themobile environment lagsbehind traditional breastimaging facilities.

The digital imagingsolution, including FCRm,Synapse PACS and SynapseManaged Services, enablesmobile mammographyproviders to concentrate onthe delivery of care while alsomanaging the ITinfrastructure, Fujifilm adds.With the option of ManagedPACS, by connecting MobileFCRm to a secure wirelessbroadband connection, imagesacquired in mobile units canbe transmitted to the user’sreading location and directlyto its data centre.

we are well established as anEnterprise IT solution provider,while in other markets, such asthe USA, we primarily intervene inthe imaging informatics marketsand have only started our ORBISroll-out. So our task as a companyis to find the right people, the rightthird party partnerships and theright way to integrate allapplications, including legacysystems, which will enable us todeliver the right solutions to meetthe needs of our customers. Thisis what plays along our corecompetencies.

‘A huge part of our business isglobal in terms of technology andapplications. In addition, in termsof hospitals there is global vision:They will need to have all relevantinformation at the same place andmake it accessible to everybodyinvolved in a patient’s care.

‘Today, different people workwith different systems, writing ondifferent papers and working atdifferent monitors. But if you wantto treat diseases, all thisinformation should be availableevery time, everywhere and fromevery participant. This challenge isbeing tackled, for example, by ourIMPAX Data Centre, our scalableand fault tolerant DICOM archivesolution designed to store clinicalDICOM data objects. The systemconsolidates data of disparatestorage systems onto a singlepoint of storage. It caters for theneeds of enterprise storage forlarge, multi-site and multi-facilityhealthcare domains.’

In the near future, he added,Agfa Healthcare’s aim is tostrengthen some of its productportfolios, such as imaging and ITsolutions, and continue to improvecustomer relationships. ‘Of coursethere will be innovations, but ourprimary goal is to ensure wedeliver according to theexpectations of our customersaround the world. We have thesolutions, the credibility, the rightpeople and the right attitude toachieve this.’

Integrated navigation forgreater operating theatreefficiencyNew horizons in terms of precisionand image quality are beingopened up particularly bycombining flat panel technologywith navigation systems orComputer Assisted Surgery (CAS).Through direct connection to anavigation system, the intra-operative image data can be useddirectly for computer-assistedinterventions.

Experience with using ZiehmImaging’s flat panel technology hasalready been gained at the firstorthopaedic spinal centre inThiene (Vicenza) in north-easternItaly, where trauma surgeons havebeen using the mobile C-armVision FD Vario 3D sinceDecember 2007. ‘We have used theC-arm as an intra-operative data

source with good results. The systemproduces high quality images withhigh contrast resolution,’ said Dr.Balsano, head of the orthopaedicdepartment. ‘Comprehensive 3-Dimaging makes it easier to positionimplants, screws and osteosynthesismaterial accurately and also allowsmuch more precise setting offractures and reconstruction of jointsurfaces compared with two-dimensional imaging methods. Thisenables surgical interventions to becarried out more precisely –particularly for complex intra-articular fracture setting andosteosynthesis in the hip and spinalareas.’

The integration of intra-operative 3-D X-ray imaging and navigation alsoincreases operating room efficiency.Intra-operative monitoring of resultsenables the number of subsequentcorrective interventions andradiological check-ups to be reduced,Ziehm adds. ‘Patients benefit fromquicker recovery times and pressureon hospital budgets can be reducedon a continuing basis. For example, astudy carried out by the Departmentof Trauma Surgery at the HanoverMedical School showed that after anintra-operative 3-D scan, repeats areunnecessary in 16 per cent of cases.

‘Because of the many advantages ofthis equipment, the use of mobile 3-DC-arms has increased in recent years.The consistent refinement of C-armsand the optimisation of image qualitywith the introduction of flat paneldetector technology make themversatile performers in clinicalsettings such as interventionalradiology, vascular surgery orcardiology. Particularly in the case ofcomplex, minimally invasiveinterventional procedures, bothphysicians and patients benefit fromenhanced spatial orientation andincreased precision.’Source: Ziehm Imaging

tumour shifts daily according tothe stomach content. ‘Withtoday’s treatment technology wecan aim at the tumour withmillimetre accuracy; however,this enormous potential canhardly be used if the tumour hasmoved significantly from theposition determined at the timeof diagnosis,’ he pointed out.Using Artiste, an observed shiftin the target position can beautomatically corrected whilethe tumour still receives the

required clinical dose andsurrounding healthy tissue isspared from radiation.

Further so-called adaptivetherapy approaches are currentlyunder investigation at the GermanCancer Research Centre. Artistewill hopefully help to track themovement of lung or intestinaltumours so that physicians will beable to initiate radiation therapyafter determination that thetumour is located at the pre-calculated position.

continued from page 7

Image-guidedradiationtherapyArtiste takescentre stagefor debutclinical use

The mobileC-arm ZiehmVision FD Vario3D provideshigh imagequality andefficientworkflow

Fully digital X-ray based3-D imaging drives MIS

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German Radiology Congress2008

booth F 25hall 4.1

to be of considerablehelp because it canmake valid pre-selec-tions by itself andmark them according-ly. So it is a significantmilestone on the roadto more reliablebreast cancer diag-

noses. However, as with all diagnos-tic benefits,’ Dr Reutter emphasised,‘the final decision is given by anexperienced consulting physician.Leaving an examination to a physi-cian’s assistant is not ethical.’ Staffresponsibility at the hospital has notdecreased since the CAD introduc-tion. Two observers still carry outthe standard assessment procedure,and even the slightest doubt in mam-mographic findings results in ultra-sound confirmation and consultation

R A D I O L O G Y

EUROPEAN HOSPITAL Vol 17 Issue 2/08 9

At the DRK Congress (Deutscher

Röntgenkongress, 30 April - 3 May,

in Berlin, Carestream Healthcare

will introduce its new digital radi-

ography and computed radiography

systems, including the DirectView

DR 9500 System, the DR 3500

System, as well as its latest single-

cassette CR products, DirectView CR

Elite and the new Kodak Point-of-

Care CR 360.

Also on show will be the

company’s IT solutions including

enhancements to its RIS/PACS

platform, and the latest version of

Carestream Information

Management Solutions.

Carestream’s rapidly expanding

digital mammography portfolio,

including computer-aided detection

(CAD) software and new CR

software that delivers enhanced

exchange of information with other

vendors’ digital mammography and

RIS/PACS systems, was also

highlighted. The CarestreamHealth

digital mammography portfolio

includes multi-modality breast

imaging workstations, CR-based

mammography systems, computer-

aided detection for CR and film-

based mammography, special

functionality for its RIS/PACS

platforms, and laser imagers.

Volker Keller, Carestream Health

Regional Market Communication

Manager for Europe North, points

out many benefits of digital

technology, adding: ‘On the clinical

side, we see great opportunities for

the implementation of healthcare IT

systems. Smaller hospitals and

clinics will benefit from an all-

digital workflow. We have several

initiatives underway to provide

comprehensive but affordable

solutions to the unique challenges of

delivering healthcare to rural

markets in developing countries.’

Digital mammography andcomputer-aided detection (CAD)in actionAs a centre of excellence for mam-mography, the Fontana Women’sHospital in Chur, Switzerland, has areputation stretching far beyondSwiss borders. Manned by Dr Gerold

Reutter MD, the local mammographycentre has used Kodak’s digital sys-tem from Carestream Health since2007.

A workstation, including two highresolution monitors, is downstreamfrom the imaging devices: a KodakDirectView CR 975 Image plate sys-tem and a high performance laserKodak DryView 8900 printer withmaximum resolution of 650 dpi.

The monitors display full field digi-tal images of the breast. To demon-strate the CAD system at work, DrReutter moved the cursor on the leftmonitor over several triangular andstar shaped symbols. ‘With these tags,the CAD system shows me points ofpotential interest. The triangles clear-ly indicate the micro calcifications;the star shaped marks indicate densersoft tissue relative to the surroundingtissue structure. We know there is ahigh correlation between the prelimi-nary stages of carcinoma and the for-mation of a micro calcium group offive calcifications/cm2. Such a groupis highlighted by the CAD systemfrom Carestream Health and thishelps in our diagnoses. The accuracyof findings is very high.’

Dr Reutter mentioned additionaladvantages in the digital CAD system.‘Foremost is vastly better image qual-ity. If you compare conventionalimages with the digital images, youwill see what I mean: the differencesin contrast, detail and resolution areobvious – the conventional imageshave a blurred, dull effect.’

Adjusting image brightness andcontrast – both not possible with tra-ditional imaging technology, heclicked the mouse to enlarge part ofthe image marked by the CAD system(the once indispensable magnifyinglens is no longer needed). ‘TheCarestream CAD system has proved

Carestream productson show and at work

Dr Gerold Reutter

with other physicians and specialists.Dr Reutter also described other ben-

efits of digital mammography. The inte-grated speech recognition systemenables direct reporting and automaticconversion into written text. All down-loaded, archived image data can beinstantly recalled. Hard copy films areno longer stored. Electronic image dataalso can be printed on films, as well ase-mailed.

‘My experience is that theCarestream CAD system is a significantstep forward in the diagnosis of breastcancer,’ Dr Reutter concluded. ‘Thedigital mammograms clearly outclasstraditional images in terms of detailresolution, making our findings morereliable. It is also a well developed sys-tem and, through regular updates,keeps pace with changes and remainsstate-of-the-art technology.’

Volker Keller

You bet. With AXIOM Luminos dRF.

As a fully digital, 2-in-1 solution for radiography and fluoroscopy (R/F), AXIOM Luminos dRF is exceptionally versatile and fast. Thanks to its 43 cm × 43 cm flat detector, time-consuming cassette handling is a thing of the past. The system easily accommodates the full range of R/F applications as well as various interventional procedures – all in one room. What’s more, with its low table height of 48 cm, AXIOM Luminos dRF is also tremendously comfortable for patients and convenient for staff. Outstanding image quality, fully digital workflow, exceptional ergonomics – when you add it all up, you have optimal resource allocation and improved utilization. www.siemens.com/answersforlife +49 69 797 6420

Answers for life.

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90184_Z1083_A4_eng.indd 1 21.04.2008 8:58:04 Uhr

10 EUROPEAN HOSPITAL Vol 17 Issue 2/08

For the second in his series of articles for European Hospital, Professor StefanSchönberg of the Institute of Clinical Radiology and Nuclear Medicine(IKRN), University Hospital Mannheim, Medical Faculty Mannheim,University of Heidelberg, invited colleagues from the Nijmegen UniversityMedical Centre (UMC St Radboud) for a roundtable discussion on:

Meet the experts D.J. Dinter1, J.O. Barentsz3, F. Lohr2, E.N.van Lin4, A.M. Weidner1,T. Hambrock3, N. Schnitzer1,F. Wenz2, S.O. Schönberg1

1 Department of Clinical Radiology andNuclear Medicine,University Hospital Mannheim,Medical Faculty Mannheim,University of Heidelberg, Germany

2 Department of Radiation Oncology,University Hospital Mannheim,Medical Faculty Mannheim,University of Heidelberg, Germany

3 Department of Radiology, University Medical CentreNijmegen, The Netherlands

4 Department of Radiation Oncology, University Medical CentreNijmegen, The Netherlands

Radiation treatment decisions in patientswith prostate cancer and suspected lymphnode metastasis based on USPIO-MRIProstate cancer is the most

frequent cancer in men withabout 49,000 newlydiagnosed cancers in

Germany and 6,000 in theNetherlands, annually. Importanttreatment options for localprostate cancer are radicalprostatectomy (RPx) and radiationtherapy (RT). Currently, afterinitially performed transrectalultrasound, multimodality highresolution MR imaging is thepreferred method for accuratelyassessing the local disease stageand is performed to guide decisionmaking for optimal treatmentchoice. Multimodality MR imagingincludes multiplanar T2-weightedimages to show morphologicattributes, chemical shift spectro-scopy with further mapping of theCholine/Citrate ratios formeasurement of alteration inmetabolism, dynamic sequences fordelineation of typical cancerhypervascularisation and diffusion-weighted sequences to showrestriction in the Brownianmovement of the water molecules.Image quality and spatial

accurate method is MRlymphography with ultra-smallsuper paramagnetic iron oxideparticles (USPIO, Sinerem). Usinga 3T scanner, metastases in nodesmeasuring 2-3 mm can bedetected. Up to now no seriousside-effects have been reported.Regrettably, this promisingtechnique, using Sineremcontrast, is not yet commerciallyavailable.

Currently, the extension ofradiation fields depends on therisk for lymph node metastasis.This risk is calculated according tothe Roach formula. Patients atlow risk (<15%) undergoirradiation of the prostate only,whereas patients with high risk(>15%) may benefit fromradiation of the whole pelvis,including the lymph nodes.Moreover, it has beendemonstrated that radiationtherapy is more effective at ahigher dose. This requires anexact delineation of both tumourand metastases. Following this,improved radiation techniques,like intensity-modulated

resolution are improved byutilising a balloon type endorectalcoil. In an innovative procedure, anendorectal balloon is also used forCT imaging and duringradiotherapy. Thereby, the prostatewill have similar shape and therectal tissue will be protected fromradiation damage because it isdisplaced away.

Another important field inprostate imaging is lymph nodestaging. This comprisesmeasurement of pelvic lymph nodesizes by CT or MRI and stratifyingpatients in risk groups for possiblelymph node metastasis accordingto the Partin or Narayan tables.These depend on Gleason-Score(histological grading) and PSAvalue. However, conventional CTand MRI can miss metastases insmall, non-enlarged lymph nodes.Furthermore, in patients at low riskfor nodal metastases based onthese tables, no additional nodaldiagnostic imaging is performed.

Recently, diagnostic imagingtechniques have become availablewhich enable improved lymphnode staging. At present, the most

radiation therapy (IMRT), areneeded for patients to benefitfrom the advanced imaging. In anew concept, the ‘dominantintraprostatic lesion’ (DIL) isirradiated with a higher dosethan the rest of the prostate. Asimilar procedure is planned forthe concept of ‘MR guided lymphnode IMRT’ (MGL-IMRT).

Currently, the above-mentionedmultimodality MR imaging, aswell as the USPIO-MRI for thelymph nodes, is only available atspecialised centres anduniversities. To further assess thevalue of these techniques, forimprovement and routineimplementation, a collaborationhas been set up between theDepartments of Radiology andRadiation Oncology in both, theUniversity Medical Centre St.Radboud, in Nijmegen, and theUniversity Hospital in Mannheim.These two centres will closelywork together on MR-imaging ofthe prostate to perform bi-centretrials and to facilitate furthermulticentre trials.

In this way the potential of

D.J. Dinter1 F. Lohr2

A.M. Weidner1 J.O. Barentsz3

improved prostate imaging toenable a more effective therapywill be optimally explored. As aconsequence of this, it isenvisioned that disease-freesurvival of patients with prostatecancer can be prolonged and side-effects and costs caused by notstage adapted treatment can bereduced.

Additionally, we would like toinvite you to the newly establishedtransatlantic meeting ACSI, whichwill take place on 20-21 June 2008in Mannheim, Germany. Details: www.mr-pet-ct.com

TRENDS IN IMAGE-GUIDED THERAPY

E.N. van Lin4

A: T2-weighted axial image of the prostate. In the right central and peripheral zone a hypo-intense area is visualised, a prostate cancer with extracapsular extension.

B: ADC-map calculated from the diffusion-weighted images showing restriction in theBrownian movement of water molecules within the cancerous area.

C: Parametric map of plasma flow, determined from dynamic contrast enhanced T1 images,obtained after bolus injection of a Gadolinium-based contrast agent. The tumour showsan increased plasma flow.

D: Metabolic map of a chemical shift spectroscopy image showing an increasedCholine/Citrate ratio in the central area of the prostate cancer tissue.

T. Hambrock3

A B

C D

ACSI 2008Advances in Cross-Sectional ImagingMannheim, Congress Center RosengartenFriday-Saturday, 20 th - 21st June 2008

Chairmen:Prof. Dr. med. Stefan O. SchönbergUniversity Medical Center Mannheim, University of Heidelberg, GermanyProf. Dr. med. Dr. h.c. Michael V. KnoppMedical Center, Columbus, Ohio State University, USA

In Cooperation with

Advances in Cross-Sectional Imagingwww.mr-pet-ct.com

Anzeige 103x133.indd 1 08.04.2008 15:13:57

EUROPEAN HOSPITAL Vol 17 Issue 2/08 11

R A D I O L O G Y

High speed MRIdevices gain use infoetal evaluation

Cynthia E Keen reports

Left: Survivor of a twinpregnancy, gestationalweek 25+4, sent to MRIfor screening for brainabnormalities afterultrasound examinationshowing slight asymmetricventriculomegaly

Right: MRI revealedgerminolytic cystic lesionson both sides and anirregular cortical plate on oneside, in the occipital region

urological and possibly oncologicalprocesses in foetuses withpotential abnormalities could beimaged. MRI has historically beenused when ultrasoundexaminations were impaired by alack of amniotic fluid, unfavourablefoetus position and/or excessiveobesity of the mother. Bothultrasound and MRI are non-invasive, non-radiation emittingdiagnostic procedures.

Use of high speed sequences inMRI now enables radiologists toobtain interference-free imaging.Almost all foetal body parts, suchas the face, neck, thorax andabdominal organs, as well as themother’s tissue can be reliably andprecisely visualized. Braindevelopment can be assessed withalmost histological precision.Surplus kidneys can be detectedand renal tissue can be superblyvisualized. It is also possible todetect intrinsic movements oforgans in real time. ‘Thesedevelopments make precise anddetailed diagnoses easier,’ DrPrayer explained.

Vienna University Hospital hasbeen using MRI for prenataldiagnostics since 1998. When afoetal abnormality is suspected inan ultrasound examination, MRI isused as an effective additionalexamination method. About 50% ofpregnant women whose foetusesare suspected of havingirregularities in the central nervoussystem and lungs have an MRIperformed at Vienna UniversityHospital. Dr Prayer said that, inAustria, the cost to perform aspecialized 3-D ultrasoundprocedure and an MRI arecomparable. ‘In comparison witholder MRI systems, the high speedsystems allow the visualization ofmoving processes,’ she pointed out.‘If a foetus with a stenosis in itsoesophagus has problemsswallowing amniotic fluid, this canbe detected in the gradient echosequence. This enablesobstetricians to plan for possiblepost-birth surgical procedures.’

Dr Prayer said that the possiblerisks of an MRI procedure includethe warming of the mother andfoetus and the fact that theexamination may cause stress toboth the mother and the foetus.The foetus may also be exposed to

Magnetic resonance imaging isgaining increasing importance as asecond imaging process in prenataldiagnosis in addition to ultrasoundexamination, according toDr Daniela Prayer, a paediatricradiologist at the University Clinicfor Radiological Diagnostics atVienna University Hospital.

Speaking at a press conference atthe ECR, she said that, used inconjunction with 3-D ultrasoundand Doppler or colour-Dopplerultrasound, MRI could establishitself as the means by whichgynaecological, gastrointestinal,

vibrations and noise. There is noindication that this causes harm, but thisfact has not been ruled out either.

‘We believe that the benefit to themother and her developing foetus is fargreater from a clinical perspective thanthe risks we can identify,’ she concluded.

Simplicity is turning fastand seeing morePhilips Brilliance iCT 256 ComputedTomography is nowturning faster than before.The extraordinary EssenceTechnologyoffers completely new possibilities for diagnose, treatment and researchof serious diseases – faster than ever with less radiation.

www.philips.com/healthcare

12 EUROPEAN HOSPITAL Vol 17 Issue 2/08

R A D I O L O G Y - C O N T R A S T M E D I A

Recently, nephrogenic systemic fibrosis (NSF), a rarekidney disease, has been associated with theadministration of gadolinium-containing contrast media,particularly gadodiamide, marketed by GE Healthcareunder the name Omniscan.European Hospital asked Dr Christoph U. Herborn, (right)Associate Professor of Radiology and Director of MRI atthe Medical Prevention Centre Hamburg (MPCH) at theUniversity Medical Centre Hamburg-Eppendorf, aboutthe possible connection between gadolinium and NSF

Before discussing a possibleconnection betweengadolinium andnephrogenic systemic

fibrosis (NSF), Dr Herborn offereda brief background: ‘In MRIimaging we use two types ofcontrast media — paramagneticand superparamagnetic.Paramagnetic contrast mediacontain the rare earth Gadolinium,which is also contained inOmniscan. As a disease, NSF wasfirst documented in 1997. It is onlyfound in patients with terminalkidney insufficiency – andsurprisingly also in patientsundergoing dialysis. The possibleconnection between contrastmedia containing gadolinium andNSF was described for the firsttime in 2006.’

an accelerator or maybe even as theactual underlying cause of thedisease.’ How may these findings

influence the use of MRI

contrast media?

‘In the last few years we havebeen promoting MRI imaging withcontrast media because it is welltolerated, the applied doses arerelatively small and we haveassumed that dialysis filters out thecontrast media after theexamination. These were clearadvantages compared with the X-ray contrast media known to benephrotoxic. But it looks as ifthings are not actually that simple.Now we have a problem withpatients suffering renalinsufficiency who may have beeninjected with contrast media

MR Angiography:A future withoutcontrast media?By Stefan G Ruehm MD PhD, Associate Professor ofRadiology at the David Geffen School of Medicine,UCLA, California, and Director of DiagnosticCardiovascular Imaging, CT, UCLA Radiological Sciences

1. Contrast-enhanced MR angiography (Hybridprotocol) in abdomen and periphery (3T) afterbolus injection of only 14 ml Gd-DTPA.Stenoses and occlusion of the left pelvis- andleg vessels2. Contrast-enhanced MR angiography of theabdomen (3T) after bolus injection of only 7ml Gd-DTPA (single dose).3. Navigator SSFP MR-Angiography of theaorta and coronary arteries without injectionof contrast media with 1.5T. Image of theAorta ascendens and the ventricle systemwithout motion artefacts as advantagecompared with contrast-enhanced MRIsequences.

Developments in MRI overthe last few years haverevolutionized thediagnosis and therapy of

cardiovascular diseases.Contrast-enhanced MRangiography has establisheditself as a non-invasive, standardprocedure for the diagnosis ofvascular diseases in the thorax,abdomen and periphery. It ischaracterized by fast acquisitiontimes and lack of invasiveness.The three-dimensional display ofdata sets is similar to thatachieved with conventionalangiographic images andradiologists and clinicians arefamiliar with it. Theparamagnetic contrast mediumbased on Gadolonium (Gd) isnormally very well tolerated. Sideeffects such as allergic reactionsare extremely rare. Unlike withiodine containing contrast media,if the maximum dose is adheredto there is no nephrotoxicity

However, the safe image ofcontrast-enhanced MRexaminations has beenquestioned with recent reportsabout a link between thesystemic and incurable diseasenephrogenic systemic fibrosis(NSF) and the administration ofcontrast media containingGadolinium. So far theoccurrence of the diseaseappears to be limited to patientswith severely limited kidneyfunction. Ironically, it is oftenpatients with increasinglydeteriorating kidney function forwhom an MR angiography isparticularly indicated toeliminate a possible renal arterystenosis. In the past it was quitecommon for patients to be giventwice or even triple the usualdose of contrast medium for thisexamination. Renal arterystenoses mostly develop becauseof arteriosclerotic changes. Thesystemic disease pattern ofarteriosclerosis and associateddiseases, such as high bloodpressure and strokes, oftenrequire clarification in severalvascular territories for theelimination of vascularpathologies. In the past, whole-body MR angiography wassuccessfully used as an efficientscreening procedure. All in all, itwould appear sensible to reducethe total dose of contrast mediabecause of the imminent risk ofNSF. Whole-body MRangiography offers advantageshere. It allows for more efficientuse of the dose of contrast mediaadministered compared withconventional protocols limited toa single vascular area. Thismakes it possible to reduce theamount of contrast media

administered compared with theconventional procedure whereseparate doses of contrast mediaare injected for the differentvascular territories to bedisplayed.

Recently published studies haveproved that the use of the most up-to-date technology, particularlyscanners with higher field strength(3-T), allows a significantreduction of the dose of contrastmedia required. Studies in our owninstitute confirmed that the use ofthe single dose Gd (0.1mmol/kg)definitely allows for combined MRangiography of the abdomen andthe lower extremities without anysacrifices in quality (Pic. 1). In thepast it was not uncommon to usedouble or even triple doses. Halfan individual dose (0.05mmol/kg)appears diagnostically sufficientfor the MR angiography of anindividual vascular area (Pic. 2). Afurther reduction of the Gd dosecould be achieved through the useof contrast media with higherrelaxivity, such as binding of theGd complex to albumin.

Despite promising strategies forthe reduction of contrast media,examinations completely withoutcontrast media would be desirable,particularly for patients withlimited kidney function or forgeneral risk and cost reduction

purposes, such as screeningprotocols. Where in the past, andbased on individual indication,native sequences such as Time ofFlight (TOF) or PC MRangiography, which are still usedtoday, were only of limited use asan alternative to contrast-enhanced MR angiographyprocedures because of motionartifacts, saturation effects andprohibitively long acquisition timesfor large vascular areas, state-freeprecession (SSFP) sequences arebecoming increasingly importantas an alternative.

Promising results have beenachieved with Navigator SSFPsequences for the screening ofhigh-grade renal artery stenosis,with sensitivities and specificitiesof 100% and 84% respectively. Ourown research has shown thatcontrast media enhanced MRangiography definitely matches thediagnostic accuracy of SSFPsequences for the detection ofpathologies of the aorta andthorax veins. Due to the ECG-synchronous data acquisition,native SSFP-MRI was actuallysuperior to contrast-enhanced MRangiography for the display of theascending aorta because of thelack of motion artifacts (Pic. 3).Although it is not yet clinicallyestablished, SSFP MR angiographycurrently appears to be thepreferred procedure for thedisplay of coronary arteries.However, it does havedisadvantages compared withcontrast-enhanced MRangiography for the display ofsmaller vessels. Moreover, the dataacquisition times in thorax andabdomen, depending on the spatialresolution desired and otherfactors, such as breathing rhythmand cooperation of the patient, areoften much longer. Additionally,SSFP MR angiography does notdeliver functional informationsuch as can be achieved withcontrast-enhanced MRangiography with chronologicaldata acquisition during injection ofthe contrast medium. Despiteseveral limits of the sequenceprotocols for native MRangiography that are currentlyavailable, examinations entirelywithout Gd-containing contrastmedia appear to have advantagesthat must not be misconceived. Itseems justified, dependent on theindication for patients with limitedkidney function, to primarily usenative MR angiography sequencesand only to proceed to usingcontrast media enhancedsequences when the initial resultsappear unclear.

For patients with normal kidneyfunction, we should weigh up theadvantages of the potential gain ofadditional information resultingfrom contrast-enhancedexamination protocols against therisk reduction achieved throughforegoing the administration ofcontrast media, along with otheraspects such as acceptance amongpatients and cost factors.

Contrast-enhanced MRangiography is sure to retain itsoutstanding significance in non-invasive vascular diagnostics inthe future. However, in the interestof a general cost and riskreduction, careful assessment ofindividual indication along withselective use of protocols withreduced doses of contrast mediaor of protocols without contrastmedia is mandatory.

If Omniscan is one of many

gadolinium-containing

contrast media, why is it the

only one being implicated?

‘It is undoubtedly related to thedata we have available. The dataon contrast media and NSF relateto the two contrast media that aremostly in use worldwide. One ofthese is Omniscan, which hasparticularly widespread use in theUSA – and it’s from there that wereceive the most data regardingcontrast media containingGadolinium and NSF, becausedata collation is most advanced inthe US. However, in principle allcontrast media containinggadolinium bear this risk. As freegadolinium is toxic we buildchemical ligands around thegadolinium-ion, called chelatecomplexes, which make thesecompounds stable. There arestandardised chemical proceduresto test this stability. However, wedo not know for sure whether thestability or instability respectivelyof paramagnetic contrast mediareally does play a role in thedevelopment of NSF.

‘There have only been about 300cases of NSF so far. Since 1988around 200 million people havebeen injected with contrast mediacontaining gadolinium, and nowwe have a serious problem —which must not beunderestimated — but only in 300patients. There is no doubt that itis a catastrophe if patients alreadysuffering kidney disease alsodevelop NSF. Despite this, I wouldadvise that this subject should beapproached in a scientific ratherthan an emotional manner. We arenot sure how this terrible diseasedevelops and what the actualcauses are. In my view there canbe no doubt that gadolinium isassociated with the developmentof NSF, be it as a trigger factor or

containing gadolinium for MRIexaminations over many years,because we thought that we couldcarry out MRI imaging with thesecontrast media without anyproblems. Not using contrast mediaat all for these patients cannot bean option. Rather, we shoulddevelop guidelines stating, forexample, that patients with renalinsufficiency from stage IV shouldideally not be given gadolinium.

‘Even more important: Asradiologists, we must emerge fromour dark rooms where we carry outthe diagnosis and take a closer lookat the patients before carrying outexaminations. We must not carryout standard procedures along thelines of “0.3mmol contrast

medium per kilogram of body

weight for an MR angiography”,but we should evaluate whethercertain types of examinations andprocedures should be used forcertain patients who may be betteroff having less or no contrast mediainjected.

‘These new procedures do exist:We can, for instance, carry outarterial vascular imaging withsteady-state free precessionsequences, or whole body and/ororgan diffusion imaging where theBrownian motion (molecularmovement) is being shown. Theseare procedures that deliveroutstanding results without the useof contrast media. This will notwork for all patients, but we shouldstill consider how we can integratethese alternatives into ourworkflow.

The radiologist should be rightnext to the equipment and ensurethat all high risk patients receivethe optimum examination. Not allour patients, of course, are at highrisk: 99% of them can be examinedwith standard procedures. But forour risk patients we definitely haveto get out of our dark rooms.

The contrastmedia controversy

Fig 1

Fig 2

Fig 3a

Fig 3b

CMIV has a new patent-pending technology that is set toradically change the way and speed at which radiologistswork. The system could produce earlier diagnoses of certain disease,according to scientist Anders Persson MD PhD, Director and Member ofthe Board of the Centre for Medical Imaging Science and Visualisation(CMIV), at Linköping University, Sweden. CMIV has worked in closecooperation with the industry-leading PACS supplier Sectra

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R A D I O L O G Y - C O N T R A S T M E D I A

Meeting with Meike Lerner of EuropeanHospital, Dr Persson spoke of ‘syntheticMRI’, new software that enables theradiologist to do a single MR scan with-out changing scanner settings – andmore. ‘A lot of MRI control parameterson the scanner – such as repetition timeTR, the echo time TE or the application ofpre-pulses, can be transferred to thePACS. Usually, a technician sets the scan-ner parameters and the radiologist hasto accept the images he receives. Thenew software means you can change TRand TE at will, generating any T1 or T2-weighted image, after the actual scan isperformed. Even a FLAIR image (FLuidAttenuated Inversion Recovery) or fatsuppression can be generated as a post-processing step. All these contrast con-trols, which are usually on the scanner,are now transferred to the radiologist, sohe can check his own best optimal con-trast settings. This may save a lot of time,because he will have all his preferredimages based on a single scan.’

Showing a whole-head 25-slice scan,he pointed out that it was obtained injust five minutes. The software enablesthis and the radiologist can use his ownpersonal optimization. ‘If he wants tolook at T2 weighted images in this way,he gets it this way. It is easy to teach thestaff, and you also have only one dataset to send,’ he pointed out. ‘MR imag-ing usually takes from 30 minutes to anhour. I can’t claim I can do an hour in fiveminutes, but you can probably save quitesome time — probably 30%. So, forevery three patients now, you could havean extra patient.

The advantage of the technique is thatit is based on quantitative values. Eachtissue has a characteristic set of MRparameters such as T1 and T2 relaxationand Proton Density (PD). If part of animage contains these values you candirectly classify the tissue. On the wholehead image he indicated ‘healthy’ refer-ence numbers for white matter, greymatter and cerebro-spinal fluid (CSF). ‘Ifyour measured values correspond tothese reference values you can be con-sidered healthy. It may be that the image

pixels contain more than one single tis-sue (partial volume); in that case themeasured values should lie on a line inbetween these reference values. If youare outside these healthy areas you areprobably looking at a pathology.Multiple Sclerosis lesions, for example,have completely different values for T1,T2 and PD than any normal brain tissue

Could MS automatically be recog-nised? ‘It is not implemented yet, butyou can see that it is more or less easyto calculate the percentage white mat-ter and grey matter, and you can actu-ally get out partial volume and showan image that is tissue specific: animage that contains only white matteror an image that contains only greymatter on a scale of 0-100%. The nextstep is then, obviously, to take thewhole brain and then remove the greyand the white matter and the CSF, thenyou would only have the disease left. Ifyou are healthy it would be a blackimage. If not, those areas would showup brightly.’

A volume estimation is also obtain-able, he added. ‘It is a simple subtrac-tion of the volume of the whole brainminus the healthy areas. What is left isthe volume of the pathology. So insteadof trying to grey scale the contrastimages to find MS lesions, you get realanswers that are independent ofthresholding or grey scaling.’ So the

HYPERPOLARISED HELIUM MRI OF THE LUNGSAndrea Martini and JoergLarsen, of the Institute for

Roentgendiagnostics,Braunschweig Teaching

Hospitals, Germany, presentan introduction to the

pulmonary ventilation anddiffusion imaging by MRI

Only few imaging modalities lendthemselves to imaging of the lungs.Conventional chest radiography is themost commonly used tool in the inves-tigation of pulmonary pathology butyields the perhaps most difficult, plainradiographs to interpret. Given theinherent density differences in lungparenchyma, computed tomography(CT) permits high contrast resolution inlung imaging, although the assess-ment of very peripheral airwaysremains limited. In contrast, scintigra-phy techniques allow imaging of venti-lation and perfusion, but lack spatialresolution. All of the aforementionedtechniques also carry a radiationpenalty. However, the possibility tocombine imaging of both structure andfunction in a non-invasive magneticresonance imaging (MRI) examination,as performed anywhere else in thebody, is hindered by the lack of freewater, which renders the lungs signaldeficient on conventional proton MRI.In addition, the innumerable air-softtissue interfaces in pulmonaryparenchyma do cause considerablesusceptibility artefacts.

Nonetheless, while hydrogen is themost frequently imaged nucleus inMRI, due to its great abundance in vir-tually all other biological tissues, anynucleus with a net nuclear spin mayprincipally be explored by MRI. Thenon-radioactive noble gas isotopes3Helium (He) and 129Xenon, for exam-ple, may be inhaled and serve as con-trast media in the determination of airspace distribution within the lungs.While the nuclear density of thesegases in their unprocessed state is too

low to produce a useful signal, polari-sation techniques can increase nuclearspin polarisation by 4-5 orders of mag-nitude, yielding a proportionally spec-tacular signal on dedicated MRI exam-ination. This allows fast breath holdimaging and holds the promise ofenhanced sensitivity and contrast inpulmonary imaging, a new techniquethat was first experimentally exploredby US researchers in guinea pigs(Middleton H et al., Magn Reson Med1995;33:271-5).

Polarisation using so-called opticalpumping methods produces spin align-ments, i.e. the spins of the gas atoms,which act as small dipoles, align intoone direction, causing ‘macroscopic’magnetisation. Polarisation is trans-ferred from polarised laser light whenHelium principally absorbs thepolarised light. The resulting gas maybe compressed, making it storable inlow gradient magnetic fields for sever-al hours (up to six days), also allowingtransporting it to remote sites forimaging applications.

MR system requirements for He-lungMR imaging (He-MRI) include a broad-band radio-frequency system, such asthat used in MR spectroscopy applica-tions and dedicated receiver coils oper-ating at the He-frequency. Owing tothe decay characteristics of thepolarised gas, as well as the need toconsider cardiac pulsation and respira-tory motion artefacts, fast low flip-angle (gradient echo) sequences (fast3-D coronal FLASH, dynamic trans-verse-axial 2-D FLASH) are employed.

While Xenon has known anaestheticproperties due to its significant solubil-

Breaking news… breaking news…Radiologists are set to gainnew control of imagesIs this the end of contrast agents?

radiologist can make a safer diagnosis?‘You see an absolute match — it’s notyour eyes or how you set the image tolook at. You can get an automatic indi-cation of where the computer found val-ues that are not normal. Of course theradiologist is still needed to decidewhether the software was right or not,

ity in biological tissues, Helium ischemically inert and absorbed only innegligible quantities. No adverseeffects have thus been reported withits use.

There are three particular approach-es to the use of hyperpolarised heliumimaging. First, pulmonary Helium con-tent may simply be quantified, a testthat is no different from a gadoliniumenhanced MRI- or iodine enhanced CT-scan. The patient inhales the agent anda cross-sectional scan is performed,usually in the axial or coronal planes(see above). The distribution of Heliumthen equates to the pulmonary ventila-tion. Second, the diffusion capacity ofthe lungs may be measured. In ahealthy lung, the branching of thebronchial tree results in a reduction inairway size towards the lung periphery.Ultimately, in the alveoli, where gasexchange takes place, diffusion capac-ity is limited. In contrast, in manychronic pulmonary diseases, such asemphysema, the peripheral airwaysare widened, resulting in a loss of

restricted diffusion, which can beaccurately assessed on apparent diffu-sion coefficient mapping. Finally,polarised Helium degrades when incontact with oxygen, with consequentloss of its MRI signal properties. Thisfact may be exploited, permitting anindirect measurement of oxygen con-centration through repeated scanningin short intervals when signal decreasecan be monitored.

Consequently, clinical applicationsfor these techniques are plentiful.Being able to consider the homogene-ity of ventilation is priceless in theinvestigation and management ofpatients with COPD, asthma as well ascystic fibrosis and other paediatricchronic lung disease in particular.Asthma and COPD are the commonestairway diseases and associated withconsiderable morbidity and mortality.The desire to consider their progres-sion has long been hampered by thelack of sensitivity of current tech-niques and further impeded by theneed to use ionising radiation. Morefrequent follow-up examinations, nowpossible through the introduction ofHe-MRI, may become integral to theevaluation of new treatment regimes,also permitting post-treatment exami-nations, even in the very short terme.g. after physiotherapy. The methodsmay also be useful before and afterlung transplantation and in the evalu-ation prior to volume reducing lungsurgery. However, such MRI examina-tions require patient compliance, con-sequently making them more difficultto undertake in babies and small chil-dren.

In this context, two seminal studieshave provided crucial evidence of theworth of MRI using noble gases ascontrast agents: Salerno and co-work-ers could demonstrate that He-MRIcorrelates with spirometric indexes inpatients with established emphysema(Radiology 2001;222:252-60), whileFain et al. have since shown that He-MRI may even detect early emphyse-matous changes in asymptomaticsmokers (Radiology 2006;239:875-83).

Clinical pulmonary function testsprovide overall information on lungfunction, i.e. they consider both lungstogether. Current lung imaging sufferslimited spatial resolution and carries aradiation penalty. HyperpolarisedHelium MRI is an emerging techniquethat may overcome these difficulties, anotion that is reflected by a rise in sci-entific publications on this subject inrecent years. However, hyperpolarisedgases are not commercially availableand produced by only a few centresworldwide. The logistics of productionand delivery to imaging sites, togetherwith the costs of agents, therefore limitthe general usefulness of the tech-nique for the foreseeable future(Kauczor HU, Br J Radiol 1998;71:701-3). Nonetheless, when these difficultiescan be overcome such as recently atSheffield’s Children’s Hospital (UK),very considerable benefits are to begained, specifically for patients withchronic lung disease.A referenced version of this article isavailable upon request by contacting JLarsen MD FRCR, ConsultantRadiologist, at j.larsen@klinikum-braun-schweig.de.

the tissue – CSF, grey matter and whitematter — always end up in the sameplace. So each tissue has its own char-acteristic values, the same combinationof T1, T2 and PD. Hence it does not floatlike a normal contrast image. It is just avalue that is fixed.’

But what if a radiologist needs to usecontrast agents? ‘Yes, you could do ascan before and after contrast. That’s apossibility. But maybe the scanning is sogood that you don’t need any contrast-ing anymore, because you have all thecontrast images. Or you could do itbefore the actual scan. You only take aquantified image after the contrastmedium injection, which saves moretime.’

Couldn’t this destroy the whole con-trast agents industry?

‘Yes,’ he replied.

Adaptability for various MRIscanners

In principle, Dr Persson explained, if ascanner has rapid quantification, thesoftware will be compatible. ‘The wholething is based on quantification. Thethree MR parameters are T1 and T2relaxation and proton density PD.Nobody does quantification that well –it is there, but hardly applied becauseother quantification methods take somuch time. That is why everyone revertsto contrast imaging. You make a con-trast image and that is the image youget, you can’t change it anymore. Thewhole concept here is that you do thissingle quantification scan, you knowthe T1, T2, and PD, then you can calcu-late how an image would look with cer-tain scanner settings. In principle, it isprecisely like a Hounsfield unit on CT, itis really a quantified measure, but in ourcase we have three outfield units simul-taneously, we have T1, T2 and PD.’

Asked what would happen if 1.5T or3T were in use, he pointed out thatmore signal would be gained on 3-Tesla: ‘That’s why it can be even faster.This is a five minute scan for 1.5 Tesla.On a 3-T scanner, it would only take twominutes, after which you have all of the

T1- and T2 weighted images.’During the two-year development of

this software a specific implementationwas made for cardiac examinations, forthe so-called Late GadoliniumEnhancement. This has already been inuse for a more than a year. Based on asingle scan of 20 seconds LGE imagescan be generated that cover the com-plete heart and show any desired inver-sion delay. Here again, the optimal con-trast can be set after the actual scan, fullcontrol for the user. ‘All the cliniciansinsist this is fantastic. They said: We wantthis. Because they have control; theylight up like, Wow, of course! It’s reallynice. People come from other universitiesto see it.

Sectra customers will have the optionto receive this new software as a plug in.‘Of course, the software needs to matchthe hospital’s particular model. But theo-retically there is no problem with anyscanner.’

This is not simply new software — it isa completely new tool, he pointed out.Apart from its clinical validation forquantification, progress will now comefrom learning further uses. ‘We are doinga lot of autopsies on corpses. That is ourreal gold standard for heart examina-tions. We can do the histology to com-pare our results. We can save a lot oftime that way. It’s also good for research,because we can develop and test thesoftware. There is a lot of validation. Atthis year’s ISMRM in Toronto there willbe several presentations regarding thisnew system from CMIV. Although thesystem is not yet marketed, many peoplenow work with it. Everyone has jumpedat this.’

CMIV is running seven projects involv-ing autopsy. As autopsy is forbidden inmany countries; additionally many fami-lies often do not want their deceased tobe touched, there is worldwide demandfor this, Dr Persson, who is working todevelop virtual autopsy, using this newsystem. ‘We can do this single quantifica-tion scan of the person and the studyresults can be produced an hour later.’continued on page 14

Multi-slice CT scannerswill soon provide datasetsup to a terabyte for single

radiology examinationsbut it may save him a lot of time.Especially important is also that if apatient has a uniform change through-out the brain, you cannot know, with acontrast image, what you are lookingat. You have the same change every-where, and so it looks normal again.Using synthetic MRI, however, thischange will be found. I suspect if youhave a MS patient with normal appear-ing white matter this technique is bet-ter than the conventional method

Could early-stage Alzheimer’s bedetected in this way? ‘We don’t knowyet. Hopefully, yes. We have started toapply this method on various patientsand the results are not yet analysed.Anyhow, here you can see the benefitsof MR quantification. You can see inthis little window down here that all

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This has aroused enormous interest,including the making of a DiscoveryChannel programme, and visits to theuniversity by all international TV com-panies. Following a visit to Washington,to present the software to the Bushadministration (described as bringingautopsies to life) this research hasgained a big grant. ‘There’s worldwidedemand for this,’ said Dr Persson, ‘andit’s coming.’

‘But imagine if you have your CT andsomeone says to you: We are going toskip the Hounsfield unit; we are goingto make it into a floating scale that canbe anything. You would be outraged.But really, using MRI it can be anythingyou are looking at; the images have noabsolute value. A lot of people tried todo this, it was really popular in the ‘80s,but it failed because nothing was fastenough. We have found a method thatis fast enough.

‘There’s already a lot here, but I can’twait to get more,’ he continued. ‘Wewant to use it on the spine, the kneeand so on. Look at this cardiac

continued from page 13 sequence from hospital imaging. Thehealthy myocardium should be black.That means that you have to set yourscanner precisely so that it becomesblack, which is very difficult; itdepends on a patient’s weight, howmuch contrast media you actually putin it, how long you waited betweencontrast injection and the scan, and soon. So a lot of people struggle to gettheir inversion time, this parameter,right. With synthetic MRI you canautomatically get the optimal inver-sion time; I just point at the area in theimage that I want to be black and thesoftware automatically recalculatesthe corresponding optimal inversiontime that makes it black. Look, I takethis little square and I place it some-where that I want to be black — thisis black blood, this is black myocardi-um. You can see there is a big pathol-ogy here, lighting up. This means that,based on a single scan, you alwayshave the optimal result, and you don’thave to test your way forward, whichis currently the usual case. That isabout four or five scans. In our insti-

tute we tracked the reduction of exam-ination time and on average it was 7minutes 45 per patient. And thatdirectly saves money. This is only avery simple application for the heart –and the patient only holds his breathone time. It is also safer, particularlyfor MRI for children, because theirparameters change – particularly ifvery young. The newborn look com-pletely different than a one year old. Itis really hard to optimize yoursequences. But with this system, youcan do it afterwards, with the brainsequence, for example, and get youroptimum settings. And instead of tendifferent specs, you only have to lookat one. It’s easier to compare the oldstudy with the new study. So itbecomes faster and safer for thepatient; you can never forget animage. With the absolute numbers it iseasier to compare a patient over timeor to send the data to another hospitalwith completely different software andcompletely different scanners, andhave the same results.’

In clinical use, radiologists haveseen patients’ examinations double innumbers, which of course, he pointed

Radiologists are set to gain new control of images

FROM HEAD TO TOEPhilips high performance CT opensup new possibilities in diagnostics

It’s diversified but preciseAlong with paedi-atric radiology, inter-ventional radiologywill have a high pro-file at the 89thGerman RadiologyCongress and 5th

Joint Congress with the AustrianRadiology Society. During a discussionwith Meike Lerner of European Hospitalcongress president Professor DierkVorwerk (above) outlined what’s onthe agenda for the expected 6,900 visi-tors.

Training, he pointed out, will aim atthose preparing to specialise in radiolo-gy. ‘In addition, we’d like to familiarisenon-radiologists (e.g. general practition-ers) with radiological results.’

International exchange will also bepromoted; guests at this year’s congresswill come from France, Korea and Turkey.

Asked about recent developments ininterventional radiology, Prof. Vorwerkobserved that the field is split into twoareas: vascular and non-vascular inter-vention. ‘In the first, there has been par-ticular progress in therapy for vessels ofthe lower leg. We can now interveneright down to the ankle. Initially, theproblem was how to cover the long dis-tance with a catheter, and also the ves-sels are very thin there. New develop-ments now allow us to treat these indi-cations with a high rate of success and,as the case may be, prevent amputation.

‘Developments in neuro-interventionin the invasive therapy for strokes,where we can significantly reduce theseverity of an event, are also worth par-ticular mention. There have always beenefforts to keep the damaged brain areasas small as possible, which used to bedone exclusively with medication –requiring a certain amount of treatmenttime. Now, we have mechanical proce-dures, intravascular and angiographic,to reduce a thrombus. Interventionaltherapy is usually combined with subse-quent lysis therapy. Therefore, we cantreat a stroke much faster and, as thecase may be, more successfully. All in allthese innovations in the vascular fieldare based on the development of new,more stable and thinner materials,’ heconcluded.

Interventional oncologyIn the non-vascular field, anothertopic of interest is interventionaloncology, which is also partly carriedout through the vessels. ‘In interven-tional oncology there is no surgery,or systemic chemotherapy to shrinkand destroy a tumour. Currently, thistherapy is focused on the liver, butincreasingly also on the lungs, kidneyand adrenal gland. Tumours on theseorgans are treated with physicalmedia, with access through the skin.What we mean by physical media areparticularly heat and cold; both candestroy tumours. We generate heatthrough microwaves, but primarilythrough radiofrequency ablation.

‘This treatment can be combinedwith medical therapy, where small“submarines” take chemotherapeu-tics to tumour locations, so systemicchemotherapy is not needed, and theeffect is exclusively directed at atumour. We can also treat a tumourradioactively in this way, so that itsroutes of supply are interrupted andthe carcinoma is destroyed throughradiation. This is called SIRT therapy,which is now covered by medicalinsurers.

‘With these procedures it remainsto be seen how often they can beused and which kinds of tumourshould be treated. Several studiesare aiming to find answers to thesequestions.’

At the congress, the professor saidradiologists and vascular surgeonswill discuss ways to optimise vascu-lar disease therapies, e.g. by settingup vascular treatment centres. ‘Asradiologists we see our main task isin the diagnosis of these diseasesand in providing minimally invasivetherapy. Surgeons undertake difficultvascular surgery, which is becomingincreasingly challenging. Vascularsurgery must keep up with theincreasing demand, and meet it com-prehensively. The entire field of inter-ventional radiology will remain excit-ing and the congress offers a forumwhere the current state of affairs andfuture developments will be dis-cussed.’

3-D cardiac and lung tissue image

Scans: legs, whole body, head and chest, head only

out, has led them to say they havemore work to do. ‘But we can alsohelp them a lot by pre-processing. Weprovide all these numbers and warn-ing images for diseases. If it says zero,all the images were black, for exam-ple. If it says 20 percent then youknow there’s something there. We caneven try to code clustering and thentry to assign some sort of illnessbefore you actually see the image.There are a lot of possibilities. This isthe future. I think we will integrateplug ins, because you should have allof the possibilities to change every-thing on the PACS viewer, but notchange your scanner.’

Sectra’s next-generation PACSDr Persson divides his time 50-50between medical and technicalresearch. He is very involved in thedevelopment of Sectra’s next-genera-tion PACS, IDS7, a web-based PACSsystem that presents a new way tohandle very large data sets. Thanks toa fresh approach in image content andtransfer, radiologists can reviewimages in a matter of seconds. Thiswhole solution is built with the data

explosion in mind. Even when imageseventually reach terabyte-size, only rel-evant information will be transmitted.

Before this, these large datasetscould only be viewed on modalityworkstations. With Sectra’s patent-pending technology transferring thevolumes to the usual PACS worksta-tion is no longer an issue. . ‘Now, youdon’t need to “shake hands” withevery slice that comes over the net-work. You do it once, then the wholevolume loads. If you want to see theskeleton, you can only pick that upfrom the archive. It saves a lot of time.We have worked with this for a verylong time. The system is being used byseveral customers, includingTelemedicine Clinic in Barcelona andSödertälje Hospital in Sweden.’

* Initiated by Linköpings University,Landstinget i Östergötland and SectraAB, the multidisciplinary Centre forMedical Image Science andVisualisation (CMIV) conducts researchto provide methods and tools to meetfuture clinical needs in image analysisand visualisation.(http://www.cmiv.liu.se/)

The new Philips 256-sliceBrilliance iCT came in to userecently at the UniversityHospital in Ulm. The system

produces quick, high-res scanswith 80% less radiation. The pin-sharp images promise newpossibilities for cardiac diagnosisand treatment, as well as researchinto severe cardiac disease. ‘Wenow have state-of-the-arttechnology that will open up newopportunities in the clinical field aswell as in research,’ said ProfessorHans-Jürgen Brambs.

‘The 256-slice will be primarily acardiac scanner for us,’ explainedDr Martin Hofmann, head of thehospital’s radiology department.‘Speed and resolution are of equalimportance for the quality ofexamination results. These twocomponents will enable us toachieve fast, reliable diagnoses.’

As the heart moves continuously,an examination scan used to becarried out during the ‘quiet’ phase,based on ECG readings, whichprevented motion artefacts on theimages. However, cardiac imageacquisition is now so fast that goodclinical results at the lowestpossible dose can be achievedeven at high cardiac rates. In thefuture, the accurate display ofunprecedented details of thecoronary vessels will be possible— and it will even be possible torecognise the circulatory phasesof the myocardial tissue.

With the Brilliance iCT scannerradiation exposure for the patientis up to 80% lower than withsystems used today. This is poss-ible, among other reasons, due tothe high speed of the equipment,so the patient is exposed for muchshorter periods of time, andbecause of the highly sensitivedetector, which is better able torecord image data and can processthem at lower doses.

To meet the increasinglycomplex clinical specifications,Philips engineers completelyredesigned the CT platform. Thisincluded a novel type of X-raytube, a specially developed

30 April - 4 MayBerlin, Germany

Interventional radiologyIN FOCUS:

Apelem has launched the BACCARA dRF43 remote controlled table, featuring a fully digitaltwo-in-one flat panel detector. This combines high spatial resolution and fine detail forgeneral radiographic and skeletal examinations and has the capacity to acquire fluoroscopicsequences with a rate of up to 30 frames per second for GI procedures and DSAapplications, the manufacturer reports. ‘By drawing on our experience in the domain of flatpanel detectors, first with the Paladio (world’s first full field flat panel detector with dynamicimages) and more recently with the Rad Flat Panel detectors featured in our Da Vinci

product range, Apelem has developed a full integration of each elementincluded in the BACCARA dRF 43 system, which greatly reduces thenumber of steps required to obtain a successful procedure.

All the parameters on both the Magnum generator and the Baccaratable are automatically set according to the appropriate examination

programme selected from the RIS code.The system provides real time fluoroscopy, up to 30fps; up to 18 fps in

full field fluoroscopy (43 x 43cm); up to 12 fps in radiography; high QDEand extended dynamic (16 bits) detector. In addition, the Thales Pixium

detector presents significant dose reduction.

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R A D I O L O G Y

In a pre-congress discussion withEuropean Hospital, Joint CongressPresident Professor RichardFotter (right) explained why pae-diatric radiology will be a subjectof special interest at the event.‘One of the topics will be the fluenttransition from paediatric radiologyto adult radiology. Due to out-standing medical care, patientswith severe and complex congeni-tal diseases now have lifeexpectancies that often go farbeyond middle age. This meansthat adult radiology is confrontedwith medical issues that differ sig-nificantly from the usual issues anddiseases in adult radiology,’explained Prof. Fotter. ‘The firstgeneration of those children whounderwent highly complex correc-tive heart surgery are now of adultage. They currently make up 80%of patients who present with con-ditions after Fallot’s Tetralogy.Paediatric radiologists therefore donot exclusively care for childrenand adolescents but also adults, i.e.those with congenital diseases andtheir secondary complications.

‘MRI and CT have becomeinvaluable tools for the follow-upand planning of further correctivesurgery, along with ultrasoundscanning,’ he pointed out. ‘As pae-diatric radiology is familiar withpathology, pathophysiology andcorrective surgery, by way of itsspecial qualifications it is increas-ingly assuming responsibility for

detector and unique, pneumaticsuspension technology for theimaging components that rotatearound the patient. ‘The specificallydeveloped suspension technologycan be compared with that used inhovercrafts,’ explained Dr GeraldPoetzsch, who heads the CTbusiness sector at Philips. ‘This isthe only technology that allows thegantry, which weighs several tons,

GE’s portable ultrasoundsystems check USA’s

Olympic athletes

As the opening of theBeijing 2008 OlympicGames nears, the USOlympic Committee

(USOC) and the General ElectricCompany (a Worldwide Partner ofthe Olympic Games) are runningtwo research programmes aimedat demonstrating that healthmonitoring and early interventionleads to injury prevention andenhanced health and sportsperformances for athletes.

These studies are continuationsfrom research at the Torino 2006Olympic Winter Games. The first isto focus on cardiac clinical

efficient energy use at rest and arobust response to demands ofexercise. In other words, theseathletes had an enlargement ofthe cavities of the heart andbetter function of the heartcompared with others of thesame age and gender.’

To confirm Torino results, thecurrent research programme willstudy athletes from thetraditionally recognised high-intensity sports, and comparedifferences in heart function andenergy use with enduranceathletes, as well as from thegeneral population.

The remote-controlled table with digital flat panel detector

30 April - 4 MayBerlin, Germany

the imaging re-quirements ofthese adult pati-ents. This meansthat paediatricradiology needsto be partly rede-fined. The Ger-man Radiology

Congress will pick up on this issueof changing definitions and respon-sibilities.’

Asked what technologicaladvances for paediatric radiologyare of particular interest, Prof.Fotter said that it is important topoint out that paediatric radiologydoes not define itself via equip-ment and technology as is oftenand increasingly happening inadult radiology. ‘Paediatric radiolo-gy is defined through the perceivedrequirements of children and ado-lescents whose inviolacy is of out-standing importance. New tech-nologies and procedures must beseen as instruments to be usedaccording to requirements. Thebasis of each use of established ornew imaging procedures is optimi-sation with regards to exposure toradiation and invasiveness. Thequality of results must be adaptedto the respective medical issue.Ultrasound, MRI, CT and digitalimaging procedures are in the fore-ground of developments. We are atthe brink of the clinical introduc-tion of the first 320-slice CTs. Thevolume acquisition promises signif-

icant advantages for the examina-tion of children and adolescents.The acquisition of large volumeswith a single rotation will allowus to achieve outstanding imagequality and three-dimensionalreconstructions of the highestquality with a lower dose com-pared with Spiral-CT.

‘In MRI, apart from whole-bodyMRI, which is due to be combinedwith diffusion technology, weneed to mention MRI of the heartand the large vessels, foetal MRIand MRI of the urinary tract in thenewborn, children and adoles-cents. The latter will replacenuclear medical procedures in themedium term and will make IVurography and CT examinations,for this purpose, obsolete. Weshould also mention MRI in chil-dren combined with ultrasoundprocedures, because these pro-vide an almost complete alterna-tive to the invasive DSA [digitalsubtraction angiography].However, fMRI to capture addic-tive behaviour in adolescents witheating disorders, and AdvancedMRI for the musculoskeletal sys-tem, are also of particular impor-tance. Particular emphasis here ison diffusion- and perfusion imag-ing for certain diseases such asPerthes disease.’

The 89th German Radiology Congress and the Joint Radiology Congressof the German and Austrian Radiological Societies

to rotate around the patient fourtimes per second. The resultingcentrifugal forces, which affect theindividual components, areenormous. At this high speed ofrotation, one ton of weight turnsinto 35 tons – comparable with theweight of a large truck.’

Thanks to the combination ofthese new developments it is nowpossible to achieve detailed and

clear images of an entire organwithin seconds, including those ofthe heart and brain, and long-termmutations can also be detected ata very early stage. Apart fromcardiac examinations, the iCT inUlm will also be used for clinicalresearch on other organs. ‘Thecombination of morphological,angiographic, dynamic andfunctional imaging opens up newpossibilities,’ said Dr Hoffman. ‘Wehope that the system will facilitatesignificant progress in the fastdiagnosis of strokes and in thehighly sensitive detection ofinternal bleeding in seriouslyinjured accident victims.’

The new Philips 256-sliceCT scanner Brilliance iCT

Hans-Jürgen Brambs Martin Hofmann Gerald Poetzsch

NEW

research, involving the USA’sOlympic athletes and hopefuls inmen’s rowing and theweightlifting teams. The secondwill monitor the musculoskeletalhealth of USA athletes competingin weightlifting, boxing, wrestlingand in the Women’s NationalSoccer Team.

‘Every day an Olympic athletespends in rehab is a day lost intraining, making earlier injurydiagnosis and real-time recoverymonitoring crucial for eliteperformance,’ explained DrMichael Reed, US OlympicCommittee Medical Director in thePerformance Services Division. ‘Asa National Olympic Committee,it’s important to have the mostinnovative tools to help predict,diagnose, treat and monitorsports injuries earlier and ensurea quick return to play. It’s mybelief that GE’s ultrasoundtechnology will become astandard tool in healthcare forathletes.’

The Cardiac ResearchProgramme Led by Malissa Wood, of theMassachusetts General HospitalHeart Centre (MGH) in Boston, theresearch team is using GE’s Vivid i– an advanced, miniaturisedcardiovascular ultrasound system– to examine athletes’ hearts pre-and post- rowing andweightlifting competitions, tolearn more about the function andperformance of highly-conditioned hearts.

For Dr Wood, the programme isongoing; she partnered with theUSOC and GE Healthcare to studythe hearts of the USA’s short trackspeed skaters for the OlympicWinter Games in Torino. So far,study results have indicatedspecific changes in heart functionthat correlate to different levelsof training. According to Dr Woodand Dr Michael Picard from MGH,those Torino results proved‘…participation by world-classspeed skaters in a vigoroustraining regimen results incardiovascular anatomic andphysiologic adaptations. Thesechanges, including cardiacchamber dilatation, enhancedventricular diastolic function andattenuated resting right ventriclesystolic function, are likelyadaptive and allow for more

Focus: point-of-injury diagnosisThe second clinical study, led byDrs. Marnix T van Holsbeeck, TonyBouffard and Scott A. Dulchavskyof Henry Ford Hospital in Detroit,Mich., centres on improving theoverall musculoskeletal health ofathletes on the field.

The research will focus on hip,shoulder, ankle and knee regionsand, similar to efforts in Torino (USwomen’s hockey team) they willinvestigate whether taking healthybaseline scans of athletes helps todetermine the extent of futuresports injuries, quicker and moreprecisely. For the Beijing Olympics,the Henry Ford investigators wantto assess whether changes inligaments, cartilage and muscleseen before the Games may havean effect on the athletesperformances during the Olympics.

According to Dr van Holsbeeck,ultrasound can highlight problemswith structure and mobility oftissues that no other examinationtechnique can show. Theresearchers are using GE’s LOGIQ i,a lightweight, portable ultrasoundsystem that enables real-timediagnosis. Designed for a modern,all-digital healthcare environment,LOGIQ i allows shared informationfor consultation and electronicarchiving. ‘Having a tool that canaccurately and immediatelydetermine the severity of an injurygives the sports physician theability to determine if an athletecan continue to compete in timecritical situations. It also can beused to guide training andrehabilitation after injuries,’ DrDulchavsky pointed out. ‘This studyempowers athletes and doctors totake a proactive approach withtheir health, potentially preventinginjuries before they even occur. Ourability to use this technology, andto stream the images across theWorld using the Internet, will be anextremely valuable tool inexpanding healthcare capabilitiesnot only during the OlympicGames, but to communitieseverywhere,’ he added.

Initial results from both clinicalstudies are expected around theopening of the Beijing Olympics. GEalso expects to conduct similarathlete research programmes inother countries.Further details:www.usolympicteam.com;www.gehealthcare.com

16 EUROPEAN HOSPITAL Vol 17 Issue 2/08

C A R D I O L O G Y

Cardiology ‘must beevidence-based’ says ACCThe emphasis is on ‘wiser healthcare spending’

Ian Mason reports from Chicago

Research by European cardiolo-gists featured in presentationsat this year’s American College

of Cardiology (ACC) meeting, held inChicago. Many speakers gave a mes-sage equally relevant on both sidesof the Atlantic: the need for wiserspending of healthcare budgets.

The ACC keynote opening sessionset the tone with a snipe at the block-buster drug Vytorin (ezetimibe/sim-vastatin). An ACC expert panel rec-ommended that Vytorin should beused only after other cholesterol-lowering drugs have failed. The

elderly cardiac patients from a studyby Dr Nicolas Mansencal and col-leagues, Hôpital UniversitaireAmbroise Paré, Boulogne, France.Their ten year study of patients aged80 plus referred to a cath-lab foracute myocardial infarction (MI)showed that although these patientshad an early increased risk of mor-tality, once this acute phase hadpassed, prognosis at one year wasexcellent and was comparable withyounger patients (Abstract: 1024-78).

Hospital night shift risk tocardiac patients

The hospital night shift may be haz-ardous for coronary patients,

according to a study of 1,650patients in seven European coun-tries performed by Dr Zbigniew

Siudak and colleagues Departmentof Interventional Cardiology,Krakow, Poland. Their resultsshowed that STelevation myocardialinfarction (STEMI) patients treatedby primary percutaneous coronaryintervention (PPCI) during nighthours were less likely to survivecompared with identical patientstreated during the day shift. Nightshift admission was an independentpredictor of in-hospital death in

Further reports from the ACC 57th Scientific Session . . . . . . . .A five-year study of 516 participantswith coronary artery disease showedthat patients who reduced their anxi-ety levels or kept them steady were60% less likely to have a heart attackor die compared with those who hadincreased anxiety levels.

The association between anxietyand heart attack remained afteradjusting for other risk factors, such asage, gender, smoking, hypertension,diabetes, body mass and cholesterol,according to Yinong Young-XuPhD, of the Lown CardiovascularResearch Foundation, Brookline, Mass.‘Pay attention to your emotional well-being. If you are having anxiety ordepression, get treatment,’ hestressed.

Another trial found that smoking isthe greatest predictor of recurrent car-diac events. Young heart attack vic-tims who continue to smoke are threetimes more likely to have a secondheart attack as those who quit smok-ing, said John Lekakis MD, of theUniversity General Hospital Attikon, inAthens, Greece.

The study of 135 patients under 35years showed that ejection fractionand smoking were equal risk factors.95% of the subjects were smokers. Ofthose, 50% continued to smoke afterthe first heart attack while the other50% quit smoking. In the first group,50% then had a second heart attack.Of those who quit, only 18% suffereda second heart attack. ‘The persistenceof smoking is the most powerful pre-dictor of a heart attack,’ Dr Lekakissaid.

Other research shows that men are

at greater risk than women for cardio-vascular problems. That difference dis-appears when the subjects are morbid-ly obese, noted Luigi Biasucci MD, ofthe Catholic University in Rome.

A study of 71 healthy patients withno signs of diabetes or heart diseasedivided the subjects into two groups.Group 1 involved 48 patients with abody mass index (BMI) of 20 to 39.9.Group 2 had 23 obese patients with aBMI of 40. In group 1, carotid plaquesand hypertension were significantlylower in females than in males. Ingroup 2, no significant differences werefound.

Vascular protection deviceevaluated

The Society of CardiovascularAngiography and Intervention (SCAI)were holding its Annual ScientificSession in conjunction with the ACCcongress. The late breaking clinical tri-als sessions presented studies relatedto acute myocardial infarction and per-cutaneous coronary intervention (PCI).

The Angioplasty Balloon-AssociatedCoronary Debris and the EZ FilterWire(A-F) study evaluated the use of a vas-cular protection device during PCIamong patients with no ST-elevationacute coronary syndromes at high riskfor embolisation. In this study, the useof the filter during PCI was not associ-ated with any differences in in-hospitalmajor adverse coronary events (MACE)or post-procedure markers of myocytenecrosis compared with conventionalPCI without the filter.

PCI is associated with myonecrosis inabout 25% of patients with acute coro-

nary syndrome. Distal embolism of ath-erosclerotic plaques or thrombi is a fre-quent cause, said Mark WebsterMD, from the cardiac catheterisationlab at Auckland City Hospital, NewZealand.

The high-risk clinical features of thepatients included elevated troponinlevels, angina at rest and dynamic ST orT waves.While 42% of the patients hademboli recovered by the device, the useof the filter did not significantly reducein-hospital MACE (11.7% with thedevice v. 9.5% for the control group) ormyocardial damage.

Several procedural factors are pre-dictors of early stent thrombosis. Themost important predictor is residualdissections, said StephanWindecker MD, of Bern UniversityHospital, Switzerland. Other predictorsinclude bifurcation stenting and longerstent length. Studies indicate thatbifurcation stenting is associated withan increased risk of stent thrombosis.‘With each centimetre of stent lengththe risk of early thrombosis increasestwofold to threefold,’ he pointed out.

To avoid these procedural problems,he advises avoiding stent overlaysbecause they are associated withincreased inflammation. He also sug-gests using stent platforms that pre-vent bifurcation and using a variablestent that prevents implanting overlylong stents.

Premature discontinuation ofantiplatelet therapy is shown to placepatients at high risk for stent thrombo-sis, he said. Deaths were likely to occurwithin the first 90 days of discontinua-tion of antiplatelet therapy.

Young doctors’enthusiasm produces avaluable source of dataon cardiac interventions

The German MRI QualityRegister resulted fromcooperation between theDepartment of Cardiology

(headed by Professor UdoSechtem) at the Robert BoschHospital in Stuttgart and theElisabeth Hospital in Essen(Headed by Professor GeorgSabin). The Institute of MedicalInformatics and Biomathematicsat Heidelberg University inLudwigshafen, collects the data,and Heiko Mahrholdt MD, inStuttgart, and Oliver Bruder MD,in Essen, are responsible forkeeping the register.

In an interview with Daniela

Zimmermann of European

Hospital, Dr Bruder explainedthat The Institute for Heart AttackResearch at HeidelbergUniversity, in Ludwigshafen,supervises cardiac studies all overEurope via a protected, onlineentry system for all participatingcentres, and then statisticallyevaluates all the collected data forthe Cardio-MRI Quality Register.‘The main objective is todocument who carries out whattype of MRI in Germany incardiology. There are furtherquestions, such as what is thequality like, how safe is theprocedure and which therapeuticconsequences result from thefindings of these examinations.What surprised us quite a lot wasthat, during the pilot phase, in thefirst year we already had 15centres with more than 2,500patients participating after only

one e-mail request. This isremarkable because the number issignificantly higher than forregisters that are paid for perpatient.’

Asked who, apart from medicalinsurers, needs this information, DrBruder pointed out that thestatutory medical insurers are ‘onlyinterested because the MRIworking groups are all quite young,very active and very motivated.They are interested in theprocedure itself, which is notsomething that can always be saidfor other registers. These youngdoctors enter the information intheir spare time, they don’t minddoing it. They want to know whocarries out MRI, how it is done andwhat the results are. For instance,we can see how many cardiaccatheterisations don’t need to becarried out because of MRIdiagnostics, and which additionaltype of diagnosis is required afterMRI examinations. And we canalso see if anything untowardhappens. We work withoutexposure to radiation but usepharmacological stressors such asMRI contrast media for instance.This is an area where we areparticularly interested in the safetyaspect. We have realised that theacceptance of the register is high,that the safety is high and that thetherapeutic consequences are verycomprehensive: only a minority ofexaminations has no immediatebenefit.

‘In the second phase of theregister we would like to transformthe whole project into a prognosticregister, having confirmed in phaseone that MRI is being used sensiblyacross Germany. During thissecond phase we’d like to gainprognostic data and to find out ifthe clinical path, such as carryingout a stress-MRI, for example, andthen not proceeding with a cardiaccatheterisation if there are nosuspect findings, or to proceedwith it if the stress MRI shows uppathological results, is the rightway of doing things. We will beable to do this as we should havedata about the one-year prognosisby then, and much as with othermethods, we should be in aposition to gauge whether patientswith inconspicuous stress-MRIshave a good prognosis or not. Wethink they do, but so far we havenot been able to confirm this withlarge numbers of data.

‘So the register will ensure thatthe procedure, which is already

Quality reporting

ACC’s broadside followed disap-pointing results from the ENHANCEstudy in which the addition of eze-timibe to simvastatin did not slowprogression of atherosclerosis.

The take home message was sim-ple: ‘We need to turn back to statins,’said Dr Harlan Krumholz, YaleUniversity School of Medicine, whoargued that ENHANCE shouldchange clinical practice by encour-aging physicians to return to evi-dence-based medicine – which forhim meant more use of statins andless use of ezetimibe.

Elsewhere at the ACC meetingpositive evidence was forthcoming;results from the ONTARGET studyadd the angiotensin II receptorblocker telmisartan (Micardis) to thegrowing list of cardiovascular drugswith hard clinical end-point data.

Lead investigator Professor Salim

Yusuf, McMaster University,Hamilton, Canada, said the resultsshowed telmisartan (80mg/day) tobe as effective as the ‘gold standard’ACE inhibitor ramipril (10mg/day) inreducing the risk of cardiovasculardeath, myocardial infarction, stroke,and hospitalisation for congestiveheart failure in the high risk popula-tion studied (over 55 years withcoronary heart disease or diabetes).

ONTARGET also examinedwhether combining telmisartan withramipril was superior to ramiprilalone. Despite the combination low-ering blood pressure more thanramipril, there was no additionalbenefit on the primary end-point,and a higher rate of hypotension-related side effects with the combi-nation.

Treat elderly hypertensivesThe Hypertension in the Very Elderly(HYVET) Trial gave a clear answerto the question of whether veryelderly people with hypertensioncan expect the same benefits fromblood pressure lowering as youngerpatients. Treatment with indapamidesustained release (SR) 1.5mgreduced deaths by 21%, fatal strokesby 64% and cardiovascular events by34%. Lead Investigator Professor

Christopher Bulpitt, ImperialCollege London said the results weregood news in light of the growingnumbers of people living beyond 80.

‘Elderly individuals with sustainedsystolic blood pressures of 160mmHg or more should now beappropriately assessed and treatedin accordance with the new find-ings,’ said Dr Nigel Beckett, the trialcoordinator at Imperial CollegeLondon.

There was further good news for

multivariate regression analysismodel (OR 1.47, 95%CI 1.11-1.94,p=0.007) (Abstract: 1017-54).

Trends in the use of drugeluting stents

The publication of data about riskof late stent thrombosis associatedwith drug eluting stents (DES) andassociated guidance from NICE(National Institute for Health andClinical Excellence) has led to a sig-nificant fall in the use of DES in theUK, according to a study reportedby Dr Sunil Nadar and colleaguesGregory Lip City Hospital,Birmingham, UK. However use ofDES remains high for complicatedlesions such as birfurcation lesions,and chronic total occlusions(Abstract: 1026-143).

Daniela Zimmermann and Dr Oliver Bruder

EUROPEAN HOSPITAL Vol 17 Issue 2/08 17

N E W SC A R D I O L O G Y

The Czech Republic’s first cardiac trans-plant took place in 1984; now about 40take place annually. The country’s firstlung transplants began ten years ago;to date around a hundred have beenperformed by Professor Pavel Pafko andcolleagues at the Motol FacultyHospital, in Prague.

Last November, Professor Jan Pirkand team, at the Institute of Clinicaland Experimental Medicine (IKEM) inPrague, performed the country’s firstsuccessful heart/lung transplant.

The 49-year-old female patient suf-fered serious lung damage due to aninherited heart disorder. By 2000, aheart/lung transplant was necessary —but not possible in the CR.

At the end of last year, due to exten-sive cooperation between Austrian spe-

widespread, will be establishedwithin clinical routine evenfurther. We will be able to deliverrelevant data regarding safety. If,thanks to industry, we canincrease the number of patientscaptured by the register to 10,000and can then confirm that 9,000 ofthese had inconspicuous stress-MRI results with an excellentprognosis, this would be a clearreason why these patients shouldnot have to undergo cardiaccatheterisation. However, thesedata are currently not availablefor any of these examinations.Achieving this would constitute areal milestone, something that wehave all been waiting for — andthis can only be achieved throughmulti-centre studies, or registers,because they deliver the numbersand registers deliver theobjectivity, because they are takenstraight from daily, clinicalexperience.

‘The results will have an impacton medical insurers, and others,but mainly on hospitalmanagement and on clinicalpathways. This procedure is notso catchy and cannot be describedwith statements such as ‘We will

carry out fewer cardiac

catheterisations’ or ‘We have a

machine that replaces all this’.What we can say is that we have asystem that can excellently carryout risk-stratification and cansteer patients away from, or to,cardiac catheterisation in a muchmore controlled manner.’

For MRI, he said, from ascientific viewpoint they aremainly interested in twoprocedures: late enhancement,which can show the accumulationof contrast media within scartissue of the myocardium. Firststudies have shown that imagingthis scar tissue – possible in thisway and with this type of spatialsolution only with MRI – is farsuperior to other prognosisparameters, such as heart musclefunction and impairments ofmyocardial wall motility. This isone aspect that we can nowdemonstrate on a grand scale: ascar is more important thanfunction and is an independentprognostic parameter.’

The second interest is inischaemic diagnostics using thestress-MRI. ‘What we can show isthat inconspicuous stress-MRIresults constitute a goodprognosis, and that those patientsdon’t really need cardiaccatheterisation, because their lifeexpectancy is the same as forthose with a healthy heart.Nuclear medicine has problemswith radiation exposure; there isprognostic data for many patientsfrom registers, which show whatwe are now trying to prove withMRI. But we can then offer aprocedure that doesn’t involveexposure to radiation, which wecan repeat however often wewant, without endangering thepatient. This is a very importantpoint. Also, nuclear medicineworks with a spatial solution thatis 30 to 40 times worse than ours.We are interested in the hard factsregarding circulation. What is theprognosis after one year – arethere problems with circulation,yes or no. Is there a scar – yes orno. Large/small scar – yes or no.

These are very simple questions.But the difference is whether youare looking at 5,000 patients or just100. This is the point. The register,unlike a study, shows real world

conditions. Everyone is included,whether they are comparative ornot. Most studies state somethinglike, patients under the age of so-and-so, or over the age of so-and-so were excluded, obese patientswere excluded, women are oftenexcluded when studies involveradiation exposure and in the end

for the MRI Quality Registerconclusions are drawn for thegeneral public from a veryrestricted pool of studyparticipants. Registers aredifferent, amongst otherreasons because they are moreobjective and because thereisn’t anyone looking for and/ortrying to engineer particulardata. They are simply abouttotal numbers. And it seems tobe working, seeing how youngdoctors have enthusiasticallygot to work on it.’

First Czech heart/lung transplantcialists, IKEM and other selected physi-cians from the Thomayerova hospital,the Czech surgical team was present asresidents when the Czech patientreceived her transplant in Austria.Surgery lasted about eight hours, with-out unexpected events or complica-tions. Following a two-month in-patient stay, she was discharged inJanuary this year, with advice torestrict visits to public places. Shereturned to the IKEM cardiac centre forweekly checkups.

At the time of going to press, theIKEM was preparing for its secondheart/lung transplant. Estimates indi-cate that 2-3 patients annually willneed this operation in the CzechRepublic.Source: http://www.ikem.cz/www/

What if you couldaccess both an angiogram

and a chest x-ray in lesstime than it takes to read

this sentence?

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Learn more about our proven healthcare IT solutions at www.agfa.com/healthcare.

18 EUROPEAN HOSPITAL Vol 17 Issue 2/08

N E W S

Russian surgeons perform cardiacautotransplantation to treat giantleft atrium, severe mitral andtricuspid regurgitation

ADVERTORIAL Sponsored by

NUTRITION AND HEALTHAbdominal girth measurements exposecardiovascular riskCardiovascular diseases kill more than 12 million people worldwide everyyear and are the cause of death for more than 50% of all Europeans overthe age of 65. Numerous risk factors – such as high cholesterol level, highblood pressure, smoking, diabetes and, in particular, obesity - favour thedevelopment of cardiac disease. According to the World Health Organisation(WHO) in Europe alone 250,000 people die annually from cardiovasculardiseases as a direct consequence of obesity.

Severe obesity in particular, linked with an increased abdominal girth andwaist measurement (abdominal obesity), increases the risk of cardiovasculardisease. Numerous studies have confirmed that the fat cells within theabdominal tissue are very metabolically active and therefore particularlydangerous. They produce hormones and messengers that lead to thedevelopment of high blood pressure and metabolic problems such asDiabetes Type 2 and elevated blood lipids. These diseases are referred towith the collective term metabolic syndrome.

This is why it is important to assess the distribution of fat in a patient’sbody along with his body mass index as an accurate measurement of thenutritional status. The Waist to Hip Ratio (WHR) indicates the ratio betweenwaist and hip measurements. A WHR larger than 1.0 in men, or larger than0.85 in women, respectively, increases the risk of suffering a heart attack orstroke.

The seca 203 body measurement tape with its inbuilt WHR calculator is aneasy to use and reliable helper for the determination of the WHR.

The abdominal girth measurement on its own also has a high significanceand is becoming increasingly important in the latest research. Measurementsof more than 88cm in women and more than 102cm in men are consideredvery alarming.

As a matter of principle, affected patients are advised to reduce their bodyweight and therefore their abdominal girth measurements. The secamultifunctional scales with a maximum capacity of 300kg are well equippedfor weighing obese patients. These scales can indicate even the smallestsuccess when it comes to weight loss as they measure weight in 100g steps.This can help to motivate patients to continue on the right path and toimprove their health.

DIABETICS ANDDRUG-ELUTING STENTSBoston Scientific Corporation hasannounced results from a pooledanalysis of patients from its TAXUS IVand TAXUS V randomised clinical trialsto compare the safety and efficacy ofthe TAXUS Express Paclitaxel-ElutingCoronary Stent System in diabeticversus non-diabetic patients.

The company reports that the resultsdemonstrate that despite the knownincreased rates of mortality and resteno-sis for diabetics versus non-diabetics inpatients with cardiovascular disease, theTAXUS Stent had comparable levels oflate loss and target lesion revascularisa-tion (TLR) across these patient popula-tions. ‘The study also showed no signifi-cant differences in target vessel revascu-larisation (TVR), stent thrombosis, ormyocardial infarction (MI), after adjust-ments were made for differences in otherbaseline characteristics between patientswith or without diabetes.’ Analysis of thedata was presented by Gregg W StoneMD, of the Columbia University Medical

The European Association forPercutaneous CardiovascularInterventions Congress (EuroPCR)aims to draw together cardiologists,surgeons, radiologists, angiologists,industry and allied healthcare partners.

During a four-day course, covering coronary, peripheral, valve and non-coronary cardiac disease, cardiothoracic surgery and vascular surgery,cases will be transmitted live from 17 collaborating centres around theworld.

The educational sessions will cover ‘the fusion of the pedagogic skillsof experienced practitioners and input from younger practitioners’, theorganisers report. ‘These highly innovative and interactive sessions arebased on a step-by-step decision-making process.’ The focus will be oncoronary, carotid and patent foramen ovale percutaneous intervention.

Also in the programme will be sessions on tools, techniques ortechnologies that may make their way into mainstream practice — CTO,bifurcation, new DES and imaging, all again with live case transmission.

Centre, New York, at the SCAI AnnualScientific Sessions in Partnership withthe ACC/i2 Summit in Chicago.

The pooled analysis included angio-graphic outcomes at nine months andclinical outcomes at three years among338 diabetic patients and 901 non-dia-betic patients treated with the TAXUSStent from the TAXUS IV and V clinicaltrials. Nine-month angiographic out-comes showed equivalent in-segmentlate loss (0.27mm vs. 0.31mm, p=0.28)and binary restenosis (14.3% vs. 15.1%,p=0.83) in diabetics and non-diabetics,respectively.

‘The TAXUS IV/V diabetic subset dataindicated that the TAXUS Stent mitigat-ed the impact of diabetes as a risk fac-tor for restenosis following stenting pro-cedures in the patients studied,’ DrStone said. ‘Diabetic patients treatedwith TAXUS Stents compared with bare-metal stents had significantly improvedevent-free survival, particularly impor-tant in high-risk patients with diabetes.’

Among its many specialties, the

909-bed AZ Sint-Jan AV Hospital in

Bruges, Belgium, has a high level of

expertise in cardiac catheterisations

and electrophysiology.

One year after the installation of

the IMPAX Cardiovascular Suite –

an IMPAX Cardiovascular PACS and

Information Management Solution

from Agfa HealthCare, the hospitalreports that it has been integratedwith most of its information systems,including the HIS and IMPAXRIS/PACS. Next, the hospital will addECG (electrocardiogram) waveformsto the IMPAX CardiovascularSolution, which will take all its

Arrythmogenic remodelling of theleft atrium is a commoncomplication of atrial fibrillation,leading to severe haemodynamicdisturbances. Different methods ofleft atrium walls suture applicationare widely used as a surgicaloption for atriomegaly treatmentand sinus rhythm recovery. Thesetechniques may also beaccomplished by Cox-Mazeprocedure. Unfortunately, theseoperations, sometimes, are noteffective.

In such cases autotransplantationmay be an alternative.

Since 1984, a 60-year-old femalehad severe thyrotoxic craw andpersistent atrial fibrillation. Since2003, she experienced shortness ofbreath after minimal physicalactivity and oedema. In December2005, the patient was admitted fortreatment at the Federal AlmazovCentre in Saint-Petersburg, withsevere congestive heart failure

the AZ Sint-Jan AV was reported tohave the most technologicallyadvanced equipment in the region.However, Dr Luc Muyldermans,Head of Cardiology, observed:‘Cardiology exams were stored onDVDs. So when clinicians needed toreview a case, they had to walk tothe storage room, find the right diskand take it back to their

workstations. To tackle thesestorage and distribution problems,we decided to implement aCardiology Picture Archiving andCommunication System (CPACS)and Information Managementsolution.’

To give the Agfa HealthCareinstallation specialists the ability tothoroughly test the system, as wellas allow the medical staff to getacquainted with it, theimplementation was carried out ingradual steps. Early last year theIMPAX Cardiovascular Suite wasinstalled to store images fromcardiac catheterisation andangiography, which resulted in astrong efficiency boost. ‘Introducinga structured image database makesthe administration of images a lotsimpler,’ Dr Muyldermans nowpoints out, adding that the web-deployment feature of the IMPAXCardiovascular Suite also results ina better service between thiscentral hospital and referringhospitals.

AZ Sint-Jan AV Hospital inBruges adapts to the newIMPAX Cardiovascular Suite

EuroPCR 2008C A R D I O L O G Y

13-14 May, Barcelona, Spain

NYHA class IV. Massive combinedtherapy decreased NYHA class toIII. Echocardiograph data revealedsevere mitral, tricuspidregurgitation and dilatation of the

cardiac chambers: LA – 106x110mm, LA volume – 810 ml, LVEDD –69 mm, LVESD – 38 mm, EF – 75%,mitral valve annulus – 50 mm,tricuspid valve annulus - 48 mm.PA pressure was 68 mmHg.

In May 2006, the patient wasselected for cardiac auto-transplantation surgery. The

Dr LucMuyldermans

AZ Sint-Jan AV Hospital in Bruges, Belgium

The HeartStation ECG management system

cardiovascular modalities intoone overall solution. ‘Anothersignificant improvement to beimplemented shortly is thecomplete automation ofdepartmental stock managementand invoice handling. The resultwill be a complete paper-freeCardiology department.’

The cardiology department at

EUROPEAN HOSPITAL Vol 17 Issue 2/08 19

N E W SC A R D I O L O G Y

The 3rd Russian Congress ofInterventional Cardio-angiol-ogy, held in Moscow inMarch, showed a manifold

increase in the number of diagnos-tic and therapeutic endovascularprocedures on the heart and ves-sels; a significant improvement intheir quality, and highlighted theopening of new Russian centresproviding high-tech medical care.

‘We meet every three years toevaluate our real experience andnew opportunities,’ said ProfessorDavid Iosseliani, director of theMoscow City Centre ofInterventional Cardiology and headof the Russian Scientific Society ofInterventional cardiologists. ‘As youknow, the new horizons are openingin Russian healthcare. Recently thegovernment decided to create 25new vascular centres in differentRussian regions. This decision wasexplained by the terrible situationof high death rate (45% mortalitycaused by acute heart attack) butone that will present a big responsi-bility for our Russian physicians. Isinterventional cardiology the newdiscipline for Russia yet? This areain cardiology developed very quick-ly in Russia in the last 10 years, butmainly in Moscow and in Saint-Petersburg. We had 20 centres intwo capitals and 20 centres in therest of Russian regions. Now thissituation will be change, I hope.’

The Congress’ organisers aimedat a broader introduction of new

Olga Ostrovskaya reportsbypass time was 194 minutes;cross clamp time - 164 minutes.The early postoperative periodwas stable and withoutcomplications.

‘This case report demonstratesmodern opportunities for surgicalremodelling of left atrium,

RUSSIAN INTERVENTIONAL CARDIOLOGISTSREAL EXPERIENCE AND NEW OPPORTUNITIES By Olga Ostrovskayainterventional cardiology achieve-ments into clinical practice and atthe establishment of closer con-tacts with foreign colleagues toreduce a certain isolation of ourinterventional cardiologists fromthe rest of the world.

The sphere of problems dis-cussed by congress participantswas very big, including the influ-ence of patients’ gender on

restenoses development after coro-nary stenting for coronary heart dis-ease; the influence of coronarystent implantation pressure on earlyand long-term results of percuta-neous coronary interventions; thetransplantation of allogenic cells totreat dilatational cardiomyopathy;the modern possibilities of helicalcomputer tomography of vessels,and so on.

SurgeonMikeGordeev

One of the main plenary lecturesof the foreign specialists wasdevoted to the problem of selec-tion of drug-eluting stents (DrDavid Holmes). CardiologistKostas Spargias (Onassis CardiacSurgery Centre, Greece) reportedon that very complicated area inthe modern cardiology – bifurca-tion lesion interventions. Most ofthese vessels (about 8-15% of PCI

in leading centres) are complex(type C on ACC/AHA class) andrequire the use of more devices.He described the use of drug-elut-ing balloons and their potential inbifurcation.

At the end of the congress, theRussian Scientific Society ofInterventional Cardiologists an-nounced new, active BoardMembers.

complicated by valve disease. Thesuccess of this operation wasachieved by all our surgical team,using anaesthesia and bypassguidelines, postoperative intensivecare management and adequatesurgical technique,’ said leadsurgeon Mike Gordeev at theAlmazov Centre. ‘After six months,this type of surgery was imple-mented here once again. Ourteam has prepared for auto-transplantation for several years.In my opinion this method is morecomplicated than usual hearttransplantation. That’s why we cannow organise big hearttransplantation in our centre.’

David Iosseliani, Directorof Moscow City Centre ofInterventional Cardiologyand head of the RussianScientific Society ofInterventional Cardiologists

KostasSpargias, ofthe OnassisHeart Centrein Greece

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N E W S

20 EUROPEAN HOSPITAL Vol 17 Issue 2/08

At the German Congress ofCardiology, this March,Professor SigmundSilber, of the Cardiologyand Clinical Practice, inMunich, presented resultsfrom the Medtronic RES-OLUTE clinical trial. The dataindicated a low number of

adverse cardiac events and no protocol-defined stent thrombosis. The next-genera-tion Medtronic Endeavor Resolute drug-elut-ing stent system with new BioLinx polymer isdesigned to address the special needs ofpatients who have complex medical condi-tions and is engineered to match the dura-tion of drug delivery with the longer healingduration often required by these patients.

In clinical results at nine months, theEndeavor RESOLUTE trial showed no targetlesion revascularisation (TLR), no target ves-sel revascularisation (TVR) and a majoradverse cardiac event (MACE) rate of just7.0%. Of the trial’s 130 patients, 129(99.2%) received clinical follow-up, and 95

Medtronic’s newgeneration drug-elutingstents

C A R D I O L O G Y

France: Smoking ban lowers cardiacemergency admissions by 15%

By Gabriela EriksenThe French Health Authorities announced in Februarythat the smoking ban — which began in February 2007for communal buildings and work places, and wasimplemented in January 2008 with effect on bars,restaurants and hotels — has produced striking results.

Professor Bertrand Dautzenberg a thoracic specialistat the Pitié-Salpêtrière Hospital in Paris has followedthe effects of the new smoking laws for the FrenchMinistry of Health since November 2006. The projectImETS* measures the effects of passive smoking onhealth every month. They use 12 parameters, four foreach section, to measure changes in the exposure tosmoke (E), the evolution of tobacco use (T) and theeffects of smoking on health (S). This results in an over-all global score known as the ETS12 index.

In collaboration with occupational safety and health(médecin de santé du travail) figures have been com-piled on the number of workplaces where smoking hasbeen banned effectively from the premises. SinceJanuary 2007 the number of workplaces with no smok-ing has risen from 43 to 86%, interestingly only 75% ofhospitals seem able to comply with this law while 98%of offices have succeeded.

The amount of air pollution from fine particles in dif-ferent public areas is measured every month in exactlythe same place. In January 2008 the amount of pollu-tion in bars and restaurants was 75% less than thatmeasured in January 2007.

The effects of passive smoking are calculated fromthe number of patients seen by the emergency servicesfor myocardial infarction (heart attack) and the numberof strokes in people aged 65 or under. The statistics arebased on 100,000 admissions from a national panel of

32 large hospitals. Normally the number of admissionsfor heart attack and stroke in the under 65’s follows aseasonal pattern. A clear reduction in the number ofmyocardial infarction of approximately 15% and forstroke 12% is seen when comparing the numbers inJanuary and February 2008 with those from the twoprevious years.

That this effect is really due to the introduction of thesmoking ban in bars and restaurants will need to beconfirmed by follow-up over coming months. Furtherstudies will be carried out all over France to confirm thestrong decrease in smoking related deaths over time.However, these figures show a similar tendency tothose observed in Italy, Ireland and Scotland whenthese countries introduced bans on tobacco.

The European Society of Cardiology together withother health institutions continuously informs the pub-lic of the overwhelming evidence of the adverse effectof smoking on cardiovascular health. The EuropeanGuidelines on CVD prevention warn that smoking isresponsible for 50% of all avoidable deaths and thatsmoking causes heart attacks at any age. The fact thatsuch a rapid improvement in public health can be seenfollowing a smoking ban should encourage other coun-tries to implement their own bans as soon as possible.

However as a note of caution: the overall sales forcigarettes in France have remained stable since 2005,the new precautions put in place are to protect non-smokers from the effects of passive smoking and havehad no affect on the number of smokers. The figures forsales in January 2008 are no different from those in anyother year.

The French are still smoking, but outdoors!* indices mensuels tabagism passif: ExpositionTabagisme Santé

First bio-degradable implantsrepair cardiac defects in childrenThe Department for Paediatric Cardiologyat the University Medical Centre, atJohannes Gutenberg University, in Mainz,has extended its range of services forlower impact treatment

According to the birth register in Mainz,an annual 1.26% of newborns are diag-nosed with congenital heart defects, mak-ing these the most common malforma-tion. Left untreated they lead to limitedquality of life and shorter life expectancy.Up to a few years ago, the only remedywas complex surgery. However, todaymany congenital heart defects can betreated with minimally invasive, cardiaccatheter technologies, most often withthe help of implants. Since 2007, thePaediatric Cardiology Department at theUniversity Medical Centre Mainz, hasused the first biologically degradableimplant system for this. Advantages resultfrom the gentler, minimally invasive inter-vention, successful repair of the defect,and then the decomposition of theimplant, when, at the same time, thebody’s natural healing response replacesthe material with its own tissue.

Originally, implants available to repaircardiac septum defects were made fromnon-absorbable materials. Completeembedding into the body’s own tissueachieved an occlusive function after onlya few months and then made the implantitself redundant. However, as the materialcannot degrade and remains in place, itcan have side effects for the growing

body, such as chronic body irritation, anincreased risk of blood clots or evenfatigue fractures of the metal parts.

The new implant system is only tempo-rary; following its absorption and incorpo-ration into the tissue, it almost completelydisintegrates. This is particularly suitablefor children with a small- to-medium-sizeASD II (atrial septal defect) and for adultswith a PFO (persistent foramen ovale).However, these PFOs are often only dis-covered when the causes of strokes ormigraines are being investigated.

At the paediatric department, congeni-tal heart defects have been treated withcatheter technologies for over 10 years. Inthat period, more than 1,500 of proce-dures performed have eliminated openheart surgery. This includes defects of thecardiac septum. Over 400 patients under-went a minimum invasive defect repair.Led by Professor Christoph Kampmann,head of the department for congenitalheart defects at the University’s PaediatricClinic has successfully used the first avail-able, biologically degradable implant sys-tem since December 2007.

‘For more than 30 years there have beenattempts to repair atrial septal defectsminimally-invasively with catheter tech-nology. The new implant system is thefirst that almost entirely degrades follow-ing successful repair. This constitutes abreakthrough in the field of cardiaccatheter technologies,’ Prof. Kampmannpointed out.

ProfessorSigmund Silber

had angiographic follow-up. In-stent latelumen loss, the study’s primary endpoint,was 0.22 mm, while in-segment late losswas 0.12 mm. In-stent angiographic binaryrestenosis (ABR) was 1.0% percent and in-segment ABR was 2.1%.

‘What is most impressive about theseresults is that they occurred in a patient pop-ulation with complex and challenging char-acteristics,’ said Professor Ian Meredith,of Monash Medical Centre and MonashUniversity Melbourne, Australia, who wasprincipal investigator of the trial. He notedthat the average lesion length in the RES-OLUTE trial was 15.5 mm and nearly 82% ofenrolled patients were classified as havingchallenging B2/C lesions. ‘The RESOLUTEtrial enrolled a high percentage of patientswith lesions that are difficult to treat, includ-ing small vessels and long lesions, and theseresults are extremely promising. Zotarolimuscontinues to be a very potent drug in pre-venting restenosis while the new BioLinxpolymer appears to be delivering the drug asintended.’

Jane McDougall reports

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competact® 15 mg / 850 mg Filmtabletten. Zusammensetzung: Arzneilich wirksame Bestandteile: Eine Tablette enthält 15 mg Pioglitazon (als Hydrochlorid) u. 850 mg Metforminhydrochlorid. Sonstige Bestandteile: Tablettenkern: Mikrokristalline Cellulose, Povidon (K30), Croscarmellose-Natrium, Magnesiumstearat (Ph.Eur.); Filmüberzug: Hypromellose, Macrogol (8000), Talkum, Titandioxid. Anwendungsgebiete: Zur Behandl. des Typ 2 Diabetes mellitus b. Pat., insbes. übergewichtigen Patienten, d. unter einer oralen Monother. m. Metformin trotz der max. verträgl. Dosen keine ausreichende Blutzuckerkontrolle erreichen. Gegenanzeigen: Überempfi ndlichkeit gegen die Wirkstoffe od. einen der son-stigen Bestandteile; Herzinsuff. od. Herzinsuff. in d. Vorgeschichte (NYHA Klassen I bis IV); akute od. chron. Erkrankungen, die eine Gewebehypoxie verursachen können, wie Herz- od. respirat. Insuff., kürzl. aufgetretener Myokardinfarkt, Schock; Leberfunktionsstör.; akute Alkoholintox., Alkoholismus; diabet. Ketoazidose od. diabet. Präkoma; Niereninsuff. od. Nierenfunktionsstör. (Kreatinin-Clearance < 60 ml / min); akute Zustände m. dem Risiko einer Veränd. d. Nierenfunkt. wie: Dehydratation, schwere Infektionen, Schock; intravaskuläre Gabe jodhaltiger Kontrastmittel. Schwangerschaft, Stillzeit. Nicht emp-fohlen b. Pat. unter 18 Jahren. Nebenwirkungen: Pioglitazon in Komb. m. Metformin: Häufi g: Anämie, Sehstör., Gewichtszunahme, Arthralgie, Kopfschmerzen, Hämaturie, erek-tile Dysfunkt., Ödeme. Gelegentlich: Flatulenz. Pioglitazon Monother.: Häufi g: Infekt. d. oberen Atemwege, Hypästhesie. Gelegentlich: Sinusitis, Schlafl osigkeit. Selten: erhöhte Leberenzymwerte u. hepatozell. Dysfunkt. (ohne nachgewiesenen Kausalzusammenhang). Kann eine Flüssigkeitsretention m. Auftreten od. Verschlechterung einer Herzinsuff. her-vorrufen (häufi ger jedoch b. Komb. m. Insulin od. Pat. m. Herzinsuff. in d. Anamnese). Nach Markteinführung Berichte über Auftreten od. Verschlechterung eines diabet. Makulaödems m. Vermind. d. Sehschärfe unter Behandlung m. Thiazolidindionen, einschließl. Pioglitazon, Kausalzusammenhang unklar (ophthalmolog. Abklärung in Betracht ziehen, wenn Pat. über Stör. d. Sehschärfe berichten). Metformin Monotherapie: Sehr häufi g: gastrointest. Beschwerden w. Übelkeit, Erbrechen, Diarrhoe, Oberbauchbeschwerden, Appetitverlust (meistens zu Beginn der Ther.). Häufi g: Geschmacksstör. Sehr selten: Abnahme d. Vitamin B12-Resorption m. Senkung d. Vitamin B12-Serumspiegel, Laktatazidose, Hautreakt. w. Erythem, Juckreiz, Urtikaria. In Einzelfällen: Leberwertveränd. od. Hepatitis, die nach Absetzen v. Metformin abklingt. Bei der Langzeittherapie erhöhte Inzidenz von Knochenfrakturen bei Frauen berücksichtigen (2,6 % vs. 1,7 % unter Vergleichsmedikation in zusammenfassend. Analyse aus klinischen Studien von bis zu 3,5 Jahren).Vorsichtsmaßnahmen: Keine klin. Erfahrungen m. Pioglitazon in einer Dreifachkomb. m. anderen oralen Antidiabetika; auf-grund einer Kumulation v. Metformin kann, primär bei diabet. Pat. mit signif. Niereninsuff., eine Laktatazidose auftreten, bei Verdacht competact® absetzen u. umgehende stationäre Behandl.; Empfehlung d. regelmäß. Kontr. d. Serum-Kreatininspiegels, d. Leberenzymwerte u. d. Gewichtes (kann in einigen Fällen Symptom einer Herzinsuff. sein); b. Pat. m. erhöhten Ausgangs-Leberenzymwerten (ALT > 2,5 x Obergrenze d. Normbereichs) od. anderen Anzeichen einer Lebererkrankung competact® nicht einsetzen; Kann eine Flüssigkeitsretention m. Auftreten od. Verschlechterung einer Herzinsuff. hervorrufen. B. Pat., die durch das Vorhandensein mind. eines Risikofaktors (z. B. früherer Herzinfarkt od. symptomat. koronare Herzkrankheit) gefährdet sind, eine dekomp. Herzinsuff. zu entw.: Behandl. m. d. niedrigsten verfügbaren Dosis beginnen u. diese stufenweise erhöhen; Beobachtung d. Pat. (bes. jene m. red. kard. Reserve) auf Anzeichen u. Symptome einer Herzinsuff., Gewichtszunahme od. Ödeme. Nach Markteinführ. Berichte über Herzinsuff. bei Komb. von Pioglitazon m. Insulin od. b. Pat. m. Herzinsuff. in d. Anamnese; b. Verschlechterung d. Herzfunkt. competact® absetzen; gleichzeitige Gabe von Insulin kann d. Risiko eines Ödems erhöhen; wg. begrenzter Erfahrungen: Anw. bei Pat. über 75 Jahren mit Vorsicht; geringfügige Red. d. mittleren Hämoglobinwerte u. d. Hämatokrits als Folge einer Hämodilution mögl.; b. Komb. m. Sulfonylharnstoff: Risiko einer dosisabh. Hypoglykämie (evtl. Red. d. Dos. d. Sulfonylharnstoffs); die Ther. sollte 48 Stunden vor einem elektiven Eingriff unter Vollnarkose abgesetzt u. i. d. R. frühestens 48 Stunden postoperativ wieder fortgesetzt werden; vor od. zum Zeitpunkt einer intravaskulären Gabe jodhaltiger Kontrastmittel für radiologische Untersuchungen sollte die Ther. abgesetzt u. erst 48 Stunden danach, nach erneuter Überprüfung d. Nierenfunkt., fortgesetzt werden; bei polyzystischem Ovarialsyndrom Mögl. einer Schwangerschaft infolge d. verbesserten Insulinwirkung. Bei der Langzeittherapie erhöhte Inzidenz von Knochenfrakturen bei Frauen berücksichtigen (2,6 % vs. 1,7 % unter Vergleichsmedikation in zusammenfassend. Analyse aus klinischen Studien von bis zu 3,5 Jahren). Vorsicht b. gleichzeit. Anw. v. Cytochrom P450 2C8-Inhibitoren (z. B. Gemfi brozil) od.-Induktoren (z. B. Rifampicin): eng maschige Kontr. d. Blutzuckereinstellung, ggf. Anpass. d. Pioglitazondos. od. Änd. d. Diabe tesbehandl. Weitere Hinweise siehe Fachinformation. Dosierung: eine Tablette competact® 15 mg / 850 mg zweimal tägl. Die Einnahme von competact® mit od. unmittelbar nach der Mahlzeit kann die mit Metformin verbundenen gastrointest. Symptome reduzieren. Darreichungsform: 98 Filmtabletten (N2), 28 Filmtabletten (AP). Verschreibungspfl ichtig. EU-Zulassungsinhaber: Takeda Global R&D Centre Ltd., London, Vereinigtes Königreich. Kontaktadresse des pharmazeutischen Unternehmers in Deutschland: Takeda Pharma GmbH, Viktoriaallee 3–5, 52066 Aachen. Weitere Informationen erhalten Sie im Internet unter: www.takeda.de Stand: Oktober 2007

actos® 45 mg / actos® 30 mg / actos® 15 mg Tabletten Wirkstoff: Pioglitazonhydrochlorid. Zusam men setzung: Arzneilich wirksamer Bestandteil: 1 Tablette actos® 45 mg / actos® 30 mg / actos® 15 mg enth. 45 mg / 30 mg / 15 mg Pioglitazon als Hydrochlorid. Sonstige Bestandteile: Carmellose-Calcium, Hyprolose, Lactose-Monohydrat, Magnesiumstearat. Anwendungsgebiete: Behandl. des Typ 2 Diabetes mellitus. Monother.: b. Pat. (insbes. übergewichtigen Pat.), die durch Diät u. Bewegung unzureichend eingestellt sind u. für die Metformin wegen Gegenanzei-gen od. Unverträglichkeit ungeeignet ist. Orale Zweifach-Kombinationsther.: zus. m. Metformin: b. Pat. (insbes. übergewichtigen Pat.), deren Blutzucker trotz einer Monother. m. max. verträgl. Dosen v. Metformin unzureichend eingestellt ist; zus. m. einem Sulfonylharnstoff: nur bei Pat. m. Metformin-Unverträglichkeit od. Pat, bei denen Metformin kontraind. ist, u. deren Blutzucker trotz einer Monother. m. max. verträgl. Dosen eines Sulfonylharnstoffs unzureichend eingestellt ist. Orale Dreifach-Kombinationsther.: zus. m. Metformin u. einem Sulfonylharnstoff b. Pat. (insbes. übergewichtigen Pat.), die trotz einer oralen Zweifach-Kombinationsther. keine ausreichende Blutzuckerkontrolle erreichen. Komb. m. Insulin: bei Pat. m. Typ 2 Diabetes mellitus, deren Blutzucker m. Insulin unzureichend eingestellt u. b. denen Metformin aufgrund von Kontraind. od. Unverträglichkeit ungeeignet ist. Gegenanzeigen: Überempfi ndlichkeit gegenüber Pioglitazon od. einem d. sonstigen Bestandteile, Herzinsuff. od. Herzinsuff. in der Anamnese (NYHA I bis IV), eingeschränkte Leberfunktion, diabet. Ketoazidose, Schwangerschaft u. Stillzeit. Nebenwirkungen: Die Inzidenzen sind defi niert als: Sehr häufi g > 1 / 10; häufi g 1–10 %; gelegentlich 0,1–1 %; selten 0,01–0,1 %; sehr selten < 0,01 %; Einzelfälle: unbekannt (Inzidenz aus vorliegenden Daten nicht abschätzbar). Monotherapie: häufi g Sehstör., Infekt. d. oberen Atemwege, Gewichtszunahme, Hypästhesie; gelegentl. Sinusitis, Schlafl osigkeit. Komb. m. Metformin: häufi g Anämie, Gewichtszunahme, Kopfschmerz, Sehstör., Gelenkschmerzen, Hämaturie, erektile Dysfunkt.; gelegentl. Flatulenz. Komb. m. einem Sulfonylharnstoff: häufi g Gewichtszunahme, Benommenheit, Flatulenz; gelegentlich Glykosurie, Hypoglykämie, erhöhte Lactatdehydrogenasewerte, Appetitsteigerung, Kopfschmerz, Schwindel, Sehstör., Schwitzen, Proteinurie, Müdigkeit. Komb. m. Metformin u. einem Sulfonylharnstoff: sehr häufi g Hypoglykämie; häufi g Gewichtszunahme, Anstieg der Kreatininphosphokinase im Blut, Arthralgie. Komb. m. Insulin: sehr häufi g Ödeme, häufi g Hpoglykämie, Bronchitis, Gewichtszunahme, Rückenschmerzen, Arthralgie, Atemnot, Herzinsuff. Nach Markteinführung: Makulaödem (Einzelfälle; Inzidenz aus vorliegenden Daten nicht abschätzbar, Kausalzusammenhang unklar). Sonstige: Häufi g Ödeme, selten Fälle erhöhter Leberenzymwerte u. hepatozellul. Dysfunkt. (ohne nachgewiesenen Kausalzusammenhang), Häufi gk. ALT-Anstieg m. Placebo vergleichbar, n. Markteinführung selten Herzinsuff. (häufi ger jedoch b. Komb. m. Insulin od. Pat. m. Herzinsuff. in d. Anamnese). Bei der Langzeittherapie erhöhte Inzidenz von Knochenfrakturen bei Frauen berücksichtigen (2,6 % vs. 1,7 % unter Vergleichsmedikation in zusammenfassend. Analyse aus klinischen Studien von bis zu 3,5 Jahren). Vorsichtsmaßnahmen: Kann eine Flüssigkeitsretention m. Auftreten od. Verschlechterung einer Herzinsuff. hervorrufen. B. Pat., die durch das Vorhandensein mind. eines Risikofaktors (z. B. früherer Herzinfarkt od. symptomat. koronare Herzkrankheit) gefährdet sind, eine dekomp. Herzinsuff. zu entw.: Behandl. m. d. niedrigsten verfügbaren Dosis beginnen u. diese stufenweise erhöhen; Beobachtung d. Pat. (bes. jene m. red. kard. Reserve) auf Anzeichen u. Symptome einer Herzinsuff., Gewichtszunahme od. Ödeme. Nach Markteinführ. Berichte über Herzinsuff. bei Komb. von Pioglitazon m. Insulin od. b. Pat. m. Herzinsuff. in d. Anamnese; b. Komb. von Pioglitazon m. Insulin Beobachtung d. Pat. auf Anzeichen u. Symptome einer Herzinsuff., Gewichtszunahme u. Ödeme. Gleichzeit. Gabe von Insulin kann das Risiko eines Ödems erhöhen. Bei Verschlechterung d. Herzfunkt. Absetzen v. Pioglitazon. Aufgrund begrenzter Erfahrungen: Anw. bei Pat. über 75 Jahren mit Vorsicht. Seltene Berichte n. Markteinführ. über eine hepatozellul. Dysfunkt.: Empfehlung zur regelmäßigen Kontr. d. Leberenzyme. Engmaschige Kontr. des Gewichtes (in einigen Fällen kann eine Gewichtszunahme Symptom einer Herzinsuff. sein). Geringfügige Red. d. mittleren Hämoglobinwerte u. des Hämatokrits als Folge einer Hämodilution mögl. B. Komb. m. Sulfonylharnstoff od. m. Insulin: Risiko einer dosisabh. Hypoglykämie (Red. d. Dos. d. Sulfonylharnstoffs bzw. d. Insulins). Nach Markteinführung Berichte über Auftreten od. Verschlechterung eines diabet. Makulaödems m. einer Vermind. d. Sehschärfe (geeignete ophalmolog. Abklärung, wenn Pat. über Stör. d. Sehschärfe berichten). Bei der Langzeittherapie erhöhte Inzidenz von Knochenfrakturen bei Frauen berücksichtigen (2,6 % vs. 1,7 % unter Vergleichsmedikation in zusammenfassend. Analyse aus klinischen Studien von bis zu 3,5 Jahren). Bei polyzystischem Ovarialsyndrom: Möglichkeit einer Schwangerschaft infolge der verbesserten Insulinwirkung. Vorsicht b. gleichzeit. Anw. v. Cytochrom P450 2C8-Inhibitoren (z. B. Gemfi brozil) od. -Induktoren (z. B. Rifampicin): engmaschige Kontr. d. Blutzuckereinstellung, ggf. Anpass. d. Pioglitazondos. od. Änd. d. Diabetesbehandl. Nicht anwenden b. Dialysepat. Nicht empfohlen b. Pat. unter 18 Jahren. Enth. Lactose-Monohydrat u. sollte deshalb nicht v. Pat. m. seltener heredit. Galactose-Intol., Lactasemangel od. Glucose-Galactose-Malabsorpt. eingenommen werden. Wechselw. sowie weitere Hinweise: siehe Fachinformation. Dosierung: Beginn d. Behandl. m. Pioglitazon: einmal täglich 15 mg od. 30 mg. Stufenweise Erhöhung d. Dos. auf bis zu 45 mg einmal tägl. mögl. Bei Komb. m. Insulin kann die bisherige Dos. d. Insulins m. Beginn d. Pioglitazonbehandl. beibehalten werden. Bei Pat., die über eine Hypoglykämie berichten, Dosisred. d. Insulins. Darreichungsform: 28 Tabl. 45 mg / 30 mg / 15 mg (N1), 98 Tabl. 45 mg / 30 mg / 15 mg (N2), 50 Tabl. 45 mg / 30 mg / 15 mg (AP). (AP). Verschreibungspfl ichtig. EU-Zulassungsinhaber: Takeda Global R&D Centre Ltd., London, Vereinigtes Königreich. Kontaktadresse des pharmazeutischen Unternehmers in Deutschland: Takeda Pharma GmbH, Viktoriaallee 3–5, 52066 Aachen. Weitere Informationen erhalten Sie im Internet unter: www.takeda.de Stand: August 2007

15/850 mg

In competact ® steckt die Kompetenz von actos®, dem PROactive-Glitazon.

Nur 2 x täglich eine Tablette

=die Power von 30 mg actos® + Metformin

zu gleichen TTK wie actos® 30 mg.

Laun148x210+PflichtRZ.indd 1 25.04.2008 10:03:03 Uhr

EUROPEAN HOSPITAL Vol 17 Issue 2/08 21

N E W S

At this year’sCongress of theGerman CardiacSociety (DGK) inMarch, its PresidentProfessor GerdHeusch spoke ofthe increasinglyunfavourable con-

ditions for scientific work at Germanuniversity departments, which is jeopar-dising the reputation of cardiacresearch in this country. ‘Germany is theworldwide leader regarding researchinto saving the heart from infarctionand repairing it when an infarction hasoccurred. Important technological inno-vations — such as coated balloons andabsorbable stents — also originated inGermany. However, these achievementswere made by a generation ofresearchers who are now in their 50sand benefited from comprehensivetraining in the basics of cardiovascularresearch. However, due to deterioratingconditions at university departments,this type of training is now very rarelyoffered.’

Research constitutes an additionalburden, which is not rewarded withmore income. In fact, with the introduc-tion of the W salary scheme, salaries forprofessors were cut to 80%. Theremaining 20% are voluntary, perfor-mance-related payments awarded bythe 16 Bundesländer (federal states).However, individual states tend to seethis as an opportunity to save money,rather than to promote scientificresearch. ‘The result is that a Professorof Cardiovascular Medicine often endsup with the same salary as a teacher,’Prof. Heusch explained. A strike byresearch assistants at the universityhospitals did nothing to change this sit-uation: Although nurses were awardedbetter pay, remuneration of scientificactivities carried out by doctors and sci-entists was not increased.

Add to this, the fact that German lawdictates an upper limit for fixed-termcontracts and you have a situationwhere many experienced scientists whohave not quite made it to professor endup leaving universities to seek a futureaway from research.

Prof. Heusch concluded: ‘It is almostas if the entire system were designednow to destroy the enthusiasm forsomeone considering entering a scien-tific career in cardiology as opposed toa purely clinical one.’

C A R D I O L O G Y

AT RISK:qualifiedcardiacresearch inGermany

Myocardial infarctionThe first minutes following reperfusion are decisive

In his lecture Focus on new therapy

strategies for heart attacks, Prof.

Hans Michael Piper, President ofthis year’s Congress of the GermanCardiac Society, gave somefascinating insights in to therapeuticmeasures after heart attacks. It ispossible to significantly limit theloss of cardiac tissue after an acutemyocardial infarction with the helpof a balloon catheter. Restoring theblood supply of the heart muscle

paves the way for cell recoveryfrom the acute infarction.

Recent experimental researchhas shown how important thesefirst minutes after a reperfusionreally are: Reperfusion can makecell damage within theundersupplied heart tissueirreversible, which scientists referto as ‘reperfusion damage’.

‘There have already beensuccessful, clinical tests with an

experimentally developed procedurefor the interruption of reperfusiondamage where ANP (atrialnatriuretic peptide), a hormonenaturally produced by the body, isinjected. In a further procedure, aseries of short, renewed vascularocclusions immediately after thebeginning of perfusion have aprotective effect on the cardiactissue,’ Prof. Piper explained. Afterthe opening of a previously

occluded cardiac vessel, therapyrevolves around the importance ofkeeping it open. Renewedthrombotic occlusion is preventedthrough inhibiting the clotting. Theinsertion of stents is then aimed atlong-term prevention of newcardiac vasoconstriction.

Further processes in a partlydamaged, partly saved and partlyhealthy heart are thencharacterised by ‘remodelling’. Theheart – although circulation hasbeen restored – changes itsstructure and cell function, whichcan possibly lead to heartinsufficiency. The therapy nowrequired, such as ACE inhibitors,can positively impact the

remodelling process and delay theonset of heart insufficiency.However, the objective is todetermine the causes of this tissueremodelling to improve therapeuticmeasures.

‘A further important field fortherapy after heart attacks is stemcell therapy which aims toregenerate the heart tissuedamaged during the acuteinfarction. Although there havebeen first reports of the successwith different cell types inexperimental studies only few havebeen clinically examined. We willhave to invest a lot of energy intothe search for the right procedurehere,’ Prof. Piper concluded.

Professor Gerd Heusch

Professor HansMichael Piper

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22 EUROPEAN HOSPITAL Vol 17 Issue 2/08

N E W S

Left: DVGCPresidentFerdinandKöckerling Right: CongressPresident RainerArbogast

Rotational artherectomy - Around33,000 patients are hospitalised annual-ly due to myocardial infarction, but onlyfive percent actually die, thanks to thevarious state-of-the-art treatments mas-tered by Czech physicians.

One new addition to their skills isrotational atherectomy, in which acatheter, tipped with a high speed rotat-ing device, is introduced through a bloodvessel in the leg or arm to pass on to ablocked artery. The tiny rotating cuttingblade rotates at over 160,000 rpm,grinding plaque into minute particles,thus opening an artery that has proveddifficult or impossible to treat with con-ventional techniques. Recently, a teamat the Brno Faculty hospital successfullyused this minimally invasive approachon a 50-year-old patient, after whichballoon angioplasty and stent installa-tion were performed. Following the pro-cedure, patients often can walk withinsix hours and most are discharged thenext day. Now the Brno patient onlyreceives conventional treatment.

Brno Faculty hospital plans to use thisprocedure annually for around 30patients from South Moravia, Zlin, andOlomouc counties.Details: http://www.fnbrno.cz/ andhttp://www.kardio-cz.cz/Robot supremacy – Earlier this year,the 100th robot-assisted vascular proce-dure was performed at Na Homolce hos-pital in Prague. Specialist medical unitsabroad have performed about 30 robot-assisted procedures). Since its first per-formance of this kind in November2005, the surgical team has gained sig-nificant experience, enabling successfulsurgery on its 100th female patient,whose narrowed pelvic blood vesselsinhibited normal blood flow into her leg.

Robotic surgery takes about the sameamount of time as a conventional proce-dure, but as the DaVinci robotic hand isfar more precise it enables movementsin a limited space and access is throughsmall holes, so healing, recovery andhospital discharge are quicker.

Robot-assisted surgery accounts forbetween 5-8% of all operations — mostfrequently an aorta to pelvic artery(-ies)by-pass — whilst aortic and pelvicaneurysms are dreaded most by vascularsurgeons.Details: http://www.homolka.cz/ andhttp://www.21stoleti.cz/Reports: Rostislav Kuklik

A new CHROMOPHARE® E-Generationhas been launched by surgical lightspecialist and operating theatre equip-ment manufacturer Berchtold GmbH &Co. KG.

With the usual standards, such asdaylight quality, minimum heat produc-tion, and intense color temperatures,the CHROMOPHARE® E-Series includessurgical lights with HID gas dischargeor BRITe™ halogen technology,Berchtold reports. ‘All lights achieve anew type of plateau-shaped illumina-tion: the light field is illuminated withuniform intensity at every point. Thelight remains cool in spite of its greaterilluminating power. The redesignedfree-form polygon reflector alsoensures superior visibility due to a min-imum of shadows.’

The gas discharge lights of the HIDseries E 805 and E 655 are also distin-guished by their very consistent illumi-nation of a large light field. In theCHROMOPHARE® E 805 this is further

125th German Society of Surgery CongressThe 125th Congress of the GermanSociety of Surgery and the annualCongress of the German Society ofVisceral Surgery (DVGC) in lateApril, examined the facts behindevidence-based medicine (EbM)under the banner Surgical Medicine– from Empiricism to Evidence, andalso evaluated current opportuni-ties in hospitals, science andresearch. ‘Is it the implementationof guidelines, the work of the soci-ety’s study centre, or the networkof evidence-based medicine thatwill move the discipline closer toits objective – the best possiblecare for patients?’ asked CongressPresident Professor RainerArbogast. ‘Clinical decision makingis a complex, often lonely and intri-cate task with profound conse-

In use: The new CHROMOPHAR® –optionally with HID gas discharge orBRITe™ halogen technology

Bigger, brighter and moreuniform surgical lighting

European Antimicrobial ResistanceSurveillance System (EARSS) aboutthe proposition of the Methicillin-resistant Staphylococcus aureus(MRSA) still show the need to avoidany risk of infection inside hospi-tals,’ he adds. ‘As keyboards, PCsand displays were initially designedfor offices, the use of speciallydeveloped products for hospitals isnecessary. Many suppliers nowoffer such products, and the cost ofthis technology is disproportionateto costs incurred when infectedpatients must have extended hospi-tal stays.’ Although many hospitalsare keen to ‘keep up’ with moderntechnology, however, many are stillnot investing in up-to-date hygienicIT equipment, much to their ownultimate cost.

enhanced by a significant increase ofillumination of 100,000 lux within thecentral light field. ‘A pleasant innova-tion is the Sleep Function, which

Medical PC-Display system with germkilling varnish and no ventilation

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nology for the operation theatrebecame the impetus for changes. Thefirst installations involved the use ofordinary PCs and display technology,as used in office environments.However, although productsinstalled should meet the specialneeds of the OT and intensive careunits (ICUs), more than 60% of allPCs used in hygiene-sensitive areashave ventilation holes and slots and alarge number of them use active ven-tilation. The risk of accumulatingmicrobes and dust particles in thecomputer is very high, and this cont-aminated dust will be distributed bythe expelled air from the machine. Asthe RKI-Guidelines request plain sur-faces and the ability to be disinfectedfor equipment used inside the OT,this should also be one of the key fea-tures for the IT equipment that is tobe used in such critical areas.

‘The latest figures from the

makes it possible to blend out the HIDlight temporarily and restore it immedi-ately to full power when needed. Thegentle low-light level GuideLite™remains present during Sleep Functionand offers a pleasant orientation glow.The innovative AutoLux function of the E805 HID light offers the option of elec-tronic intensity control; this makes it pos-sible to increase or reduce the light fieldarea with no change in either the qualityor intensity of illumination. Refocusing isnot needed.’

The light intensity of CHROMO-PHARE® BRITe™ lights with halogentechnology is up to 50% greater thanever, at the same level of energy con-sumption and with no increase in tem-perature at the light head, Berchtoldadds. ‘The response to the new operationlights has been very positive. Operatingsurgeons affirm without exception thatthe new types of illumination improvequality and efficiency of operations.’Meet us at TopClinia Hall 1, Stand 1C16Details: Berchtold GmbH & Co. KGKlaus Hammerl, Global Product Manager.Phone: +49 (0)7461 / 181-0,Fax: +49 (0)7461 / 181-200Info@BERCHTOLD.biz andwww.BERCHTOLD.biz

Germ-free IT inthe operationtheatre

quences; it can be supported, butnot substituted, by randomised,controlled studies (RCT). Moreover,we must remember that the termevidence has a very different mean-ing in continental Europe comparedwith Scotland, where the talk is ofempirical evidence.’

The focus of several sessions fellon quality assurance. During an’hour of the senators’, experiencedsurgeons evaluated training sur-geons during their academic studiesand in hospitals.

Two important meetings, held

jointly with the new SurgicalWorking Group for Peri-operativeMedicine within the GermanSociety of Surgery, focused on peri-operative therapy in surgery.

The European Topic chosen bythe DGVC was The DifferentiatedTherapy of Rectal Carcinoma, drewin international experts in thefield, some of whom became hon-orary DGVC members. ‘In this areain particular we have gained newfindings through prospective andrandomised studies that will havean impact on our therapeuticstrategies. The sessions onCertification Procedures andMinimum Quantities were closelylinked to these topics,’ said DGVCPresident 2007/2008, ProfessorFerdinand Köckerling.

Proportion of MRSA isolates inparticipating countries in 2006 © EARSS

CZECHSURGERY NEWS

Among the major changesto operating theatres(OT) in recent years is theintroduction of informa-tion technology (IT)equipment.

Dirk Cordt, General Manager forsales and marketing of medical displaytechnology at Totoku Europe, pointsout, ‘The introduction of more IT tech-

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EUROPEAN HOSPITAL Vol 17 Issue 2/08 23

N E W SS U R G E R Y

Moscow’s medical mighty Ready and willing to save children worldwideBy Professor Gennady Souchkevich, Deputy Director of theMoscow Research and Clinical Institute of EmergencyChildren’s Surgery and TraumaThe Moscow Research and ClinicalInstitute of Emergency Children’sSurgery and Trauma was foundedthree years ago to provide childrenwith 24-hour treatments for severebrain trauma injury and combinedtrauma, fractures in variouslocations, spinal injury, urgentsurgery for abdominal cavitydiseases, and purulent-inflammatoryprocesses in soft tissues and bones.There are no analogues for thishospital anywhere in the world.

About 60,000 children haveconsultations and treatmentsannually at the Institute; 9 000 ofthese are hospitalised.

The building provides five basicclinical departments: neurotrauma,purulent surgery, trauma, cleansurgery, anaesthesiology andresuscitation.

The reception unit has sixcubicles and an anti-trauma ward,with separate entrances. Bearing inmind the time factor in emergencycases, critically ill patients areimmediately delivered to the anti-trauma ward, which is equipped forresuscitation as well as surgery,having two surgical tables. Theequipment also includes ultrasound,electrocardiograph, encephalo-graph, Doppler and others. Near theanti-trauma ward is a radiologicaldiagnostics department, containingultra-modern equipment (MRI 3-T,KT, X-ray etc.), as well as anexpress laboratory and a room forfunctional and endoscopicdiagnostics. A patient is delivered tothe resuscitation unit or operatingtheatre only after his or her

condition has been stabilised in theanti-trauma ward.

The anaesthesiology department,resuscitation unit and surgical blockare equipped with the most modernsystems to monitor patients’ vitalactivities, with breathing andnarcosis apparatus. They also havespecial air-conditioning and venti-lation systems.

On the roof of the six-storybuilding is a helipad, where criticalpatients arrive in a sanitised heli-copter. The helipad can receivepatients 24/7.

For use in emergencies, theInstitution also has back-upelectrical and water supply systems.

Children in all wards are undervideo observation.

Via the IT system, data from X-ray, ultrasound, the laboratory andso on, are transmitted directly tothe attending physician’s desk.

A group of the Institute’s highlyqualified physicians has formed amobile paediatric team thatselflessly provides medical care tochildren in disaster areas all overthe world. They have activelytreated young victims in Armenia,Georgia, Iran, Egypt, Japan, Turkey,Algeria, Pakistan, Indonesia,Sakhalin, at the train-crash inCheljabinsk and at military conflicts

in Nagorny Karabakh, Ingushetia,North Ossetia, Dagestan, Chechnja,Yugoslavia, Romania, in the MiddleEast, as well as at the terrorist sitesin Nord-Ost (Moscow), Beslan andelsewhere.

Each leading specialist in theInstitute is worth writing about.However, I would like to say a fewwords about our Executive Directorand chief, Professor Leonid Roshal.He is a brilliant paediatric surgeonand organiser, and is recognisedworldwide as a specialist in disastermedicine. Journalists have calledhim the ‘Children’s Doctor of theWorld’. Prof Roshal is a courageous

and fearless man who is alwaysready to depart immediately towherever children are involved indisaster and need medical help.While doing this, he never thinksabout glory or honours, becausehe is directed by the conscienceof a true citizen of the world.

This is only a brief descriptionof the active life of our medicalestablishment, which stands atthe ready for all the children ofthe world.You will find more detailedinformation about our Institution atour web-site:http://www.mosgorzdrav.ru/niindht

Safe:Trac A DGU trauma surgery training courseA new trauma surgery training pro-gramme has been launched by theGerman Society of Trauma Surgery(Deutsche Gesellschaft für Unfall-chirurgie - DGU).

Aimed at all professions engaged intrauma care, Safe:Trac (Safety in TraumaCare) consists of four training modules,the DGU reports. ‘It covers patient safe-ty issues from the site of the accident toclinical care. Via the umbrella organisa-tion German Society for Surgery(Deutsche Gesellschaft für Chirurgie -DGCH) the project is being supported byeight professional associations. In addi-tion to the surgery-oriented critical inci-dent reporting system (CIRS), which hasalready been implemented by DGCH,Safe:Trac is a further major step towardsincreased patient safety?’

Professor Hartmut Siebert MD,Director General of DGU, added: ‘Thedifferent interdisciplinary Safe:Trac

Manufacturingreusable

instruments The manufacture of reusableinstruments needs stringent careto meet constantly increasing pro-cessing regulations and alsoensure survival in repeated heavyuse. ‘Quality is what matters mostto us,’ Komet Medical points out,‘especially when it comes to thefollowing points.’

es, video scenarios and sufficient roomfor discussion ensure that each topic iscovered in detail. Emphasis will be puton the participants’ experience in theirdaily trauma work. The entire teamshould be trained together if we wanta security culture to be promoted andlived in trauma care’.

The training modules include thescientific basics and knowledge onincident development; limitations ofhuman performance and stress man-agement; complications managementand error avoidance; situation-ade-quate awareness; risk assessment anddecision-making; communication;leadership/organisation/cooperation(team work); safety culture vs. blamingculture.

DGU trainers are specifically pre-pared physicians, certified accordingto the requirements for aviation crewresource management trainers.

CHILDCARE HELPS WOMEN SURGEONS Ways to meet the needs of women surgeons who are mothers yet, like their malecolleagues, also work night shifts and carry out lengthy procedures, was againdiscussed at the 125th Congress of the German Society of Surgery (DGCH) inApril. ‘There is no doubt that there should be a stronger female influence insurgery, which is why the Federal Minister of Family Affairs, Dr Ursula von derLeyen, held an important lecture on this topic, followed by an open discussion,’explained the DGCH President Rainer E J Arbogast MD.

Emphasising the need for a flexible approach to child care, the Murnau TraumaCentre in Germany was mentioned. This has an in-house nursery, where openinghours reflect hospital shifts. Carers look employees for 365 days a year. Thescheme has not only increased staff satisfaction but also, said Erwin Kinateder,Administrative Director of the Centre, it has saved on costs. ‘This is largely basedon the fact that we have lower staff turnover and less time taken off work. In2004, an in-house study showed that we saved about 82,000 euros.’

Since the nursery opened in 1977 the number of places has increased continu-ously to reach the 100 available today. From 5.15 a.m. until 9.30 p.m. the carerstend babies from aged eight weeks and children up to ten years old – who notonly eat and sleep at the nursery but are also helped with their homework

training modules were developed incooperation with aviation psychologistsand based on the Crew ResourceManagement seminars for flying staff inEurope. That means the contents complywith the Joint Aviation (JAA*) require-ments and were adapted by a team ofacute care specialists and psychologiststo the specific requirements of thehealthcare target groups.’

During training, participants from allprofessional groups directly involvedwith patient care, work with case studiesto increase awareness of the mecha-nisms of incident development. Based onthis, they can then devise strategies toavoid errors in particularly critical orrisky situations, the DGU elucidates. ‘Thiswill actively promote and further aninterdisciplinary safety culture. The train-ing modules are geared towards theindividual participant groups. Practicallyoriented group and small group exercis-

Raw materials: ‘Due to experiencein the production of reusableinstruments since 1923, the manu-facturer Gebr. Brasseler has placedgreat emphasis on high-qualitymaterials. All incoming goods aresubject to permanent controls, toensure the instruments are stableand resistant enough for validatedreprocessing cycles and repeatedsurgical use.’ Construction: ‘In Komet’s R&Ddepartment the instruments arevery critically examined right fromthe start. It is only under this pre-condition that we can offerreusable instruments. A goodexample of the precaution is: Theinstruments have to be free of cor-ners that might prove hard toreach during reprocessing and thatmight therefore become a danger-ous source of contamination.’ Durability: ‘Only sharp instru-ments in perfect technical condi-tion pass the final quality controlat our headquarters in Lemgo,Germany. The product life of theindividual instrument largelydepends on the stress it mustendure during operations. Carefulcontrols during each validatedreprocessing cycle are necessary toconfirm the sharpness andreusability of the instrumentsbefore the next operation.’ Product details: Komet Medical,Gebr. Brasseler GmbH & Co. KGE-Mail: info@kometmedical.dewww.kometmedical.de

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Success for wirelessretina implants

Following 12 years of development,German surgeons and technicians have suc-cessfully implanted the world’s first visionprosthesis in six blind patients. Millions ofpeople suffer Retinitis pigmentosa, in whicheyesight diminishes continuously as retinacells die, resulting finally in blindness.However, part of the nerve cells usuallyremains intact, which is where vision pros-theses can help.

Led by Professor Wilfried Mokwa,engineers at RWTH Aachen University andat the Fraunhofer Institute ofMicroelectronic Circuits and Systems inDuisburg, developed the vision prosthesis,named EPIRET3 to treat the condition.Today, it is the only system, worldwide, thatworks wirelessly, i.e. the complete implantis fixed into the eye and needs no connec-tion to external cable links, whereas otherretina implants do. This reduces surgerytime, simplifies handling and reducespatient stress.

Six patients, all blind for several years,volunteered for the procedure. During afour-week test phase, specialists at the neu-rophysics group in Philipps UniversityMarburg used various electrical test stimulito stimulate the patients’ retinas. These trig-gered visual impressions in all the patients,who could distinguish optical patterns.

Following this initial success, the nextstep is to extend the duration of the implan-tation and further improve the surgicaltechnology. To ensure patients can find theirway around their surroundings the systemwill have to be linked with a camera thattransmits wireless signals to the implant.

Since this system has proved effectiveand safe in the first patients, several med-ical technology companies have set up acompany to develop a marketable retinaimplant, which should become available formore patients in a few years. It may also beused to treat advanced, age-related macu-lar degeneration – a commoner eye diseasethat causes about 50% age-related blind-ness.

Since 1995, the German Federal Ministryof Education and Research has invested17.5 million euros to promote the develop-ment of vision prostheses. Thomas Rachel,Parliamentary Secretary of State at theMinistry, commented: ‘Scientists and techni-cians have jointly achieved something out-standing. We hope that many blind peoplewill soon reap the benefits of these results.’

A morphological study of gastric polyps performedon a population from Western RomaniaBy Ovidiu Cristian Fratila, Adrian Maghiar, Marcel Stoita, Tiberia Ilias, DanaPuscasiu, of the Clinical County Hospital, University of Oradea, Romania

Dr OvidiuCristian

Fratila

Gastric polyps (GP) are typicallyfound incidentally, when upper gas-trointestinal (GI) endoscopy is per-formed for an unrelated indication.Gastric polyps are uncommon andhave an incidence of less than onepercent. Only rarely do they causesymptoms or other clinical signs.Nevertheless, their discovery can beimportant, because many polypshave malignant potential.

According to recent data, any gas-tric epithelial polypoid lesion (even<20 mm) should be biopsied orremoved, whenever this is consid-ered feasible and safe.

Study aims and methods We analysed the prevalence, distribu-tion and histological aspects of theremoved GP from patients undergo-ing upper GI endoscopy.

We studied the endoscopic and his-tological features of gastric polyps(location, multiplicity, presence ofdysplasia/adenocarcinoma) resectedin Oradea Clinical County Hospitalduring one year. In this time 929upper endoscopic examinationswere made using an Olympus Exera

CLE145 video endoscope. Everypatient had only one examination.Resection was performed applying aStorz 860021 source with cut andcoagulation power of 80 and 40watts, respectively. The followingclinical, endoscopic, and histologicfeatures (H&E, modifiedRomanowsky stain) were evaluatedin each patient: age, gender, locationof polyp(s), size and type, symptoms,morphological alterations and thepresence of gastritis in the surround-ing mucosa.

Results and discussionsGPs were found in 16 patients(2.54%), 11 men and five women,aged between 43-76 years. 45% werelocated in the antrum and 55% in the

corpus, no polyps being found in thegastric fundus. The epigastric pain,heartburn and anaemia wereobserved in 18.7% of the patients. In11 of 16 patients (68.7%), polyp sizewas less than 10 mm. Most of the GPwere sessile (85%). Hyperplasticpolyps, the most frequent histologi-cal type of GP reported in literature,accounted for seven cases in ourstudy, followed by inflammatoryfibroid polyps (6 cases) and adeno-matous polyps in three cases.

The clinical findings depended onthe polyp size and location. Somepatients had no specific digestivesymptoms. Erosion or ulceration ofthe polyp may cause occult bleeding,anaemia. Upper gastrointestinalbleeding may occur in large lesions.Larger polyps with the potential topass from the antrum to the pyloruscan cause intermittent obstruction.

Symptoms such as pain, nausea,vomiting were frequent and couldnot be attributed solely to the polyp,since there were frequently otherendoscopic alterations, implyingother gastroenterological diseases.

In our study, hyperplastic polypswere more frequent in the antrum,followed by the body, none in thefundus. The risk of developing carci-noma in hyperplastic polyps is lowand they are not considered pre-can-

Sessile gastric polyps Endoscopic polipectomy

Hyperplastic polyp with distorted or dilatedgastric pits, associated with proliferativesmooth muscles from muscularis mucosa;stroma is characterised by dilated bloodvessels, moderate inflammation (H&E, ob. x10)

Adenomatous sessile gastric polyps made upby proliferative glands with mild epithelialdysplasia (H&E, ob. x10)

Adenomatous sessile gastric polyp made upby proliferative glands with mild epithelialdysplasia (H&E, ob. x10)

cerous lesions. Previous reportsshowed that the risk of focal adenocar-cinoma is less than one percent andoccasionally greater than one percent.

Histopathological analysis of fundicgastric polyps revealed no alterations,and there was no association betweenthem and stomach adenocarcinoma.Besides, the association betweenfundic gastric polyps and patients tak-ing longstanding proton-pumpinhibitors were not recorded.

There is a strong associationbetween different forms of gastritisand the development of GP, whichemphasise the importance of biopsy ofnonpolypoidal gastric mucosa duringendoscopy. Larger studies are needed.

Conclusions1. In our population, the prevalence ofGP is low (2.54%). 2. Generally, GP areasymptomatic and used to be foundduring gastroscopy as a lesion lowerthan 10 millimetres. 3. Most are diag-nosed histologically as benign 4. Wenever observed hyperplastic and ade-nomatous lesions simultaneously. 5.Larger studies are needed to reveal theassociation between different forms ofgastritis and the development of GP.

The 10,000thAlphamaquetThis June, the 10,000th Alphamaquet surgi-cal table made by Maquet GmbH of Rastatt,Germany, will be delivered to the depart-ment of thoracic surgery at BarmherzigenBrüder Hospital, Regensburg, along withother Maquet medical technology on order.

The Alphamaquet 1150 series of surgicaltables provides ten different table tops, andis thus used across the surgical disciplines. Itis also used in practically every university

hospital in Germany, the Netherlands,Belgium, Switzerland, Austria andScandinavia, as well as other leading hospi-tals in France, Italy and Japan.

Their continuing revisions of design andconstruction have reflected our changinglifestyles and Western affluence. When firstlaunched in 1995, the load-bearing capacitywas sufficient at up to 135 kg. Three yearslater, the system was oriented to loads of 185kg and, in a further development, to weightsof 225 kg. Today, some surgical patients mayhave a body weight of up to 360 kg, so thesetables are used in centres that specialise inbariatric surgery in many countries.

‘Thanks to its consistent and continual fur-ther development the Alphamaquet is nowregarded as state-of-the-art,’ said Maquet’sCEO Dr Heribert Ballhaus. ‘The system hasconsistently been amended in line with thechanges and rapidly growing needs in surgi-cal techniques — for example the growth inminimally-invasive surgery — and also withthe rapid development in medical imaging inX-rays, CT, MR and ultrasound.’

Integration of imaging diagnostics was thelast major development, Maquet reports.‘The patient may be transported to diagnos-tics at any time, i.e. before, during or after anoperation. This allows for selective therapiesand helps to avoid subsequent surgical inter-vention.’

The tables have an average service life of20 to 30 years, and technical improvementscan be integrated at any time without prob-lems, explained Dr Dieter Engel, the firm’stechnical director, adding that the system canalso be expanded to include additional com-ponents. ‘Maquet is a long-term partner forhospitals, and for us partnership means – inaddition to 100% reliability – the continualimplementation of surgical requirements inour systems.’

O P H T H A L M O L O G Y

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EUROPEAN HOSPITAL Vol 17 Issue 2/08 25

I T & T E L E M E D I C I N E

Telemedicine for operating theatres

In all major projects with lots ofparticipants, success comes fromtimely planning between every

department and company involved

In Genk, Belgium, the ZiekenhuisOost Limburg hospital simplifiedsurgical workflow by installing atelemedicine system in a newlyconstructed interdisciplinary surgicalwing. Dr Hubert Van der Put, MedicalDirector of ZOL, recalls its initiationand subsequent success.

For some years, surgeon Dr KurtVanderspeeten and ZOL’s IT managerPhilip Verheye had hoped to install avisual system to support operating the-atre workflow, provide access to patientdata in a standardised format through-out the hospital, and automatically doc-ument and archive data. However, up to2004, this was a major technical andfinancial challenge due to the differentformats of imaging devices and otherdata sources. ‘Although there had beensuggestions about using one solution oranother, none of the known solutionswere convincing for our individual andcomplex needs,’ Philip Verheyeexplained.

However, when planning began for anew, 14-ward interdisciplinary surgicalwing at the Sint-Jan campus, a workingparty of members of the medical, IT,finance and administration departmentswas formed to discuss initial require-ments for a central amalgamation of allpatient data and imaging results. Themain focus was on hospital-wide dataavailability and documentation. Toattain the best possible investment pro-tection, they favoured open, standard-ised hardware/software interfaces.

From a shortlist of telemedicineproviders, Maquet won the tender tosupply a universally deployable system,having taken into account the best-pos-sible investment protection with a viewto the short-term amortisation of thesystem and the avoidance of lateramendments. Significance was attachedabove all to the system being universal-ly deployable, regardless of manufactur-ers or a specific discipline.

Every 8-12 weeks during the 21/2-year project, the working party met withinvolved companies, e.g. Olympus(endoscopy), Zeiss (microscopy) andMEDA (anaesthesia), to discuss theincorporation of data migration and

interfacing with the existing IT.Problem-free access to the SiemensPACS had to be guaranteed, as did localhigh definition visualisation in theoperating theatre. The HIS developedby ZOL was not affected; mainte-nance/repairs would be carried out bythe hospital’s software developmentdepartment.

From a surgical perspective thedeployment of the system was to pro-vide the operating theatre team withthe best-possible visual support. ‘Toevaluate a situation we need all theavailable patient data as the basis forfurther steps. The possibility to view allof a patient’s data immediately savesus lots of time during surgery, becausewe no longer have to wait for this to bede-archived once a request has beensubmitted,’ said Dr ConstantinusPolitis, Head of the Oral and Maxillo-Facial Surgery Department. ‘At thesame time, the operation of the system

— already tested in radiology — wasused. Its added value lies in clear auto-matic patient allocation and that theexisting image viewing solution mayalso be utilised for theatre imaging.There are no additional costs for thepurchase of proprietary archiving andviewing software or for personneltraining.

Two electromagnetically shieldedtheatres proved a challenge for elec-tronic installations. This was resolvedby Maquet, which developed andimplemented solutions to avoidunwanted electrical fields created bythe video line and data cable.

In 2006 came the simultaneous, suc-cessful launch of the surgical wing andtelemedicine system.

The regular exchange of informationand the excellent cooperation betweenall the project participants played aspecial role in that success, Maquetpoints out: ‘Thanks to the intensivepreparation phase with the specialistdepartments at ZOL and the companiestaking part in the project it was possi-ble to avoid all the relevant problems inthe implementation. Everyday prob-lems, such as a potential difference of80 volts between the monitor frameand the floor caused by the wrongcabling on a grounding strip, werequickly identified and rectified throughclose co-operation between the com-panies involved. With the choice of atelemedicine provider that exclusivelyspecialises in system solutions for theOR, and also has extensive experiencein communications electronics, it waspossible to verify additional potentialfor savings.’

What could have been done better?‘Even more timely planning with all thedepartments and companies involved,which could have further minimised thecommunication problems inevitablyassociated with major projects with alarge number of participants.’

conhIT 2008Held this April in Berlin, this event aims to becomean important venue for healthcare IT in Germany.Guido Gebhardt reports

Although much has been done in thelast three or four months, iSoft needs tobecome a stronger global organisation,Gary Cohen emphasised. ‘We are nowanalysing the consolidations of ouroperations. Until two months agoGermany and Netherlands were twoseparate organisations, today they areone. Until about three months agoiSoft’s international organisationsweren’t fully amalgamated. Now theyare, along with strong systems and pro-cedures. We want to become a qualityorganisation - whether it is sigma 6 orCMM Level 5.’

‘We are setting up IT systems toensure that, for example, the entirecompany works on one wide area net-work, so that we can have VOIP in thewhole organisation,’ explained AndreaFiumicelli. We need to have quality sys-tems, so that we do not have multiplesupport centres in each country.Currently, we have over 200 productsto support globally. We need to reducethese to about 20 or 30 products, soperhaps then we will need only two orthree support centres worldwide.

‘We are now rebranding the wholecompany on iSoft. In Australia, forexample, we brand everything underIBA and iSoft. In future, everything willbe iSoft. Our sales people must sellevery product in the same way as inEurope — in Australia, China or Saudi-Arabia. Globally, iSoft has a good nameand reputation, from which we want tobenefit.

‘There are few key themes, that thehealthcare providers either public orprivate in Europe will need to address

From 2004-07, VHitG (Verband derHersteller von IT-Systemen imGesundheitswesen) and MesseFrankfurt jointly organised ITeG (IT-Messe und Dialog imGesundheitswesen). When VhitGmoved the event to Berlin, their cooper-ation ended. Messe Berlin became thenew partner of what is now calledconhIT. The organisation team, headedby Jens Naumann, VhitG chairman,developed an entirely new concept.However, things got off to a bad start.The lobby exuded all the charm of atrain station.There were not even chairsto sit on. At the opening session, about50% of the 600 seats remained empty.Was the move to Berlin and the newpartnership really wise? No, poor atten-dance could not be blamed on a badevent concept nor on the venue. BothFrankfurt (2004-06) and Berlin (2007-08) are within easy reach – and IT is stillvital for good hospital management.

Raimund Hosch, CEO of MesseBerlin, emphasised the exchange char-acter of the conhIT concept: Due to thetiming of trade fair, congress and acad-emy exhibitors as well as visitors hadtime to collect and exchange informa-tion. Therefore, conhIT could become, ashe put it, ‘step by step an importantevent in Europe’.

At the opening session, Dr KlausTheo Schröder, State Secretary withthe German Federal Ministry of Health,announced the next roll-out phase forthe electronic patient record (EPR). ‘Inthe second half of 2008 we want todeploy card readers, as well as cards, sothat we can realise the full potential ofthe system’, he explained.

Peter Waegemann, CEO of theMedical Records Institute in Boston,demonstrated that even the ratherunsexy issue of the EPR can be present-ed with wit and verve. In the USA, heexplained, EPRs on a cell phone, or as

xml file, and telemedical therapies, orcomputer-assisted medicine, are a real-ity. The major goal must be the intro-duction of computer-controlled therapysupport, he added. A physician can nolonger exclusively rely on thingslearned in medical school, or fromexperience. New medical knowledgesprings from a wide variety of sources,‘We have to move away from intuitivetreatment to healthcare that is scienceand computer-based,’ he urged. In e-healthcare, doctors and nurses world-wide will have access to patient data.‘Today,’ he added, ‘this is impossiblebecause we are dealing with data silosthat are not networked. We mustensure treatment continuity by offeringthe EPR.’ In the USA, a data standardhas been introduced: Continuity ofCare Record (CCR). It provides encrypt-ed data sets in xml, which contain dataon previous therapies, medication anda list of physicians the patient hasseen. A patient can call up his CCR datasets by cell phone and forward them toa physician. ‘Sooner or later, we will allhave a digital patient companion,’ heconcluded.

In terms of issues and content,conhIT 2008 struck a high level. So whywas there so little interest amonghealthcare IT professionals? Since nei-ther the venue nor the organisersappear to be the problem, VhitG maywant to reconsider its dates. InGermany, a major portion of healthcareIT investments currently go to radiolo-gy. In March, ECR (European Congressof Radiology) in Vienna was on theagenda; in May the German RadiologyCongress (DRK) will take place. Fourweeks later is the Hauptstadtkongress.In 2007, there was also CARS. So, with-in a few weeks, five healthcare IT con-gresses were scheduled. Even if thefocus of events is different – the tar-geted users are always identical.

Computer assistedradiology & surgery

CARS 2008

International consolidationIn October 2007, the IBA Health Group — Australia’s largestlisted specialist health IT company, led by executivechairman and CEO Gary Cohen — took over iSoft PLC. InApril 2008, IBA appointed Andrea Fiumicelli as ChiefOperating Officer. Formerly responsible for Agfa’s HealthcareIT worldwide R&D and sales/service organisation in Europe,and 20-plus international subsidiaries, he is now based atiSoft’s European HQ in Banbury, UK , At conhIT 2008 in BerlinGuido Gebhardt spoke with them about the challenges thisnew role represents

in the next three to five years,’ AndreaFiumicelli continued. One definitely isthe continuum of care, he pointed out.‘An efficient, economical healthcaresystem must address connectivity andinteroperability between primary, sec-ondary and tertiary care. Through thecreation and implementation ofprocesses that will require IP-solu-tions, efficiency in healthcare systemswill increase.’ Next comes chronic dis-ease management, he said. ‘Today 75-80% of healthcare money in eachcountry is spent on major chronic dis-eases. We need preventive campaignsto inform people about their risks.’

The third theme, he believes, isquality. ‘If you measure healthcare, itis a two or three sigma industry. Wellorganised companies run a six sigmasystem to avoid errors. These are threekey themes that could changeEurope´s healthcare systems.’

Asked what lies in store for iSoft inthe near future, Andrea Fiumicelli said:‘IBA will become not just an infra-structure player, but will also be aplayer that connects and provides anempowering of the consumer. So theconsumer can access health records orinteract with the healthcare system —whether to order a prescription andget it delivered, or to find healthcareinformation. IBA will be an essentialelement in connecting and empower-ing the consumer. Most importantly,iSoft´s solution Lorenzo already has amedical semantic terminology ser-vices engine embedded. This strongknow-how was one of the reasonswhy I joined Gary and IBA.’

Discussions within the working partyensured that any changes in theirneeds, or in technology, would be takeninto account in the planning. For exam-ple, it was possible to amend the inter-face and cabling to new HD (high defi-nition) technology for manufacturers’endoscopic camera systems. Analoguecamera systems and digital HD systemscan be installed in the future withouttechnical changes.

Real-time data exchange Whereas DVDs were originally plannedas data carriers, the disadvantagesassociated with this format soonbecame clear. The lack of fully automat-ic patient allocation and the adminis-tration of an ever-increasing mediaarchive would have meant a consider-ably increased workload for medicalpersonnel. Instead the DICOM format

Gary Cohen

AndreaFiumicelli

has to be simple and intuitive for thesurgeons and the theatre team.’

Today, each theatre has at least onehigh-resolution wall monitor and a flatscreen attached to the ceiling unit.Using a touch-screen the individualimage sources can be transferred toindividual monitors. The system auto-matically collects patient data from thetheatre planning and managementtool and clearly allocates each stillimage or video made during a surgicalprocedure. For teaching purposes livevideo images may be broadcast fromthe theatre over the local IT network tothe auditorium.

‘‘

By CARS organiser,Heinz U Lemke PhD,Visiting Professor forComputer AssistedSurgery, at LeipzigUniversity, and ResearchProfessor of Radiology at theUniversity of Southern California, LA, USA

The International Congress of CARS aimsto provide a forum to close the gapbetween diagnostic and interventionalradiology, surgery and informatics and toencourage interdisciplinary research anddevelopment activities in an internation-al environment.

To increase the value of health care forthe citizens, the focus of the InternationalCongress of CARS is on providing bal-anced and in-depth information on newdiagnostic and therapeutic processes.This includes results from multidiscipli-nary R&D efforts, providers’ experiences,patient outcomes, economic and man-agement considerations, as well as scien-tific/medical validation results. It can beexpected that the resulting awareness byusers and providers will speed up theacceptance of CARS into clinical practice.

CARS distinguishes itself most clearlyfrom other congresses in its focus oninnovative solutions to image and modelguided diagnosis and therapy. Fulfillingmodern clinical requirements with R&Dexcellence is the core value provided in66 scientific/medical sessions, workshopsand tutorials of the CARS 2008 pro-gramme.

The main emphasis of the presenta-tions of the CARS Congress is on infor-mation technologies in radiology andsurgery for clinical application fields,such as:● Medical Imaging, e.g. CT, MR, US,

SPECT, PET, DR, Molecular Imaging,and Virtual Endoscopy

● Image Processing and Display● Hospital-wide PACS and Telemedicine● Computer Applications for

Neurosurgery, Head and Neck,Orthopaedics, Ear Nose and Throat,Cardiovascular and Thoraco-abdominal Surgery, andPlastic/Reconstructive Surgery

● Image Guided Therapy● Surgical Robotics and Instrumentation● Surgical Navigation and Simulation● CAD for Breast, Prostate, Chest,

Colon, Liver, Brain, Skeletal andVascular Imaging

● Cranial and Maxillofacial ImageGuided Surgery

● Surgical Workflow● Surgical DICOM and IHE● Digital Operating RoomAltogether, 474 lecture and poster pre-sentations were selected from 662 sub-missions received from 42 countries. Inaddition, 90 invited presentations frominternational experts have been includedto provide CARS attendees with the lat-est developments on advanced methodsand technologies for health care. Withthis level of active participation, whichsubstantially exceeded any expectations,CARS 2008 in Barcelona will provide ahighly professional program for the par-ticipants.

In addition to the regular sessions ofCARS, special events have been includedto focus on highly innovative develop-ments which impact the future of healthcare. Examples are sessions on biomark-ers, model-guided therapy and the digitaloperating room.Details: www.cars-int.org E-mail: hulemke@cars-int.org. Phone: +49-7742-922 436 /4Address: CARS Office, Im Gut 15,79790 Kuessaberg, Germany.

25-28 JuneBarcelona,

Spain

The 22nd International Congressand Exhibition

Joint Congress ofCAR/ISCAS/CMI/CAD/EuroPACS

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Seven years of lab re-organisationBarcelona, Spain - TheHospital Clinic is a tertiarylevel University Hospitalthat provides a broad range

of services, from basic healthcarecoverage to 550,000 people, toacademic and advanced researchactivities. Hospital Clinic is aleading institution in certain patho-logies, being the reference forSpain in different areas.

Ten years ago, we began aproject to develop a patient-centredcare delivery model: all healthcaredepartments would be organisedbetter to address patient needs.Named The Prisma Project, it re-sulted in a holistic re-engineeringprogramme with two lines of

action. The first goal was todevelop a radically innovativeorganisational model to enable thisnew care delivery model. Second,identify and execute cross-functional projects that improvehealthcare operations and patientcare.

The new organisation groupedservices and clinical specialties inunits based on functional anddiagnostic criteria that wouldenable improved patient care.

These units, called ClinicalInstitutes (or centres forlaboratories and imaging formerdepartments) have managementand self organisational autonomyand responsibility. Following thismodel, all laboratories weregrouped in a new structure calledBiomedical Diagnostic Centre

(BDC).In the context of Prisma, the

BDC decided to create a Core Lab,a new laboratory to centralise thehigher volume routine and stattesting in clinical chemistry,immunology, haematology,coagulation and microbiology. TheCore Lab goal was to driveoperational efficiencies withoutsacrificing scientific knowledgeand provide top quality results tothe laboratory services. This goalcould be achieved by leveragingnew technologies anddemonstrating superior service tothe functional labs that aredependent on our results toprovide optimal diagnostics to ourphysicians.

In 2000, we selected through apublic tender, ADVIA LabCell fromSiemens Healthcare Diagnostics(formerly Bayer Diagnostics) asour optimal solution. In March2001, the automation system wentlive, becoming one of theEuropean pioneers for totallaboratory automation.

ADVIA LabCell is the keyelement organisation, because itmanages all samples in the CoreLab for both connected and non-connected analysers (i.e.nephelometer, electrophoresis andso on). The system has beenextended several times since itsinstallation seven years ago. Thisflexibility has been critical toadapt to our changing needs. Nine

analysers are actually connected:two ADVIA 2400 for clinicalchemistry, two ADVIA 2120 forhaematology, two Stago STA-r forcoagulation and three ADVIACentaur for immunoassay. We alsohave connected three samplemanagers (for loading, unloading,complex sorting and total samplearchiving) and twocentrifuge/decapper modules.

The Core Lab has achievedseveral benefits through ADVIALabCell. We have optimisedresource utilisation. We have savedeight FTEs that have been relocatedin new technologies and researchlabs. This has been important toincrease our revenue by taking highadded-value testing. We haveobviously reduced the number ofanalysers and have reduced thespace required by over 120 sq/m.

Efficiency and quality have alsoimproved. In 2007, over 5,400,000results were produced in the CoreLab, representing more than 85% ofthe BDC total activity. In the lastfive years, activity has increasedover 35%. Due to vendorconsolidation and by maximisingplatform consolidation, reagentcosts have decreased, reducing ourcost per test by 17%. The overallfinancial impact has been

significant, completing the returnof the automation investment inless than five years.

ADVIA LabCell has deliveredother workflow improvements.The system and analysers point-of-space connectivity allow forefficient sample sharing. Thismeans that we can deliver morethan 80 different tests from asingle serum specimen. Noaliquots are needed in the CoreLab. Reducing tubes benefits thepatient by minimising the amountof drawn blood, while eliminatingaliquots means less waste due todead volumes, and less waste dueto tips and cups required. Overall,it has provided a significant costreduction by reducing more than140,000 tubes annually.

After seven years of experience,the design of the Core Lab and theADVIA LabCell implementationhas represented a majoropportunity to change the overallDiagnostic Centre organisationalmodel. We have obtainedsignificant financial and qualityimprovements that ultimatelydeliver better patient care.

By J L Bedini, head of Hospital Clinic Core Lab, and A Mira, manager of the Biomedical Diagnostic Centre

LAB AUTOMATIONFLEXIBILITY IS A KEY TO SUCCESSThe Netherlands - Automating a lab-oratory is a very individual process withvarying demands and needs. In mostcases, the new systems have to bematched with existing instrumentation.Thus an intensive exchange betweenexperts and industry is the first steptowards the successful installation ofautomated systems. In March, duringthe Amsterdam Clinical AutomationConference, organised jointly by theAmerican Association for ClinicalChemistry (AACC), the Association forClinical Biochemistry (ACB) and theNetherlands Society for ClinicalChemistry and Laboratory Medicine(NVKC) held in The Netherlands, AACCPresident Larry A Broussard spokewith European Hospital representative,Gabriela Eriksen about the importanceof such events for hospitals and com-panies

The primary goal of the conference,Larry Broussard explained, was to pro-vide participants, such as hospitaladministrators, laboratory managersand staff, with enough information tomake an intelligent decision regardinglab automation. ‘That sounds quitestraight-forward, but in view of the rolethe lab plays within hospital organisa-tion, it still is difficult to transfer theright information to the right people.Although the lab provides 70-80% ofdata used by physicians to make diag-

noses, we are seen as the black box ofthe hospital that produces informationby performing tests. There is the per-ception that these tests can be per-formed by just anyone if they use theright instruments. However, we are welltrained professionals who serve as lab-oratory directors as well as clinical con-sultants who help physicians to inter-pret test results.’

When talking about automating thelab, the ultimate decision makers areoften not aware of some of the issuesconnected with this work, he pointedout. ‘If you are going to automate thesample handling, it has to be compati-ble with the instrumentation that runsthe samples. For example, there may becertain instruments and/or specifictests that do not have the accuracy andprecision that laboratory professionalsconsider necessary to produce consis-tently accurate results. In a nutshell: Ifyou don’t want to purchase automatedequipment, that forces you to compro-mise the quality of the test results andtherefore that of the diagnoses; muchinformation and interaction is neces-sary. The decision makers have to meetthe lab experts, who need to meet theindustry and vice versa. That’s whythese conferences are so important.

At the conference he observed aneed for flexibility; due to new tech-niques for new tests, the lab is growing

continuously, hepointed out. ‘Tobenefit from aninnovation, a pri-mary laboratoryrequirement is thepossibility to inte-grate new tech-nologies into thecurrent systems.The companiesthat provide the

system must address that aspect.‘Another important topic is logistics,

especially sample handling and theproper identification of samples. If welook at laboratory errors, they tend tooccur most often in pre-analyticalstages, which means sample collect-ing and handling prior to performingthe analysis itself or, in the post-ana-lytical stages, the handling of theresults after analysis. So, one of theprimary focuses of the laboratorycommunity is to reduce errors in sam-ple or patient identification, for exam-ple with RFID solutions,’ he empha-sised.

Conferences are very effective infinding solutions for such problems, heexplained, because they are interna-tional and can compare situationsworldwide: they may be differentcountries, but much the same prob-lems occur. ‘In some cases we can alllearn from each other, because thereare some regulations in the USA, orsome instrumentation and testingoptions that are first introduced inEurope, or the other way round andwe can share the experiences.’

AACC PresidentLarry Broussard

Above: Core LabTop right:Dr J L BediniBottom right:A Mira

EUROPEAN HOSPITAL Vol 17 Issue 2/08 27

N E W SL A B O R A T O R Y

Clinical biologyIT’S TIME FOR ‘EURO COMPATIBILITY’by Bernard Gouget, Senior Counsellor for PublicHealth at the French Hospital Federation (FHF),representative and Deputy General SecretaryInternational of the SFBC*and EFCC**, and memberof the Francophone Federation of Clinical Biologyand Laboratory Medicine (FIFBCML)France - Clinical biology is facedwith many internal and externaldevelopments, notably advances inmedical science, automation,quality assurance, electronic datatransmission, and the impact of theEuropean legislation. On St.Valentine’s Day, The FrenchHospital Federation (GérardVincent, Chief executive manager)in collaboration of the FrenchSociety for Clinical Biology (SFBC;Société Française de BiologieClinique) organised a meeting

on the evolution of hospitalbiology – a conference thatgathered more than 450participants from the private andpublic sectors with backgrounds inmedicine, engineering, andadministration.

Over the past few months, theFrench Inspector General of SocialAffairs released a report highlycritical of private-sector medical

biology. Consequently, twomissions were launched with theaim of initiating reform in Frenchmedical biology, and reorganisingpublic sector laboratory medicine.This renewed interest owesnothing to chance, but rather tothe heightened awareness of thecentral role of laboratorymedicine as a necessarycomplement to the evolution ofhealthcare facilities. In effect,laboratory medicine unitesspecialties that contribute tomedical diagnoses (with theselection and therapeutic follow-up of medication, and of thosethat have an impact on quality andsafety).

One of the major challengesfacing our healthcare systemtoday is the system’s ability tointernalise the scientificdevelopments in which laboratorybiology takes a special place, by

guaranteeing equal access tohealthcare. This access cannot beguaranteed without consideringpatient information, geographicallocation, and the requirements ofIT and communications. In otheraspects of healthcare systems, justas assessing the relevance of med-lab analyses ensures that quality isguaranteed, so does the assessmentand just compensation of thosewho contribute to thatachievement. In reviewing Labmedicine, it is thus, in certainways, that questioning the qualityof care provided and the future ofthe public hospital that determineother developments; developmentssuch as collaboration betweenhospitals and strategic groups,efficiency, and the emergence ofpredictive medicine, translationalresearch connecting basic researchto patient care, and fosteringinnovation.

It becomes necessary, then, toreform the 1975 law that governsthe terms under which oneexercises one’s profession to meetthe current challenges of quality,competitiveness, financial issues,and to consider a new commonlegal framework. Quality ofhealthcare must be guaranteed inthe same manner in the privatesector and at the hospital, as bothsectors should contribute tomaintain the permanent provisionof healthcare. It is necessary toestablish synergies between theprivate and public sectors, and tobuild on the strengths of

professionals in order to perform,from the start, at a European level.

We have to learn to managedevelopments efficiently, and torespond to the strong growth ofdemand for biological diagnoses.One of the common approaches isquality, which requires regulation,as elsewhere in healthcare sector,through the adoption ofprofessional reference and dueprocess, as well as controls byboth peers and nationalauthorities. In this sense, the workof the European Federation ofClinical Chemistry on theaccreditation of laboratories inEurope makes a strong point for aEuropean quality medical biology

provider contributing to thisregulatory dynamic balance.

The FHF is contributing to thiscollective intelligence in definingthe most innovative experiments— in putting this issue in aEuropean framework, assessingthe capacity of technicalplatforms to cooperate with otherEuropean healthcare networks,making an inventory of thepotential, but also preparing theconditions for a successfulchangeover.*SFBC : Société française de biologieClinique** EFCC: European Federation ofClinical Chemistry and LaboratoryMedicine

The modern laboratory informationand management system

By Dr AndreasBess (right),Head of ITConsulting atmgm

Germany - Managing a lab for out-and in-patient care involves not onlymastering increasing pressures in termsof efficiency and cost-optimisation, butalso being au courant with ever evolv-ing clinical issues and state-of-the-artlab technology and procedures. In addi-tion to its core business – providing thefoundation for fast and high-qualitydiagnoses for a wide range of medicaldisciplines – the modern lab must per-form accounting and controlling tasks,from identifying and documenting bill-able services to generating invoices.

These varied tasks require data pro-cessing and data management supportthat only a sophisticated lab informa-tion and management system (LIMS)can offer.

First and foremost, to accommodateseveral facilities in a lab cluster whileensuring full compliance with privacyand data protection regulations, LIMSarchitecture must be scalable. It mustsupport different lab disciplines, such asclinical chemistry and endocrinology,haematology and immuno-haematol-ogy, microbiology, molecular biology,immunology, virology, toxicology, phar-macology and infection serology downto transfusion serology and blood depotmanagement – to name but a few.Additionally, the system must allowoutsourcing certain services to externalproviders, for highly specialised proce-dures, for example.

A state-of-the-art LIMS offers orderentry by the client. Data are transmittedvia an HL7 interface, or a web-basedLIMS tool, to the lab where the LIMSensures that samples and orders areidentified properly and that the digitalorder and samples are linked in a waycompliant with all quality assuranceand regulatory criteria.

After being logged in, the order isprocessed. The LIMS supports rule-based review of order-specimen-mater-

ial and subsequent queuing or assign-ment to available analysts or teams,according to the individual lab’sorganisational structure. The LIMSaccompanies the order through allstages of workflow and allows track-ing of the order along the entireprocess chain.

Analyses results are recorded anddocumented in the traditional quanti-tative forms, as well as in semi- andfull qualitative forms and charts andgraphs. Today, the ability to recordresults online, directly from lab instru-mentation, is an absolute must. Inaddition, decentralised equipment forpoint of care testing (POCT) must bemanaged by the LIMS, both in terms ofrecording results and of quality assur-ance procedures.

Medical validation is supported by atechnical validation, which means astaged release process is performed inwhich the results are tested on thebasis of reference tables and plausibil-ity criteria, possibly also in communi-cation with lab instrumentation andthe information services provided bythe manufacturers of reagents andequipment. Using plausibilities andcustomisable rules the LIMS generateswork sheets and task lists that areassigned to certain staff or physicians.

Efficient communication and trans-mission of results is a major challengein a lab with many different clients. Amodern LIMS offers a wide range offlexible (and printable) forms and for-mats that can be transmitted in vari-ous ways via different communication

standards. Anything, from simple andunstructured test results down the mostcomplex, highly structured and detailedreports that can be imported directlyinto the client’s system, should be pos-sible at the touch of a button. If theLIMS opts for the paper-less approach,and the data are available only in elec-tronic form, certain aspects assume crit-ical importance, such as validity andlong-term access to the data, authenti-cation and electronic signature.

All LIMS components are governedby statutory and voluntary qualityassurance requirements. QA in a labenvironment is a complex process thatinvolves the implementation of nation-al and international regulations, as wellas standardised operating procedures(SOP).

The lab components of an LIMS, suchas order management and result trans-mission, are complemented by sophisti-cated statistical, reporting and account-ing functionalities, which includerecording of billable services as well asbilling itself. The LIMS collects and rep-resents data on all services provided bythe lab and generates detailed anditemised invoices that satisfy therequirements of the lab and client.Consequently, the billing and account-ing functionalities of an LIMS should behighly flexible and customisable.

The control-oriented functionalitiesof a LIMS offer comprehensive report-ing options for long-term controlling aswell as for ad hoc analytical and statis-tical purposes, and answer both stan-dard and highly individualised queries.

In short: a modern LIMS shouldensure fast and cost-effective servicewhile integrating all information flowsthat serve one overall goal: to controlthe entire lab – both from a clinicaland a business viewpoint – while com-plying with regulatory and customerrequirements.Details: www.mgm-gmbh.deContact: post@mgm-gmbh.de orbess@mgm-gmbh.de

6 T H M C C - C O N G R E S S

The International Congress for Decision Makers in the Hospital Market

■ The Hospital-World of Tomorrow■ Successful Internationalization Strategies

for Hospitals■ Innovative Capitalization Models

– Improving Financial Performance ■ Benchmarking as an Appropriate Tool to Gain Excellence■ Opportunities and Threats of E-health and IT-Innovation■ Cooperation among Healthcare Stakeholders■ Quality and Transparency:

Key-Factors in Successful Competition■ The Impact of Medical Technology■ Migration: Patient / Staff / Training

MCC

2008

www.hospitalworld.info

WithSimultaneousTranslation

Strategic Options for the Hospital MarketSeptember 8 – 10, 2008, Berlin, Germany

Eric De Roodenbeke Director General, International Hos-pital Federation, France

Georg BaumCOO, Deutsche Krankenhaus-gesellschaft e.V., Germany

Dr. Robert BiderCEO, Klinik Hirslanden AG, Switzerland

Andreas Dahm-Griess Head of Business Center Healthcare, T-Systems Business Services GmbH, Germany

Dr. Günter Danner Dep. Dir., Bureau of the Joint Asso-ciations of German Statutory Social Insurance in Brus-sels, Belgium

Moderator: Your Experts:

Dr. Edwin de la H. HertzogChairman, Medi-Clinic Corporation Limited, South Africa

Khawar Mann Partner, Apax Partner Ltd, UK

Filippo Monteleone Director General, Générale de Santé, France

Drs. Guy Peeters CEO, Academisch Ziekenhuis Maas-tricht AZM, The Netherlands

Jörg Reschke CEO, Helios Kliniken GmbH, Germany

More information: Phone +49 (0)2421 12177-13MCC - The Communication Company · Scharnhorststraße 67a 52351 Dueren, Germany · E-Mail: mcc@mcc-seminare.de

Prof. Dr. Henning Saß CEO / Med. Director, University Hospital Aachen, Germany

Curtis J. Schroeder Group Chief Execu-tive Officer, Bum-rungrad Hospital Public Company Ltd., Thailand

Walter Wellinghausen Ret. Privy Council, Consultant to the Supervisory Board, Marseille-Kliniken AG, Germany

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28 EUROPEAN HOSPITAL Vol 17 Issue 2/08

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On the nearhorizonRegular patient screeningfor PhenylketonuriaThe first FDA-approved prescription med-ication that reduces blood phenylalanine(Phe) levels in patients withPhenylketonuria (PKU) — a genetic dis-order that prevents the normal use ofprotein foods and can lead to impairedbrain development if untreated — couldresult in more regular screening of bloodphenylalanine (Phe) levels in PKUpatients.

Biochrom Ltd, based in Cambridge, UK,reports that it is ready to provide both thenecessary screening instrumentation andthe PKU diagnostic reagents. ‘TheBiochrom 30 Physiological is a compactbench-top instrument designed for meta-bolic disorder screening and researchapplications. The instrument’s LithiumHigh Performance Columns perform a fullroutine analysis of physiological fluids,enabling the determination of up to 53different amino acids, including physio-logically important amino acids for earlydetection of hereditary metabolic disor-ders and the effectiveness of nutrientabsorption. The Biochrom 30 Physio-logical incorporates customised load andgo applications for simplicity of opera-tion, and the instrument’s software sup-ports a graphical user interface that fullyintegrates instrument control and datahandling functions and provides flexibledata export and customised reporting,’the company explains.

‘The IVD (In Vitro Diagnostic) Directiverequires that equipment and reagentsused for the in vitro diagnosis of PKU aresubject to stringent quality controls, certi-fied by an external, notified body.Biochrom was the first Amino AcidAnalyser manufacturer to achieve thiscertification for its PKU diagnosticreagents from the UK notified body, LRQA(Lloyds Register Quality Assurance), aspart of the company’s approval under thenew ISO 13485:2003 standard,’explained Sally Bee, Biochrom’s AminoAcid Analysis Marketing Manager.Details: www.biochrom.co.uk

14,000 urologistsflock to EAU 2008

Nearly 14 000 urologistsfrom 84 countries attendedthe 23rd Annual congressof the European

Association of Urology held inMilan, where changing horizons inthe diagnosis and therapy ofprostate cancer, a symposium spon-sored by Ipsen, underlined the mainfocus of the entire event.

New biomarkers for PCa werehighlighted at the launch of PRO-CABIO, a joint initiative of the urol-ogy department at Erasmus MedicalCentre, Rotterdam and theEuropean Randomised Study ofScreening for Prostate Cancer(ERSPC). Under the umbrella of thePRIAS study, a jointacademic/industrial partnership,PROCABIO focuses on targetedtherapy through the developmentand assessment of biomarkers. Newmarkers to detect and predict theoutcome in early prostate cancerare urgently needed. The ‘gold stan-dard’ biomarker, prostate-specificantigen (PSA), has limited diagnos-tic specificity and prognostic value.Its use has lead to a sharp decreasein the prevalence of advancedstages of prostate, but it is thoughtthat up to 50% of diagnosed patients,especially those with PSA levelslower than 10 ng/ml, would havebeen better served by active surveil-lance than invasive techniques.Exosomes from prostate cancercells have been identified as poten-tial biomarkers that are isolatedfrom patient’s serum to predict,from early stage, the outcome of thedisease.

Biomolecular diagnostics ofprostate cancer, taking a geneticrather than a proteomic approachsuggest, according to Schneider etal. (Dresden) that only four tran-script genes may be sufficient forPCa detection in minimal prostatetissue samples.

For more traditional PSA moni-toring, Beckman Coulter offers twonew WHO-calibrated Access assaysthat measure total prostate antigen(tPSA) and free (fPSA). Comparedwith the traditional Hybritech cali-brated assays the new assays gave

25% lower values for both tPSA andfPSA. In clinical practice this lowercut-off for tPSA should be consid-ered when using this assay.

Imaging techniques One Hamburg-based group has apromising new technique for PCadetection that uses ultrasound-based real-time-elastography (HI-RTE, Hitachi Real-time TissueElastography). Tested in 67 patientsundergoing radical prostatectomy,elastography was shown to have asensitivity of between 76-90% and aspecificity of 68-78% depending ontumour location, with best resultsat the gland apex. The authors thinkthere is high potential for elastogra-phy to improve PCa detection. Butwhether it can be used for targetedbiopsies and is as sensitive asextended biopsy schemes needs tobe determined. Results obtained inInnsbruck show that the use of astiffness-grading system canenhance the PCa detection rate andincrease diagnostic accuracy inreal-time-elastography.

Prostate cancer treatmentThe recovery of erectile functionand avoidance of positive surgicalmargins are competing outcomes ofradical, retro pubic prostatectomy.The decision to preserve or resectthe neurovascular bundle duringthe procedure is based on informa-tion concerning the presence and

LEAN PRINCIPLESBEFORE AND THROUGHOUT THE AUTOMATION PROCESS‘Lean Laboratory’ and ‘LeanAutomation’ are vital ingredientsfor the efficient and productiverunning of today’s modernPathology laboratories. Automationserves as an essential endorsementto Lean, says Paul M Button,Senior Consultant at ValuMetrix,Ortho Clinical Diagnostics*

There is ample evidence from aroundthe world that process improvementstrategies based on Lean solutions cancut costs, dramatically reduce process-ing times and free up valuable staff.Enthusiasts can also demonstrate thatsickness and absenteeism in the Leanworkplace can plummet.

In pathology such gains can be direct-ly translated into availability of extrabeds and improved patient care. Theunderlying principle of Lean – to changethe culture, create flow and eliminatewaste in all its forms – is logical andreadily understandable. It should be nosurprise that Lean process improvementis the methodology of choice for theUK’s National Health Service (NHS).Considering its outcomes, it is clear thatif Lean were a piece of equipment,every laboratory manager would buyone. But Lean is not a piece of equip-ment; it is a fundamental change inworking practices and the thinking

The majority of laboratories wouldbenefit from automation, but thisshould not be incorporated until afterlean implementation. Automating anon-Lean process will result in‘automating waste’ and this is very dif-ficult to rectify. Achieving an efficientflow is usually impossible withoutsome level of automation. The key is toachieve the right level of automation.Too little means you lose efficiency;too much means you lose reliabilityand affordability.

ValuMetrix Services offer a com-bined Lean and Automation approach,whereby the initial phase ensures thatthe laboratory implements Lean princi-ples followed by subsequent phasesthat implement automation at theappropriate points in the operations.This is done by a Lean techniqueknown as Value Stream Mapping,which moves the laboratory from thecurrent state through a series of futurestates to achieve the ideal world-classlaboratory.

The results can be astronomical withsubstantial reductions in turn-around-times, substantial reductions in error,substantial cost savings and signifi-cant increases in productivity therebyallowing business growth withoutincreasing head-count.

Further information on Lean and/orLaboratory automation can beobtained via your local Ortho ClinicalDiagnostics office.* A Johnson & Johnson Company

At the internation-al forefront of

microscopy for 169years, in the past two years,

the Royal Microscopical Society(RMS) has seen membershipincrease by 7%. The Society isresponsible for the Microscienceexhibition and conference; with a10% increase in exhibition spacefrom 2006, and 110% since 2002,this year will make this the biggestshow in Europe that focuses onmicroscopy, imaging and analysis.

‘The drive towards greatersophistication and miniaturisationof products that we use every dayin society, from mobile phones topharmaceuticals, inevitably meansthat we need to improve our scien-tific understanding at a finer scale,’said RMS President Professor MarkRainforth. ‘Consequently, greateremphasis is now placed onmicroscopy as the basic tool forproviding that understanding.Microscopy and imaging are expe-riencing a renaissance with theadvent of numerous new excitingtechniques, many of which will beshowcased at Microscience 2008.’

With key international compa-nies such as: Bruker, FEI, Hitachi,Jeol, Leica, Olympus, Oxford

location of the extra capsularextension (ECE). Nurembergresearchers have investigatedwhether dynamic contrast-enhanced endorectal MRI (eMRI)could be used accurately to depictthe positions of the structuresinvolved and aid decision-making.Obtaining excellent results, itappears to be a very sensitive pre-operative, clinical staging-methodto identify candidates for nervesparing RP. In patients with satis-factory erectile function, but a highclinical probability of ECE disease,functional eMRI should be includedin pre-operative tests and theresults acted upon.

An alternative and equally innov-ative technique was proposed in anAmerican study evaluating multi-photon microscopy with secondharmonic generation (SHG) and flu-orescence following excitation oftissues for in vivo imaging of theprostate. The procedure providesreal-time microscopic details thatcorrelate well with histologicalfindings and may play a greater rolein nerve sparing RP in future.

UK medical teams are trying amore personalised approach tooperational procedures. Pre-opera-tive MRI data giving the location ofthe prostate, the surrounding boneand also tumour position, locationof blood vessels and nerve bundlesis overlaid on the surgeon’s videodisplay to aid robot-assisted radical

surgery. Treatment options inadvanced prostate cancer were notforgotten. Radical retro pubicprostatectomy appears to be thebest treatment option with aGleason score �8. According to agroup from Moscow and Emporia,Kansas, nearly 72% of patientsremained progression-free for fiveyears post-surgery. Findings froman Italian study endorsed this,showing a higher rate (3-foldgreater) of secondary malignanciesin patients treated by exter-nal–beam radiation therapy ratherthan RP, without neo- or adjuvanthormonal therapy for localisedprostate cancer.

Intra-operative radiotherapy(IORT) for prostate cancer is a rela-tively new technique whereby highdoses of radiotherapy are givenduring surgical treatment. The vol-ume treated includes the prostate,the seminal vesicles and periopro-static area and the mean exposuretime was 30 minutes. In the so-fartested, small number of patientswith locally advanced prostate can-cer, the procedure represents aneasy, safe alternative, feasible inacceptable surgery time and withminimal toxicity. The procedurewas found to be suitable for 96% ofcases and 2 year follow-up finds all28 patients are still alive.

Other NewsBayer Schering Healthcare used theEAU to launch its new range ofmen’s healthcare products; Levitra,Testogel and Nebido, aimed to treatmen caught in the cycle betweenerectile dysfunction, low testos-terone and the metabolic syn-drome.

The EAU announced several newupdates of their guidelines includ-ing one on the management of neu-rogenic lower urinary tract dys-function (NLUTD), a multi-facetedpathology treatment of which tonow had been outside the urologi-cal field.(Downloads: www.uroweb.org/professional-resources/guidelines).Congress details:http://webcasts.prous.com/EAU2008/.

behind them. It is an attitude of mind,which constantly seeks to challengeand refine every aspect of working life.It is proven to work, but it can also hurt.

Established practices are demolishedin the search for culture change, flowcreation and waste elimination. Batchworking and specialisation go out; sin-gle piece flow and cross training enter.Laboratory staff that are desperate formore space, discover they can workbetter with significantly less. Managerscan discover the factors that reallyimpact on their workflow; biochemistswalk less as Lean processes improvelaboratory layout.

Johnson & Johnson’s ValuMetrixServices group first made its ProcessExcellence methodologies, whichinclude Lean, available to healthcareorganisations in 1999. Its proven suc-cess is based on a training and mentor-ing model that recognises that culturechange should not be imposed and thatcommunications and commitment lie atthe heart of any successful project.Unlike many consultancy or changemanagement processes, ValuMetrixactually sets out to transfer intellectualcapital and knowledge to the clientorganisation. The result is that futureprocess improvement projects can berun from internal resources.

Prostate cancer high on the agenda

Instruments, Veeco, Carl Zeiss UKand Carl Zeiss SMT exhibiting along-side nearly 100 others, the exhibi-tion will provide an eclectic selec-tion of the very latest microscopyrelated scientific equipment underone roof. There will also be a num-ber of companies new to the event,including Agilent Technologies, GEHealthcare, Smiths Detection,Thermo Scientific, Asylum Research,Cambridge Analytical Instruments,CEMMNT, Close-Ups, EdinburghInstruments, EMS, EssenInstruments, HWL ScientificInstruments, Laser 2000,Nanofactory, Nanonis, Attocube,Michelson Diagnostics, Mad CityLabs, Millbrook Instruments, QioptiqImaging Solutions, Tescan andSympatec.

‘We see Microscience as theMotor Show of Microscopy!’ saidRob Flavin, RMS Executive Director.‘In addition to the exhibition, therewill be specialist workshops demon-strating many of the newmicroscopy techniques and a chanceto pick up basic information on dif-ferent fundamental techniques inour RMS Learning Zone. These fea-tures are free to all visitors.’ Event details:www.microscience2008.org.uk

23-26 JuneLondon,England

MICROSCIENCE 2008

The next big development inbiological targeted therapies foradvanced breast cancer will be drugsacting via multiple mechanisms,experts told delegates attending the1st Asian Breast Cancer conference,held in New Delhi 9-10 February.

Professor Martine Piccart, Directorof Medicine at the Jules BordetInstitute, Belgium, and currentPresident of the EuropeanOrganisation for Research andTreatment of Cancer (EORTC), toldoncologists attending the First AsianBreast Cancer Conference in NewDelhi, India this month (February2008) that several biologicaltherapies directed at more than onetarget are in development. ‘It ishoped these will add to what hasbeen achieved by agents such asHER2/neu receptor inhibitortrastuzamab (Herceptin) andlapitinib (Tykerb), and the vascularendothelial growth factor (VEGF)blocker bevacizumab (Avastin). Newmulti-targeted agents, may furtherimprove median survival beyond thecurrently achievable 2-3 years’.

Sunitinib malate (Sutent), a smallmolecule oral tyrosine kinase

With 121 high level lectures and65 published posters, Analytica2008 – organised by the GermanChemical Society (GDCh), theSociety for Biochemistry andMolecular Biology (GBM) and theGerman United Society of ClinicalChemistry and LaboratoryMedicine (DGKL) – was again anotable bio-chemistry event.

EUROPEAN HOSPITAL Vol 17 Issue 2/08 29

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Multiple-targeted therapies The next big thing in advanced breast cancer

By Olwen Glynn Owen MScinhibitor, currently approved fortreatment of metastatic renalcarcinoma and gastrointestinalstromal tumour (GIST), is currentlythe most advanced in clinicaldevelopment of around 10investigational multi-targeted agentsfor metastatic breast cancer,speakers disclosed. All are activeagainst two or more targets. Othersinclude recentin (AZD2171), AMG706 and pazopanib.

The principal focus of new agentsis against angiogenesis, ProfessorJohn Crown, Consultant MedicalOncologist at St Vincent’s UniversityHospital, Dublin, told delegates; buttargeting VEGF alone is not enough.Several drugs act on additionalneovascularisation mechanisms .‘Sunitinib targets all VEGF andplatelet-derived growth factors(PDGF), the stem cell receptor KITand other factors including ,’ henoted. ‘PDGF has a role instabilising new blood vessels andtumours expressing PDGF and KITare associated with poor prognosis.

KIT is increasingly recognised intriple-negative breast cancers thatoncologists scratch their headsover,’ he added. ‘Some of thesedifficult-to-treat, HER 2 andhormone-receptor-negative patientsrespond to sunitinib so that’s ofgreat interest.’

Sunitinib has shown proof ofconcept in preclinical models ofadvanced breast cancer and hasdemonstrated activity as a singleagent in clinical studies, heremarked. In a phase II clinicalstudy of heavily pre-treatedmetastatic breast cancer patients,single-agent sunitinib therapyshowed an 11 per cent partialresponse rate. In another study of 22patients who had failed adjuvantanthracycline-containing regimens,sunitinib combined at a dose of37.5mg/day with docetaxel(75mg/m2 every three weeks), usinga dosing schedule of two weeks onand one week off, showedsynergistic activity achieving a 72per cent partial response rate in 18evaluable patients treated over 159cycles. ‘This is clearly a very activecombination and it has gone on to

Research on small RNA moleculescould bring new therapiesThe discovery of small RNA molecules and theirrelevance for gene regulation has dramaticallychanged our understanding of many essential cellularprocesses – and provides the opportunity to developnew ways for treating various diseases. By selectivelyinhibiting gene expression and thereby ‘silencing’genes involved in pathogenesis, the RNA moleculesconstitute a unique tool to treat cancer, neurologicaldisorders or viral infections and other human diseases.At the XX International Congress of Genetics, held inBerlin (12-17 July) experts will present results from thelatest research in RNA biology and discuss potentialapplications.

‘Today, small RNAs are increasingly developing intoa therapeutic tool and there is reasonable hope thatthis will be successful in the near future,’ explained

Professor Alfred Nordheim, Secretary General of theXX International Congress of Genetics.

Apart from RNA genetics, modern genetic researchis already contributing much to combat diseases. Inrecent years, improved sequencing techniques madepossible the rapid diagnosis of infectious bacteria orother pathogens. Bacterial cultures of patientspecimens, which often take days to grow in the lab,thus become redundant, and effective therapies can beimplemented sooner. ‘There is hardly a disease without a genetic component’, the professorobserved. ‘Not only pathogens, but also food, lifestyleor radiation can make us sick by influencing andchanging our genetic information, or its expression.We are now beginning to understand the functioningof a cell on the molecular level.’

The trend towards automationwas keenly discussed, in terms ofcosts and competitive needs. It wasobserved that this promotesincreasing investments in (semi)-automated systems, and thatautomation is also called for whendevelopment is heading from labo-ratory analytics towards processanalytics. Automated sample han-dling, for instance, not only guaran-tees a high capacity of samples butalso facilitates fast and reliableonline diagnostics for differentsubstances. This in turn results inincreased importance of the inter-action between technology and therespective software tools.

Nanobiotechnology intumour diagnosticsMore precise, quicker andcheaper laboratory analysis ispromised due to a new typeof technology — Immune-SERS-Microscopics — devel-oped by researchers at theInstitute for PhysicalChemistry at WürzburgUniversity, which is currentlyawaiting patent. In this, goldnanoparticles of a certainshape and size are coveredwith a layer of organic mole-cules (Raman markers). This isprotected by a layer of glasscoated with different ligatessuch as antibodies. Theserespectively bind to specificbiomolecules, such as those inblood samples. Through expo-sure to laser light these giveoff characteristic signalswhich can then be detected.The method allows the deter-mination of type and numberof many different biomole-cules at the same time, whichfacilitates, for example, moreexact tumour analysis andtherefore improved, individ-ual therapy – faster and lesscostly than previously.

further investigation in a largerphase III trial,’ he noted. Toxicitywas as expected given the inclusionof docetaxel but was manageable,he added

Current phase III trials are nowinvestigating sunitinib with taxanesor capecitabine in advanced breastcancer both in chemotherapy-naïveand heavily pre-treated patients whohave failed multiple chemotherapyregimens. One trial will investigate acombination of paclitaxel andsunitinib against paclitaxel andbevacizumab as first-line therapy.Another is looking at a combinationof docetaxel and sunitinib as firstline therapy. In previously-treatedpatients, sunitinib is being

investigated in combination withcapecitabine in one trial and is beingcompared as single-agent therapyagainst capecitabine in another. Afurther phase II trial is exploringsunitinib as second-line therapy versusstandard care in previously-treatedtriple negative patients.

If sunitinib shows sufficient clinicalactivity in phase III metastatic breastcancer trials in combination withchemotherapy, one of the next reallyinteresting lines of investigation to bepursued will be to look at it incombination with HER2/neuantagonists, he suggested. Trials arecurrently still recruiting patients.Further information can be obtained atwww.suntrials.com.

Analytica 2008

The top event focussing on the”clinic principle“

TopClinica is the new, attractive platform for

suppliers of medical technology, medical products

and services concerned with the “clinic principle“.

Over 150 exhibitors from Germany and abroad

will offer commercial and medical decision-makers

in clinics a first-class international forum as well

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11 to 13 June 2008Cooperation partnerCongress partner

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N E W SИнфекционные болезни

Томотерапия: раковые опухоли подточным прицелом новой техникиБолее высокие шансы на выздоровление и меньше побочныхпоследствий – клиника Гелиос Берлин-Бух – это одна изпервых клиник Германии, использующая в лечении онколо-гических пациентов аппарат томотерапии.

Эксперты мирового уровня из Индии о туберкулезе.

Число заболеваний туберку-лезом в Индии составляетпятую часть от общего числазаболеваний по всемуземному шару, это самаятяжелая статистика потуберкулезу в мире.Источник: Всемирная орган-изация здравоохранения,Женева Доклад ВОЗ 2006 года:Организация контролятуберкулеза на глобальномуровне; наблюдение, планиро-вание и финансирование.Каждые три минуты два челове-ка в Индии умирают от тубер-кулеза. Это соответствует чис-лу: 370.000 смертей ежегодно.Туберкулез в Индии – это такжекрайне большие экономическиепотери, прямые расходы насчи-тывают 300 миллионов $ CША,при косвенных расходах в 3миллиарда $ CША.

Обновленная национальнаяпрограмма по контролю тубер-кулеза является самой обшир-ной подобной программой вмире, это ставит сотрудниковсистемы здравоохранения Ин-дии на уровень мировых экс-пертов в вопросах диагностики,лечения и общей организацииконтроля, терапии и профила-ктики населения по поводу туб-еркулеза. Программа началадействовать в октябре 1993года в качестве предварител-ьного проекта, после того, какВсемирная организация здрав-оохранения, Шведское аген-тство по международному

развитию, а также правительс-тво Индии сочли, что существо-вавшие на то время инициа-тивы по контролю и лечениютуберкулеза нуждаются вкапитальном пересмотре исовершенствовании.

Обновленная национальнаяпрограмма по контролютуберкулеза уже в качествепробного проекта достигластоль впечатляющих резу-льтатов, что с 1997 года она ст-ала действовать в качестве по-стоянной национальной програ-ммы. Через десять лет в рам-ках указанной программыудалось достигнуть 70%-ноговыявления туберкулеза, приуспешном излечивании в 85%случаев. На 31 декабря 2007года было проведено лечение6,7 миллиона пациентов и бо-лее чем 1,2 миллиону людейспасли жизнь. В настоящеевремя ежемесячно проводитсятерапия более чем 100.000

пациентов. Широко используется

стратегия DOTS, что означает:Ускоренный курс амбулаторнойтерапии, проходящий поднепосредственным контролем.Данный подход пре-

дусматривает:- своевременное выявление

заболевания; - лечение с назначением

полного курса медикаментовв продолжении 6 месяцев,или, в случаемультирезистентных формтуберкулеза, в продолжении18-24 месяцев;

- агрессивное наблюдениепациента в течение всегопериода лечения.

В рамках Национальной прог-раммы по контролютуберкулеза при участиинациональных, региональных иместных властей по всейстране организованы и действ-уют специальные кабинеты.

Некоторые активные пациентытакже вовлечены в эту работу.

Индийские радиологи нараб-отали большой опыт ввыявлении как обычных, так иредких форм туберкулеза. Этозаболевание стало одной изтем под рубрикой«Европейское радиологическоеобщество (ESR) встречается сИндией», обсуждавшихся входе недавнего Европейскогорадиологического конгресса2008 (ECR). Открывая сессию,доктор наук Х.Сатишчандра (DrH Satishchandra), профессор,глава отделения Медицинскогоучебного и исследовательскогоинститута г. Бангалор (Bangalo-re Medical College and ResearchInstitute), продемонстрировалдиагностические изображениясимптомов туберкулеза,полученные при помощи рент-гена, компьютерной томогра-фии и магнитно-резонанснойвизуализации. Симптомы могутбыть очень похожи насимптомы других заболеваний.Так, например, проявлениятуберкулеза легких могут бытьочень схожи с проявлениямиширокого спектра заболеваний,от пневмонии до злокачест-венных опухолей. Симптомыабдоминальной формытуберкулеза могут быть сходныс симптоматикой новоо-бразований иливоспалительных процессоворганов брюшной полости.

Случаи заболевания туберк-улезом в большинствеевропейских страннемногочисленны, однакоследует учитывать, что к этомузаболеванию особенно воспри-

имчивы больные СПИДом. Воз-никновение в последнее времяорганизмов, резистентных к ле-карствам, а также увеличениечисла заболеваний диабетом иСПИДом привели к появлениютуберкулеза в его измененныхпроявлениях. Для выявленияабдоминального туберкулезаприменяется ультразвуковаядиагностика. Доктор наук С.Дода, фирма «Дода имиджинг»(Doda Imaging), Нью-Дели, ра-ссказал, как он в своей частнойпрактике использует данную ме-тодику, экспериментируя и имп-ровизируя в ходе работы. Приисследовании спинальных и па-равертебральных структурмагнитно-резонанснаявизуализация очень эффект-ивна в очерчивании типичныхмоделей, по которым про-исходит поражение туберкул-езом этих областей. Она такжеочень полезна в отслеживаниирезультатов лечения. Длядиагностики интракраниальноготуберкулеза используетсяспектроскопия.

Академические больницыИндии находятся на переднемкрае по некоторым направлени-ям исследовательской работыпо диагностике и лечению туб-еркулеза. Доктор Сатишчандраподчеркнул, что радиологи Ев-ропы в случае затруднений враспознавании скрытых формтуберкулеза могут обратиться законсультацией к своим индий-ским коллегам, так как ониявляются экспертами в областитакой диагностики.

Дополнительная информацияи статистика: www.eurotb.org, атакже: www.tbcindia.org

Автор: Цинтия Е. Кин(Cynthia E. Keen)

В Германии ежегодно около400.000 человек становятсяпациентами онкологическихклиник. Примерно 60 процен-тов из них подвергаетсялечению при помощи лучевойтерапии. При облучении обы-чными аппаратами опухолей,расположенных в труднодост-упных местах, рядом с важн-ыми, чувствительными орган-ами, такими, как головной мозг,легкие, простата, органы вполости живота, часто прихо-дится мириться с тяжёлымипобочными последствиями. К

упомянутым последствиямотносятся, например, кровоте-чения, хронические воспаленияили ограничения в функцияхорганов. «Томотерапия откры-вает новые возможности ипозволяет индивидуально длякаждого пациента подбиратьметодики лечения», отмечает судовлетворением профессордр. Роберт Кремпиен. По мнен-ию главного врача клиникилучевой терапии центра ГелиосБерлин-Бух, новая техника явл-яется огромным шагом вперёд.«При помощи новой системы

Одна пятая всех заболеваний туберкулёзом в мире приходится на Индию.Источник: ВОЗ, Женева; Доклад ВОЗ 2006 г.: „Организация контроля туберкул-еза на глобальном уровне; наблюдение, планирование и финансирование.“

Тревожные случаи заболевания туберкулёзом в АвстрииЕжегодно в мире от туберк-улёза умирают более 1,5 мил-лионов человек. Одна третьнаселения планеты инфици-рована бактерией „Myobacte-rium tuberculosis“, у 9 милли-онов человек развиваетсятуберкулёз. Конечно, в Евр-опе примнимают к сведениюинформацию о том, чтоказалось бы «побеждённая»болезнь вновь наступает,однако маштабы этого наст-

упления, очевидно, все ещёнедооцениваются.

Только в феврале этого годав венском детском саду неско-лько детей были зараженывоспитательницей, а в началемарта на итальяно-австрийскойгранице в селении Арнольд-штайн у жены владельца бул-очной была диагностированаоткрытая форма туберкулёза.Местные власти и клиникибыли заняты тем, чтобы не

допустить дальнейшее расп-ространение болезни. И всё-же, количество заболевшихтуберкулёзом в Австрии чутьменее 1000 человек в годостаётся константным. Умень-шение количества заболева-ний затрудняется из-за нали-чия широкого обмена товар-ами и туристами со странами,в которых населениеподвержено высокому рискузаболевания туберкулёзом.

томотерапии мы можем теперьлечить онкологических паци-ентов, в отношении которыхприменение лучевой терапиидо сих пор считалось невозм-ожным».

Томотерапевтическая техн-ика представляет собой комб-инацию из линейного ускор-ителя и компьютерного томог-рафа, а методика лечения припомощи этой техники являетсяна данный момент во всёммире самой современной влучевой терапии. Лишь оченьнемногие клиники Германии

Австрийскоенаселение и власти,ответственные заздравоохранение вАвстрии,взволнованынеобычно высокимколичеством детейзаболевших впоследнее времякорью. Первыеслучаи заболеваниязафиксированы водной из частныхшкол Зальцбурга,однако, в течениемарта, началаапреля отмечено всёбольшее количествозаболеваний. Тольков округе Зальцбургав течениенескольких днейбылозафиксированоболее 180заболевших,отдельные случаизаболеваний былиобнаружены награнице с Баварией,

в Верхней Австрии, атакже в земле Бург.Имевшееся подозрениео специальномзаражении здоровыхдетей при контактах сбольными на такназываемых«праздниках кори» неподтвердилось.

Несмотря на то, что вшкольном планепрививок рекомендованакомбинированнаяпрививка против кори,эпидемического пароти-та и краснухи для всехдетей, эта прививкасделана только 90 %школьников. Посколькуинфицированный корьюребёнок может всреднем заразить около15 незащищённыхпрививкой человек, товновь открытадисскуссия онеобходимостиосуществления обязате-льных прививок для всехшкольников.

Многочисленныеслучаи заболеваниякорью в Зальцбурге

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N E W SРадиология

располагают в настоящее вре-мя аппаратом стоимостью в 3,5миллиона евро. Применяемаяметодика облучения всех зло-качественных клеток даёт реш-ающие преимущества при леч-ении опухолей головного мозга,лёгких, простаты, а такжеопухолей, находящихся побли-зости от важных органов.

В то время как компьютер-ный томограф высокого раз-решения перед каждой дозойоблучения с большой точно-стью локализует положениеопухоли, линейный ускоритель,вращающийся вокруг пациента,облучает опухоль со всех сто-рон. «Мы щадим тем самымчувствительные органы, неподвергаем их облучению иодновременно облучаем самуопухоль по разным направле-ниям», - поясняет профессорКремпиен, подчеркивая глав-ное преимущество даннойметодики. Кроме того, дозаоблучения, при помощи кото-рой разрушается раковаяопухоль, может быть индиви-дуально скорректирована взависимости от «плотностиопухоли», т.е. от количестваопухолевых клеток. Такимобразом улучшается защитаздоровых тканей вокруг опух-оли и соседних с ней органов.

Другим положительныммоментом является то, что припомощи системы томотерапииможно осуществлять облуче-ние опухолевых очагов и мета-стазов в ходе одной рабочейпроцедуры. Интенсивностьоблучения устанавливается сбольшой точностью в зависим-ости от масштаба распростра-нения, размера и характераопухоли. Таким образом можетбыть повышена защита здор-овых тканей вокруг опухоли исоседних с ней органов. В зав-исимости от размера и характ-ера опухоли время облучениясоставляет от 5 до 20 минут.

Положение органов и опухо-лей в организме постоянноменяется. Например, в завис-имости от наполненности моче-вого пузыря простата можетсмещаться на расстояние додвух сантиметров, а в процессеоблучения к тому же уменьшат-ься. До настоящего временипри облучении обычнымиаппаратами врачи компенсир-уют смещение органов путемувеличения поверхности облуч-ения, с тем, чтобы в любомслучае гарантировать попада-ние луча в цель. При такойтерапии карциномы простатыоблучению подвергается такжеи часть кишечника, что в лучш-ем случае вызывает болезнен-ное раздражение кишечника, ав худшем - необратимые хро-нические воспаления. В про-тивоположность этому, систематомотерапии реагирует на

Университетский медицинский центр«Гамбург-Эппендорф» (UKE) Университетский медицинский центр

«Гамбург-Эппендорф» (UKE) – самый крупный

медицинский центр в северной Германии. Центр

пользуется известностью благодаря высокому

качеству медицины, а также тем, что своей

исследовательской деятельностью прокладыва-

ет новые пути в медицине. Новейшие апробиро-

ванные результаты медицинских исследований

в лечении пациентов используются в наших

специализированных отделениях. Медицинский

центр «Гамбург-Эппендорф» занимает первое

место в Германии по количеству новых апроби-

рованных лечебных методик в Европе. Осново-

полагающей философией UKE является посто-

янная деятельность по развитию новых и

улучшенению имеющихся методов диагностики

и лечения заболеваний, при этом особый упор

делается на решение сложных медицинских

проблем к которым относятся: рак, транспланта-

ции, болезни сердца, системные детские

заболевания, специальная урология, редкие

болезни кишечного тракта, диабет, специальные

офтальмология и отоларингология. Центр

располагает ведущим в мире клиническим

отделением по лечению рака простаты.

Вышеизложенные факторы делают UKЕ

привлекательным для пациентов из всех стран

мира; больные желают получить здесь

первоклассное обслуживание в части

диагностики, лечения и последующей

реабилитации. Таким образом, Медицинский

Центр является лидером в глобальном

высоко-специализированном мире медицины.

Центр UKE отвечает высоким требованиям,

которые предъявляют ему задачи лечения

пациентов из разных стран. Пациенты, а также

их родные и друзья получают медицинскую

помощь, которая включает в себя диагностику и

терапию; помимо этого, предоставляется

организационно-административное

обслуживание, как для пациента, так и для его

близких, например, услуги переводчиков и

персональных тренеров-инструкторов из числа

носителей родного для пациента языка.

Университетский медицинский центр

«Гамбург-Эппендорф» считается в Германии

пионером в области исследований, образования

и медицинской подготовки; он, в то же время,

является надежным источником альтернативных

медицинских заключений. Центр UKE имеет

специальный отдел для работы с иностранными

пациентами, который координирует все органи-

зационные, финансовые, административные и

личные проблемы пациентов.

Контакт:

тел.: +49 40 42 803 1690

patients@uke.uni-hamburg.de; www.uke.io.de

происходящиесмещенияорганов вовремя процессаоблучения.Аппараттомотерапииперед каждойдозой облучениявыдаёт припомощи встр-оенногокомпьютерноготомографаактуальноеизображение

опухоли в ее реальной велич-ине и местоположении. Таким

деятелей ГДР», коротконазывавшаяся «правите-льственная клиника». Вскорепосле этого (с 1976 до 1980г.г.) по соседству былапостроена «клиника пообслуживанию сотрудниковМинистерства государ-ственной безопасности ГДР исотрудников дружественныхорганов госбезопасности». В1988 году медицинский ком-плекс Берлин-Бух мог прини-мать одновременно 5.000пациентов, требующихлечения и ухода. Говорили,что это «крупнейшая клиникаЕвразии».

образом, облучение попадаетточно в цель, вне зависимостиот смещения органов.

История клиники, в которойработает профессор д-р Робе-рт Кремпиен, начинает отсчёт с1899 года и является неотъем-лемой составной частью истор-ии развития медицины Федера-тивной республики Германия.Уже в 20-х годах прошлогостолетия со строительствоминститута головного мозга им.Кайзера Вильгельма был зало-жен фундамент для проведен-ия биомедицинских исследо-ваний.

В ГДР, с основанием Академ-

ии Наук, данныеисследования получилидальнейшее развитие.Возникли академическиеинституты и клиники в Берл-ине-Бух, которые осуществл-яли научные исследования вобласти терапии онкологиче-ских заболеваний изаболеваний сердечно-сосудистой системы. Всемидесятых годахпоявились ещё две клиники:с 1973 по 1976 год наХобрехтсфельдер шоссевведена в строй «клиника пообслуживанию членовправительства и партийных

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N E W SКардиология

Важна оценка степени общего риска

Статины снижают рисксердечно-сосудистых забол-еваний, при этом уровеньсодержания холестерина вкрови не играет роли.

Последние рекомендацииЕвропейского общества по бор-ьбе с гипертонией и Европей-ского кардиологического обще-ства (ESH/ESC) советуютиспользовать статины в лечен-ии пациентов

группы высокого рисканезависимо от уровня содержа-ния холестерина. Оба назван-ные Общества опубликовалисовместные рекомендации подиагностике и лечению гипе-ртонии в Европе в 2003 году.Эти рекомендации былипересмотрены в конце 2007года; в их более актуальномварианте отражены прогрес-сивные возможности лечениягипертонии, а также результатынекоторых основных провод-имых на международномуровне исследований в обла-сти сердечно-сосудистоймедицины. Новый подход кпроблеме отдает предпочтениееё комплексному решению сточки зрения оценки абсолю-тного риска возникновениясердечно-сосудистых забол-еваний у конкретного пациента,в противовес учёту лишьотдельных факторов риска.

В терапии кардиоваскуляр-

Рекомендации по лечению гипертонииных факторов риска лечениепо нескольким направлениямпредставляется гораздо болееэффективным, чем терапиятолько по одному из направле-ний. Так, например, снижениена 10 % кровяного давления ина 10% общего уровня содерж-ания холестерина в крови даётснижение риска кардиоваску-лярного заболевания болеечем на 40%.

Конечные данные исследо-ваний ASCOT-ЭСКОТ (Англо-скандинавские исследованиярезультатов терапии сердечныхзаболеваний), которые прод-емонстрировали столь значит-ельные улучшения в леченииисердечно-сосудистых заболе-ваний, явились существеннымстимулом к изменению вышеу-помянутых рекомендаций.Были проведены рандомизиро-ванные исследования прим-ерно у 20.000 пациентов извсех стран Северной Европы,страдающих гипертонией инаходящихся на амбулаторномили стационарном лечении, поодному из направлений иссле-дований ЭСКОТ, а именно,снижению уровня липидов. Всепациенты, участвовавшие висследованиях по этому нап-равлению, имели общий уров-ень содержания сывороточногохолестерина < 6,5 ммоль/л, вих анамнезе не было ниишемической болезни сердца,

ни сердечного инфаркта, но поусловиям исследования у нихдолжны были наблюдатьсядополнительно 3 показателя науровне риска возникновениясердечно-сосудистого заболе-вания. Рандомизация с двойн-ой степенью анонимности озн-ачала, что пациенты в допол-нение к назначенной анитиги-пертонической терапии каждыйдень получали 10 мг аторвас-татина, или же плацебо.

В ходе рандомизированногоисследования было абсолютнонеясно, будут ли наблюдатьсясинергические эффекты вплане предотвращения карди-оваскулярных инцидентов врезультате мер по снижениюкровяного давления на фонеснижения уровня липидов. Упациентов наблюдались один-аковые показатели снижениякровяного давления, но сниже-ние уровня липидов на этомфоне привело к существенномуулучшению общих результатов.

Исследования были оконч-ены почти на 3 года и 4 месяцараньше, чем это было запла-нировано, так как по основнымпоказателям были полученысущественные позитивныерезультаты, а именно: умень-шение на 36% относительногориска нелетального инфарктамиокарда и летальной ишемич-еской болезни сердца, уменьш-ение на 45% относительного

риска формирования нелет-ального инфаркта миокарда,уменьшение на 27% относит-ельного риска инсульта.

Анализ результатов исследо-вания показал, что существ-енные положительные резуль-таты начинают проявлятьсяуже после трех месяцев посленачала терапии. Данныерезультаты являются оченьважными, так как терапиястатинами ранее назначаласьлишь больным, страдающимгиперхолистеринемией. Новыерекомендации разъясняют, чтопациенты - гипертоники сповышенной степенью рискавозникновения сердечно-сосуд-истых заболеваний (более,чем 20%), но с нормальнымуровнем содержания холесте-рина, также могут получитьпользу от назначения терапиистатинами. Для врачей напрактике это означает, что прилечении пациента с высокойстепенью риска они сначалаоценивают степень риска, и взависимости от результата, вслучае, если это являетсяединственной возможностьюпредотвращения серьезныхкардиоваскулярных осложне-ний, назначают агрессивнуютерапию.

В случае пациентов-диаб-етиков, а также пациентов,имеющих в анамнезе серде-чно-сосудистые заболевания,

необходимо также применениеболее агрессивных терапий, стем, чтобы постараться предо-твратить серьезные сердечно-сосудистые инциденты. Новыерекомендации также высказыв-аются в пользу начала антигип-ертонической терапии дляпациентов, страдающих диабе-том, на стадии, когда кровяноедавление варьирует в диапаз-оне от повышенного до нор-мального.

Приницип подхода к лечениюсердечно-сосудистых заболе-ваний с точки зрения оценкисовокупного риска, заявленныйв рекомендациях ESH/ESC,соответствует принципам,изложенным в большей частимеждународных рекомендацийпо лечению сердечно-сосудистых заболеваний.

Ссылка на источники:Mancia G. (Манча Дж.)

Лечение повышенногоартериального давленияEuropean Heart Journal 2007, 28,1462-1536

Sever Peter S. Терапия поснижению уровня липидов ипациенты с множественнымифакторами риска: что новогомы узнали из Англо-скандин-авских исследований резуль-татов лечения сердечных заб-олеваний (ASCOT) The Ameri-can Journal of Medicine 2005;volume118; Issue 12 Supplement1, pages 3-9

Университетский Центр сердца меди-цинского комплекса Гамбург-Эппен-дорф (UKE)

Информация об Универси-тетском Центре сердца UKEчасто попадает на страницынемецких и иностранных газет,благодаря проводимым таминновационным хирургическимвмешательствам и операциямна открытом сердце. Так, спец-иалисты Центра сердца, кард-иологи и хирурги, осуществилиустановку нового кл-апана аорты паци-енту в возрасте 81года без проведенияоперации. Посколькуоперация на откр-ытом сердце предс-тавляла для пациен-та большую опасн-ость, специалистыЦентра серца реши-лись установить сер-дечный клапан черезсосуд при помощиспециального катет-ера. При помощи ультразвукабыли проведены необходимыеизмерения сердечного клапанапациента, после чего катетербыл введен через сосуд доповреждённого места в сердце.Затем, баллон, который былзакреплён на катетере раскр-ылся так, что старый клапансильно растянулся и возникломесто для размещения новогоклапана. Новый клапан в слож-енном состоянии был введёнпри помощи катетера в левыйжелудочек сердца и там раскр-ыт. Хирургическое вмешательс-тво с использованием такойконструкции было осуществл-

ено в конце прошлого года впе-рвые в мире в университетскомЦентре сердца. У данного пац-иента высокого риска такоехирургическое вмешательствобыло единственной возможнос-тью для спасения жизни.

Университетский Центр сер-дца известен также благодаряи другим выдающимся медиц-инским успехам. Например,такое широко распространён-

ное сердечное забо-левание как аритмияизлечивается в Центресердца при помощиоперационного роботас навигатором.Такаяметодика, по срав-нению с традиционны-ми, имеет ряд преиму-ществ: они заключаю-тся в том, что трёх-мерная навигация роб-ота позволяет добиват-ься гораздо более выс-кой точности и безопа-

сности проведения вмешател-ьства. При таких видах хирур-гических вмешательств небыло ещё ни одного случаямедицинских осложнений илитехнических проблем, а у паци-ентов не наблюдалось рециди-вов. Философией университ-етского Центра сердца являет-ся внедрение и использованиещадящих для пациентов мето-дик лечения. Малоинвазивныехирургические вмешательствапользуются у пациентов всёбольшим спросом, и специал-исты Центра сердца предлаг-ают такие процедуры в полномобъёме.

Университетский Центр сер-дца является одним из ведущихи широко известных в Германиии в Европе благодаряпроведению сложных и компле-ксных хирургических вмешател-ьств с использованием новей-ших технологий. Особенно этоотносится к операциям по восс-тановлению сердечных клапан-ов, успех которых обеспеченмноголетним позитивным опыт-ом, накопленным специалиста-ми кардиохирургии Центрасердца.

Университетская база Центрасердца позволяет гарантир-овать, что новейшие данные,полученные в ходе научныхисследований, быстро внедр-яются в медицинскую практику.Широкая известность Центрасердца не только в Германии,но и за её пределами привле-кает в Гамбург многих иностра-нных пациентов для прохож-дения лечения. Междунаро-дный отдел Университетскогоцентра UKE берёт на себя всевопросы по индивидуальномуобслуживанию таких иностра-нных пациентов. Для пацие-нтов, говорящих на русскомязыке контактным лицом явля-ется сотрудница меджународ-ного отдела Ирма Агрикола(тел.: +49 177 4001903), с котор-ой Вы можете связаться влюбое время. Ваши вопросыВы можете также направить нарусском языке по следующемуадресу электронной почты:patients@uke.uni-hamburg.de. Навсе Ваши вопросы Вам будетдан ответ на русском языке.

Профессор, д-р., д-р.,ГерманРайхенспурнер

Мы рады тому, что с публикацией

русской специальной части нашего

издания мы продолжаем обмен

информацией между западно-

европейским и российским секторами

медицины. Этому способствуют в

англоязычной части журнала статьи

наших российских корреспондентов и

авторов.

Профессор Геннадий Сушкевич в своей

статье рассказывает о работе

московского научно-

исследовательского института

неотложной детской хирургиии и

травматологии на стр. 23

Наш российский корреспондент Ольга

Островская сообщает о междунаро-

дной конференции передовых

технологий лечения диабета (ATTD),

прошедшей в Праге (стр. 3) и о 3-ем

российском съезде интервенционных

кардиоангиологов, состоявшемся в

марте этого года в Москве (стр. 19)

Наша информация

32 EUROPEAN HOSPITAL Vol 17 Issue 2/08

Хирургия / Кардиология

По данным регистра рожд-аемости г. Майнца примерно у1,26 процента всех новорож-деных младенцев ежегоднодиагностируется врождённыйпорок сердца. В связи с этим,врождённые пороки сердцасчитаются наиболее частовстречающейся аномалиейразвития. Если упомянутаяаномалия не подвергаетсялечению, это может привести кухудшению качества жизни иуменьшению продолжительн-ости жизни. До недавнеговремени врождённые порокисердца устранялись путёмпроведения сложных операций– сегодня значительная их

Детская кардиология университетской клиники г. Майнцарасширила спектр щадящих методик лечения.Имплантированапервая биологи-чески устраня-ющаяся системапо лечениюпороков детско-го сердца.

часть излечивается путем ма-лоинвазивных хирургическихвмешательств, а именно, припомощи катетеров для зондир-ования сердца, в большинствеслучаев путём введения импл-антатов. В детской кардиологииуниверситетской клиники г.Майнца с декабря 2007 годаприменяется первая биолог-ически устраняющаяся системаимплантатов. Преимуществаэтой системы вытекают изприменения малоинвазивногометода вмешательства, а такжеиз того обстоятельства, чтопороки излечиваются в ходероста сердца, а имплантатвпоследствии практическиполностью устраняется биол-огически. Одновременно есте-ственная реакция заживленияспособствует замещениюимплантата тканями собств-енного организма.

Имевшиеся на рынке импла-нтатные системы для устран-ения порока сердечной перего-родки изготавливались изнепоглощаемого материала.Через несколько месяцевпосле их внедрения они полн-

остью врастали в ткани орган-изма и выполняли свою функ-цию по устранению порока,одновременно отпадала необ-ходимость и в имплантате.Однако, поскольку такая систе-ма не может быть устранена иостаётся в растущем орган-изме, это может приводить кпобочным последствиям,таким, как например, хронич-еское раздражение от прису-тствия постороннего предмета,повышенный риск образованиятромбов. Могут иметь местодаже усталостные трещиныметаллических частей системы.

Новая имплантатная системаявляется временной для орган-изма системой по устранениюпороков сердца, так как послезаживления и обрастания соб-ственными тканями организмаона практически полностьюрастворяется. Наиболее подхо-дящей эта система являетсядля детей, имеющих так назыв-аемый малый или средний пор-ок предсердия (ASD II), а такжедля взрослых с персистирующ-им овальным отверстием(PFO). Часто порок PFO

выявляется лишь при уточнен-ии причин инсульта или мигре-ни.

В детской кардиологии кли-ники университета им. ИоганаГутенберга г. Майнца в течение10 лет осуществляется лечениеврождённых пороков при помо-щи катетеров зондированиясердца. За это время прове-дено более 1500 таких вмеша-тельств, что позволило полно-стью отказаться от операций наоткрытом сердце. К вышеуп-омянутым малоинвазивнымвмешательствам относятсятакже и вмешательства поустранению порока межжелуд-очной перегородки сердца.Малоинвазивное вмешательс-тво для устранения данногопорока проведено у более чем400 пациентов. С декабря 2007года в отделении врожденныхпороков Центра детской июношеской медицины клиникиуниверситета им. Иогана Гутен-берга в г.Майнце под руководс-твом профессора д-ра Крист-офа Кампманна успешно прим-еняется первая сертифициро-ванная биологически устран-

яющаяся система имплантатов.В течение 30 лет предприни-

маются попытки устраненияпороков сердца в областимежпредсердной перегородкипри помощи малоинвазивныххирургических вмешательств сиспользованием катетеровзондирования сердца. Новаясистема имплантатов являетсяпервой системой, которая послеуспешного устранения порокасердца практически полностьюудаляется из организма. «Темсамым удалось добиться оченьсущественного прогресса вобласти использования катет-еров зондирования сердца» -говорит руководитель отделенияврождённых пороков сердцаЦентра детской и юношескоймедицины клиники университетаим. Иогана Гутенберга в г.Майнце.

Комплексный. Ведущий.

Современнейший. Университетский медицинский комплексШАРИТЕ – это в целом около 3500койкомест и 15 000 сотрудников в болеечем 80 специализированных клиниках,каждая из которых уже являетсявысококвалифированной единицей. Будучи учебной и научной базойзнаменитых Берлинских университетов имени Гумбольдта и СвободногоУниверситета мы, образно говоря, концентрируем диагностику и лечение,научные исследования и обучение под одной крышей.

Превосходство. Целенаправленность. Взаимодействие

специальностей.Ни в одной другой клинике Европы нет такого средоточия известныхврачей, специалистов и корифеев как в Университетском медицинскомкомплексе ШАРИТЕ. Соответственно превосходным является иоснащение медицинской техникой. Взаимодействие между различнымиспециальностями, комплексная медицина, коллегиальность и, конечно же, высочайшая квалификация всего врачебно-профессорского состава

обеспечивают медицинское обслуживание высшего качества.

Сердечность. Компетенция.

Внимательность.Главное в ШАРИТЕ – это здоровье ихорошее самочувствие наших пациентов.Личные консультации и доступная дляпонимания информация важны для настак же, как и индивидуальное об-служивание пациентов.

Организация. Расходы. Сервис.Для организационной поддержки Вашего стационарного лечения вШАРИТЕ обращайтесь, пожалуйста, в наш оффис „Charité International“.Сотрудники этого центра консультации и оформления иностранныхпациентов позаботятся о всех юридических и административных формаль-ностях - разумеется при соблюдении строжайшей конфиденциальности.Здесь Вы также получите ответ по всем вопросам въездных документов,

размещения, языковой поддержки и трансфера из аэропорта.

История болезниДля оценки возможности лечения в ШАРИТЕ нам нужна как можно болееподробная и – что очень важно – самая последняя мединская информация

о Вас (выписка из истории болезни).

Стоимость стационарного лечения и уходаПри необходимости стационарного лечения Charité International вышлетВам в самый возможно короткий срок индивидуальное предложение. В немсодержится сообщение о расходах на лечение и уход, а также о

максимальном времени пребывания в нашей клинике.

Наш адрес

Charité InternationalAugustenburger Platz 113344 Berlin – Germanywww.charite.de/klinikum/internationalEmail: charite.international@charite.deTel: +49 30 / 450 570 000Fax: +49 30 / 450 570 977

Шарите - Университетский медицинский комплексг.Берлин Крупнейшая университетская клиника Европы

В результате 12-летнейработы немецкие хирурги итехнические специалистыуспешно имплантировалипервый в мире улучшающийзрение протез шести слепымпациентам.

Миллионы людей страдаютпигментным ретинитом(Retinitis pigmentosa), болез-нью, в ходе которой происхо-дит прогрессирующее сниже-ние зрения вследствие отмир-ания клеток сетчатки, в резуль-тате чего наступает слепота.Часть нервных клеток, тем неменее, остаются невреди-мыми, и именно в этом случаеможет помочь протез.

Исследовательская группа,возглавляемая профессоромВильфридом Моква (ProfessorWilfried Mokwa) в составеинженеров из Рейн-Вестфал-ьского технического универси-тета, г.Аахен, Аахенского унив-ерситета (RWTH Aachen Uni-versity) и из Института микр-оэлекторонных схем и системФрауэнхофера в Дуйсбурге(Fraunhofer Institute of Micro-electronic Circuits and Systems,Duisburg) разработали улуч-шающий зрение протез, полу-чивший название EPIRET3,который помогает больнымпигментным ретинитом Наданный момент это единств-енная во всем мире система,которая функционирует в ре-жиме беспроводного питания,иными словами, имплантатполностью фиксируется в глаз,при этом нет необходимости вподсоединении к внешнимисточникам питания с помо-щью кабеля, в отличие от дру-гих протезов. Такой принципсокращает время операции,упрощает применение и уме-ньшает стресс для пациента.

Шесть пациентов, утратив-шие зрение несколько летназад, стали добровольцами иподверглись процедуре имп-лантирования. В период четы-

рехнедельной испытательнойфазы специалисты из группынейрофизики МарбургскогоУниверситета Филиппс, (Philipps–Universitдt Marburg) проводилитесты, в ходе которых сетчаткапациентов стимулироваласьразличными электрическимистимуляторами. В результатевсе пациенты получализрительные впечатления иразличали оптические образы.

После этого первоначальногопрогресса последовал следую-щий этап, задачей которогобыло продлить длительностьношения протеза и соверше-

нствовать хирургическую тех-нологию. Для того, чтобы обе-спечить пациентам возможностьориентироваться в окружающейобстановке, система должнабыть подсоединена к камере,которая осуществляет транс-миссию радиосигналов, или жеоптоэлектронную трансимиссиюна протез.

Система, имплантирoвaннаяпервой опытной группе паци-ентов, продемонстрировалаэффективность и безопасность.В результате несколько комп-аний, занимающихся меди-цинскими технологиями, учред-

или фирму по разработке прот-еза сетчатки, который можнобыло бы представить на рынокс тем, чтобы через нескольколет он стал доступен большемучислу пациентов. Такой импл-антат можно также использо-вать при другом, более распр-остраненном офтальмологи-ческом возрастном заболева-нии – запущенной старческойдегенерации желтого пятна.Данное заболевание являетсяв 50% случаев причинойстарческой слепоты.

Начиная с 1995 года Федер-альное министерство науки и

образования Германии инвес-тировало 17,5 миллионов евров исследования по разработкевозвращающих зрениепротезов.

Парламентский статс-секре-тарь при Федеральном мини-стерстве по вопросам науки иобразования Германии ТомасРахель комментирует это так:«Ученые и технические специ-алисты добились выдающихсярезультатов. Мы надеемся, чтолюди, утратившие зрение, вскором времени смогутвоспользоваться даннымидостижениями».

Успешная имплантация беспроводного протеза в сетчатку

EUROPEAN HOSPITAL Vol 17 Issue 2/08 33

Хирургия

Обучающие курсы по травматической хирургии;Немецкое общество травматической хирургииНемецкое обществотравматической хирургии(Deutsche Gesellschaft fürUnfallchirurgie - DGU). начало реализацию новойобучающей программы потравматической хирургии.

Курсы предназначены дляперсонала всех специальностей,имеющих отношению к лечениютравм. Курсы называются «СэйфТрэк» (Safe:Trac - Обеспечениебезопасности пациента влечебном обслуживании травм)и состоят из 4 частей-модулей.DGU информирует, что програм-ма охватывает весь комплекспроблем по соблюдению безопа-сности пациента на всех этапах:начиная от места происшествия,где получена травма, до леченияв клинике. При посредничествеорганизатора - Немецкого общес-тва травматической хирургии -проект поддерживает 8 профе-ссиональных ассоциаций.

Немецкое общество травмати-ческой хирургии уже ввело впрактику работы систему регис-трации критических инцидентовприменительно к хирургии. Обуч-

ающие курсы «СэйфТрэк» - ещеодин шаг на пути к повышениюгарантии безопасности пациента.

Профессор Хартмут Зиберт,Доктор медицины (HartmutSiebert MD), который являетсягенеральным директором выше-упомянутого Общества, расска-зывает: «Различные междисцип-линарные обучающие модули“Сэйф Трэк“ были разработаны всотрудничестве с авиционнымипсихологами. Они базируются наматериалах семинаров по управ-лению ресурсами экипажа (CrewResource Management), которыепроводятся для персонала, рабо-тающего в европейской авиации.Это означает, что программаобучения находится в соответст-вии с требованиями, предъявля-емыми Объединенным управлен-ием гражданской авиации Европ-ейского Союза; она адаптирова-на коллективом высококвалифи-цированных медиков и психолог-ов применительно к спецификезадач здравоохранения.»

Немецкое общество травма-тической хирургии далее разъя-сняет, что в рамках программыкурсов участники из всех проф-

ессиональных групп, непосредс-твенно связанных с обслуживан-ием пациента, работают над уче-бными проблемными ситуаци-ями; тем самым они повышаютсвои знания в области механи-зма возникновения и развитияинцидентов риска. Основываясьна этом, они могут впоследствиивырабатывать стратегии, позво-ляющие избежать особо крит-ических и рискованных ситуаций.

«Все это должно активноспособствовать дальнейшемусовершенствованию культурыбезопасности пациента намеждисциплинарном уровне.Обучающие модули адаптируют-ся под конкретные группы участ-ников. Существенную роль приобучении играют: практическаяориентация, проведение упражн-ений в небольших группах, испо-льзование видеосценариев.Достаточное время уделяетсятакже обсуждению проблем.Указанные обучающие методы,гарантируют, что каждая темаразбирается самым детальнымобразом.

Обучение опирается наиспользование собственного

опыта участников в их ежеднев-ной работе с пациентами травм-атологии, и этому фактору при-дается особо важное значение.Вся команда должна проходитьсовместное тренировочноеобучение, если мы хотим доби-ться такого результата, прикотором культура соблюдениябезопасности пациента была бывведена в качестве неотъемлем-ого элемента в практику повсед-невной работы и получиларазвитие».

Программа обучающих моду-лей имеет научную основу, вкл-ючая теорию возникновениякритических инцидентов. Онаохватывает круг проблем, такихкак: - ограниченные возможности

человеческого фактора истрессовый менеджмент;

- менеджмент в осложненнойситуации и пути избежанияошибок;

- оценка риска и принятиерешения;

- вопросы коммуникации; - лидерство, вопросы

организации и кооперации(работа в команде);

- культура безопасности, культ-ивирование ответственностивместо культивирования вины.

Обучающие специалисты Неме-цкого общества травматическойхирургии – это врачи, получив-шие специальную подготовку исертифицированные в соответ-ствии с требованиями, предъяв-ляемыми к обучающим специ-алистам по управлению ресу-рсами экипажа в авиации.

Компьютер в помощь врачам

Детская нейрохирургия клиникиCharité

Детская нейрохирургия –это относительно молодаядисциплина, находящаяся на

пути к становлению. Прогрессв детской анестезии иреанимационной медицине запоследние два десятилетияпозволил разработатьобширный операционныйинструментарий длянедоношенных младенцев,детей и подростков.

В последнее время особоезначение для операционноголечения заболеваний центр-

альной нервной системыприобреликомпьютеризированныеметоды. Без нейронавигацииуже нельзя больше представ-ить лечение опухолей головн-

ого мозга у детей. Она позво-ляет точно локализовать глу-боко залегающие процессы вцентральных отделах голов-ного мозга и производить ща-дящее оперирование сиспользованиеммикрохирургической техники.Для этого осуществляетсявысокоразрешающая маг-нитно-резонансная томогр-афия (МРТ) головы в трехм-

ерном диапазоне. Так произ-водится виртуальноепланирование операции накомпьютере. С помощьюоптического сканированиярельефа лица достигается

пространственнаялокализация головыв операционномзале посредствомнавигационнойсистемы. Теперьнавигацияруководит операц-ией, в соответствиес виртуальнымпланом еёпроведения, следуяпредварительнозаданнымпараметрам:1. определениеместа разреза кожи2. определениеместа вскрытиячерепной коробки3. путь черезткань головногомозга

При этом,напрмер, при помо-щи операционногомикроскопа

определяетсярапространение опухоли втканях головного мозга(фотография 1). В навигациюможно интегрироватьэндоскопию, инструменты, атакже метаболические ифункциональныеграфические данные.

Преимущества данногометода проведения операций: 1. повышенная безопасность,

2. уменьшение числа точекпроникновения,

3. более щадящийхарактер вмешательствадля маленьких пациентов.

Компьютеризированныеметоды применяются также вобласти диагностики илечения детских пороковразвития. Их целью являетсяулучшение планированиясложных операций. Тяжелойзадачей в практикеоперативной терапии поустранению пороков развитиячерепной коробки, в рамкахсложных синостозов швов,является пластическаяреконструкция черепа воптимальную эстетическуюформу головы. При помощимагнитно-резонанснойтомографии получают трехм-ерное изображение поверхн-ости головы. Необходимуюподдержку при этом оказы-вают самая современнаякомпьютерная техника исложные программы. Наэкране происходит виртуал-ьное преобразование формыпорока развития, которое внаибольшей степени прибл-ижается к существующейформе головы. Результат ввиде трехмерной моделииспользуется как образец воперационном зале. Такимобразом достигаетсяоптимальное изменениеформы головы.

Так, разработанный клин-икой Charitй метод позволяетдобиваться выдающихсяпластических результатов.

Определение распространения опухоли при помощи операционного микроскопа

34 EUROPEAN HOSPITAL Vol 17 Issue 2/08

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N E W S Урология

Европейская урологическая ассоциация - 23-йЕжегодный конгресс, Милан 2008

сбалансировать. Врач основы-вается на имеющихся у негоданных о том, вышла ли опухольза пределы капсулы простаты, ив каком месте, а затем прини-мает решение: можно ли сохр-анить в ходе операции нейрова-скулярный пучок, или же егонеобходимо удалить.

Группа учёных из Нюрнбергапровела исследование по воз-можности использования магн-итно-резонансной визуализации сдополнительным применениемконтрастных средств для получ-ения точного представления орасположении интересующихврача структур. Рассмотренатакже проблема, в какой меретакая методика способна помочьпринятию оптимального реш-ения. Были получены оченьхорошие результаты. Даннаявизуализация представляетсявысокочувствительной и можетпроводиться в условиях клиникидо операции, в целях выявленияпациентов, которым можетсделана щадящая нервные узлырадикальная простатоэктомия. Упациентов с удовлетворительнойэректильной функцией, но с вы-сокой клинической вероятностьюлокально-прогрессирующегохарактера опухоли (Т3) предо-перационные исследования дол-жны включать функциональную

эндоректоральную магнитно-резонансную визуализацию, и, наосновании полученныхрезультатов, должны предпр-иниматься последующие шаги.

Альтернативная, такжеинновативная технология былапредложена по результатамамериканского исследования пооценке применения микроскопиитканей с использованием вызва-нной мультифотонами флуоресц-енции и генерации вторых оптич-еских гармоник в целях визуал-изации простаты in vivo. Даннаяметодика позволяет визуализ-ировать микроскопическиедетали и хорошо сочетается сгистологическими результатами.В будущем она может игратьболее существенную роль восуществлении радикальныхпростатэктомий с сохранениемнервных узлов.

Медицинские исследования вВеликобритании стремятся кболее персонализированнномуподходу при осуществленииопераций. Предоперационныеобследования методом магнитно-резонансной визуализациипредоставляют информацию орасположении простаты, окру-жающих костей, а также о расп-оложении опухоли, кровеносныхсосудов, нервных пучков; все этиданные передаются на видеоди-сплей хирурга для проведениярадикальной хирургическойоперации с помощью робота.

Не упускается также из видавыбор терапии лечения рака наболее поздних клинических ста-диях. Радикальная ретролобко-вая простатэктомия предс-тавляется лучшим способом

лечения при показателях тяжестизаболевания по шкале Глисена>_8 – таково заключение группыисследователей из Москвы иг.Эмпория (Emporia), Канзас,США. Примерно у 72%пациентов, по данным этойгруппы, в течении пяти лет послеоперации не наблюдалось дал-ьнейшего прогресса заболева-ния. Результаты итальянскогоисследования, похоже, подвержд-ают это мнение. Сравнилипациентов с локализованнойформой рака простаты которыепрошли терапию путем наруж-ного направленного облучения, спациентами, подвергшимися поуказанному поводу радикальнойпростатэктомии, при этом непроводились ни адъювантная, нинеоадъювантная гормонотерпия.В первой группе было выявленов три раза больше случаевповторных злокачественныхновообразований.

Интра-оперативная радиотер-апия по поводу рака простатыявляется относительно новойметодикой. Суть даннойметодики в том, чтовысокодозированнаярадиотерапия осуществляется входе хирургического вмешат-ельства. При этом облучениюподвергаются простата,семенные пузырьки, а такжепериопростатическая область.Среднее время облучениясоставляет 30 минут. Порезультатам обследованиянебольшого числа пациентов,прошедших такое лечение поповоду локально-прогрессиру-ющего рака простаты, можносделать выводы, что такаярадиотерапия представляетсобой простую и безопаснуюальтернативу, котораяукладывается в рамкидопустимого для проведенияданной операции времени, имеетминимальную токсичность.Данная методика лечения в 96%случаев признана соответствую-щей, последующее двухлетнеенаблюдение показывает, что все

Около 14.000 урологов из 84стран радовались весеннемусолнцу Милана, куда они приб-ыли для участия в ежегодном ко-нгрессе. На конгрессе обсужд-ались все аспекты урологии, какв ходе практических обучающихсеминаров, так и на пленарных инаучных заседаниях.

Расширение горизонтов в диа-гностике и терапии рака проста-ты – такова была тема симпоз-иума, организованного фирмой«ИПСЕН» (Ipsen). Основныеположения, представленные наэтом симпозиуме, конечно, пол-учили резонанс в рамках всегоконгресса в целом .

Диагностика рака простатыНовые биомаркеры для

диагностики рака простаты былипредметом обсуждения на пресс-конференции, целью которойбыло заявить о начале инициа-тивы PROCABIO (ПРОКАБИО -Исследования биомаркеров ракапростаты на клиническом фонеприменения методики активногоконтроля). ПРОКАБИO являетсясовместной инициативой отдел-ения урологии Медицинскогоцентра Эразмус в Роттердаме(Голландия) и Европейскогорандомизированного исследова-ния по скринингу рака простаты(ERSPC). Данная инициативаосуществляется под эгидойисследований PRIAS (Междунар-одные исследования по выявле-нию рака простаты), в рамкахобъединенного научно-промышл-енного партнерства и нацеленана удовлетворение потребностейв целевой терапии путем разра-ботки и оценки биомаркеров.Существует неотложная потреб-ность в новых маркерах длявыявления рака простаты наранней стадии и прогнозирован-ия его развития. Биомаркер «зол-отой стандарт», как называютпростатспецифичный антиген(PSA), ограничен в своейдиагностической специфичности,ограничены также его возможно-сти в прогнозировании исхода.Использование указанногобиомаркера привело к резкомусокращению превалированиядиагностики на поздних стадияхразвития болезни. Существует,вместе с тем, точка зрения, чтодо 50% пациентов с диагнозомрака простаты, в особенности, теиз них, у которых уровень PSAниже 10 нг/мл, получили бы луч-шее медицинское обслуживаниев рамках методики активногоконтроля, чем при примененииинвазивных методик. Экзосомыиз раковых клеток простатыидентифицированы в качествепотенциальных биомаркеров;выделеннные из сыворотки кровипациента, они уже на раннейстадии могут дать информациюо прогнозе заболевания.

Биомолекулярная диагностикарака простаты берет ориентациюскорее на генетические, чем напротеомические аналитическиеметоды. По мнению г-на Шней-дера (Schneider) и его коллег изДрездена, достаточно транск-

риптов всего лишь четырех геновдля выявления рака простаты напробах ткани простаты,минимальных по размеру.

Для мониторинга уровняпростатспецифичного антигенаболее традиционным способомфирма «Beckman Coulter»предлагает две калиброванных всоответствии со стандартамиВЗО системы Access® для опре-деления общего уровня конце-нтрации в сыворотке кровипростатспецифичного антигена(tPSA), а также определенияуровня концентрации свободнойфракции простатспецифичногоантигена (fPSA). Новые системыкалиброваны таким образом, чтодают численные значения пок-азателей tPSA и fPSA , которыена 25% ниже по сравнению скалибровкой, принятой в тради-ционных системах Hybritech. Вклинической практике при испол-ьзовании новой системы следуетучитывать указанные измененияв калибровке

В диагностике рака простатытакже имеет значение технологиявизуализации. Группа немецкихисследователей из Гамбургаимеет в распоряжении многообе-щающую новую методику длявыявления рака простаты, (HI-RTE, Hitachi Real-time TissueElastography). Данная методика

использует эластографию врежиме реального времени,основанную на примененииультразвука. Метод испытан на67 пациентах, подлежащихпроведению радикальной прос-татэктомии, причем метод элас-тографии продемонстрировалчувствительность от 76% до 90%и специфичность от 68% до 78%,в зависимости от местоположен-ия опухоли; лучшие результатынаблюдаются, если опухоль расп-оложена в верхушечной частижелезы. Авторы считают, что уметода эластографии большойпотенциал в планесовершенствования диагностикирака простаты. Предстоит, одн-ако, еще установить возможностьиспользования данного методадля проведения направленныхбиопсий, а также уточнить,является ли упомянутаяметодика столь же чувствительн-ой по сравнению с расширен-ными схемами биопсии.

Результаты, полученные вИнсбруке, демонстрируют, чтоиспользование методики,основанной на сопоставлениистепени уплотнения тканей,может увеличить позитивнуюстатистику выявления ракапростаты, а также повыситьточность диагностики методомэластографии в режимереального времени.

Лечение рака простатыВосстановить эректильную

функцию и при этом полностьюудалить опухоль, не оставляяпозитивных на рак тканей – этодве несовпадающие цели ради-кальной ретролобковой прост-атэктомии, которые необходимо

пациенты живы.Другие новости Группа по медицинским прод-

уктам фирмы «Байер», «BayerSchering Healthcare»,представила на конгрессеЕвропейской урологическойассоциации новую сериюмедикаментов для пациентов-мужчин. Levitra®, Testogel® иNebido® - эти препараты обесп-ечивают урологам необходимыевозможности для лечения паци-ентов, у которых наблюдаетсяпорочный круг проблем, таких,как: эректильная дисфункция,низкий уровень тестостерона,метаболический синдром.

Европейская урологическаяассоциация опубликоваланекоторые обновления к своимрекомендациям. В частности, этокасается терапии нейрогеннойдисфункции нижнего мочевоготракта. Это многостороняяпатология, лечение которойвыходит за рамки компетенциитолько урологии.

Все рекомендации и текстыЕвропейской урологическойассоциации можно найти настранице интернета:www.uroweb.org/professional-resources/guidelines.

Видеоинформацию о всехнаучных и пленарныхзаседаниях, а такжевидеоинформацию о КурсахЕвропейской школы урологии/European School of Urology (ESU)Courses)/ можно найти настранице интернета:http://webcasts.prous.com/EAU2008/.

Следующий конгресс будетпроводиться в Швеции в г.Стокгольм с 17 по 21 марта.

EUROPEAN HOSPITAL Vol 17 Issue 2/08 35

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36 EUROPEAN HOSPITAL Vol 17 Issue 2/08

Austria - An unusually high number ofmeasles cases is currently causing con-cern amongst the public as well as healthofficials. Presumed to have originated ina private school in Salzburg, increasingnumbers of cases were being reported atthe end of March and beginning of April.In the Salzburg area alone, over 180cases were reported within a few days;isolated cases were also reported acrossthe border in Bavaria, in Upper Austriaand in Burgenland. Rumours that the dis-ease may have been spread through‘measles parties’, where healthy pupilsand those struck down by the diseasemeet intentionally to contract measles,have not been confirmed.

Due to the long incubation period (10-14 days) a further spread cannot be ruledout, particularly because one of theinfected pupils took part in a billiardtournament with 120 participants. In theaffected areas, particularly in nurseriesand schools, healthcare officials organ-ised a comprehensive vaccination pro-gramme and raised measles awarenessvia the media. Pharmacies have orderedsufficient supplies of vaccines and offerthe combined measles, mumps andrubella (MMR) vaccination at reducedrates.

Although MMR vaccination is recom-mended for all Austrian children, uptakeis currently only around 90%. As a personinfected with measles can infect an aver-age of 15 unprotected people, thedebate around compulsory vaccinationshas been fuelled again.

There is currently no medicinal therapyagainst the virus.

The Berlin TB SymposiumBy Dr Timo Ulrichs, Head of the TB section,Koch-Metchnikov-ForumThe WHO-Euro region ranges from Portugal to the East Asian parts ofRussia, including Central Asia and the Southern Caucasus. Because ofthe increasing numbers of tuberculosis and rates of multidrug resis-tance (MDR TB), tuberculosis was declared a regional emergency in2004. According to the WHO Global TB Report published in March2008, 49 patients get tuberculosis and seven die – every hour!

In order to discuss possible ways for more efficient TB control,WHO-Euro and the German Federal Ministry of Health invited thehealth ministers from all 53 member states of the WHO-Euro regionto a Ministerial Forum in Berlin, in October 2007. There, the healthministers adopted the Berlin Declaration on Tuberculosis, whichnames the current problems in TB control and asks all member statesfor immediate action.

As a follow-up to the Ministerial Forum, the Koch-Metchnikov-Forum (KMF), together with other TB control expert centres, namelythe Robert Koch Institute (RKI), the German Central Committee (DZK)against Tuberculosis and the KNCV Tuberculosis Foundation, organ-ised a scientific symposium in Berlin with the focus on the latestresults in research on new diagnostics and treatment strategies, aswell as novel vaccine development and prevention strategies for effi-cient tuberculosis control.

Speakers from the EU, US and Eastern Europe, including Russia,highlighted current R&D problems and practical TB control. WHO-Euro presented the most recent data on the spread of MDR TBthroughout the WHO-Euro region (harbouring 12 out of 14 regionsworldwide with high burden of MDR TB). Contributions also pointedto new developments in basic TB research, especially various novelvaccine candidates already in early clinical testing phases and basedon an EU-funded research network (TB-VAC). The Aeras TBFoundation, funded by the Gates Foundation and supporting TB vac-cine research, suggested ways of collaboration. Presentations werealso given by other nongovernmental organisations, e.g. TB Alliance(development of new TB drugs) and FIND Diagnostics (developmentof new diagnostic techniques).

Held on World Tuberculosis Day 2008, the symposium drew 150participants, including many from East European partner countries ofthe KMF, including the Russian Federation and Moldova.The Berlin Declaration on Tuberculosis:http://www.euro.who.int/Document/E90833.pdf

Alarming TB casesin AustriaA third of the world’s population is infected with the bacteri-um Myobacterium tuberculosis which infects around nine mil-lion people annually.

Although there is European awareness that this disease —although long thought defeated — is on the rise again, theextent of the danger is obviously underestimated, and risk isstill thought to be restricted to underdeveloped countries.

However, according to WHO data, eight people in Europedie from TB every hour and another 50 are being infected.Every hour! The old EU member states report an average of 13cases of TB per 100,000 people; the ten new member statesreport twice as many. The figure for Romania and Bulgariastands at around 53 cases per 100,000 people and in the for-mer Soviet Republic this figure rises to just under 100 casesper 100,000.

There is increasingly alarming news from highly developedcountries: as recently as February this year children in aViennese nursery were infected by one of their carers and atthe beginning of March the wife of a bakery-owner in theAustrian town of Arnoldstein close to the Italian border wasdiagnosed with open TB. Local hospitals and health trustswere stretched to prevent a further spread of the disease.Nevertheless, the number of TB cases in Austria has remainedconstant with just under 1,000 cases annually. Further con-tainment is doubtlessly being made difficult by the country’sproximity to Eastern Europe and its comprehensive move-ments of people and goods.

Successful vaccine development in preclinical testsHowever, Austria has produces more positive news: Biotechfirm Intercell, specialist in prophylactic and therapeutic vac-cines development, has announced that a TB vaccine, whichconsists of antigens from the Statens Serum Institute (SSI) andAdjuvans IC31 by Intercell is currently being tested in clinicalstudies. Additinally, this is undergoing further development incooperation with the SSI and Sanofi Pasteur. SSI and Intercellwill continue their TB vaccine R&D cooperation with Intercell’sown Adjuvans IC31.

The participation by Sanofi Pasteur means that the activitiesare being escalated to advanced stages, aiming to make a TBvaccine available as soon as possible

Inhaled TB vaccineUSA - A new tuberculosis vaccine successfully tested at the Universityof North Carolina (UNC) is easier to administer and store and just aseffective as one commonly used worldwide, according to researchpublished in the Proceedings of the National Academy of Sciences.

Led by Professor Tony Hickey PhD, of the molecular pharmaceuticalsdivision of the UNC School of Pharmacy, a team of scientists vetted adry powder vaccine provided by Harvard University. This is adminis-tered using an inhaler. ‘It is at least as good as the injectable vaccine,’Prof. Hickey concluded. ‘The real advantage is that this vaccine doesnot need to be refrigerated. It also doesn’t require needles, syringesand water like the injectable vaccine. Administering it is as easy asbreathing in, making it ideal for use in developing countries.’

The vaccine is spray dried instead of freeze dried. Spray drying isthe process of spraying a liquid through a heated gas, such as nitro-gen, to create a powder. Traditional TB vaccines are freeze dried,requiring refrigerated storage and transportation, and a source ofclean water to reconstitute the vaccine for injection. Spray dried vac-cines do not need refrigeration or water before use.

Prof. Hickey’s group specialises in developing drugs and vaccinesthat can be inhaled as a dry powder. The vaccine used in the studywas a Bacillus Calmette-Guérin (BCG) vaccine, which is not commonin the USA but is used extensively throughout the world. Given to 100million infants annually, the current BCG vaccine for TB is the world’smost widely administered childhood vaccine.

As an expert on the delivery of vaccines and medicines via dryaerosol, Prof. Hickey said that breathing in a TB vaccine is beneficialbecause inhalation is the way TB is contracted. He also believes thissuccessful vaccine test could encourage the development of others.‘Other bacterial vaccines are being developed that might benefit fromthis technology,’ he said.

Prof. Hickey is a co-founder of Oriel Therapeutics, a company thatdevelops dry-powder inhaler products to deliver medicines effective-ly to the lungs to treat a wide range of respiratory diseases, such asasthma and chronic obstructive pulmonary disease. He is also thefounder, president and CEO of Cirrus Pharmaceuticals – both based inNorth Carolina.Study co-authors: UNC School of Pharmacy research assistant professorLucila Garcia-Contreras PhD, and postdoctoral fellows Pavan Muttil andDanielle Padilla. E-contact: ahickey@unc.edu.School of Pharmacy contact: DavidEtchison. david_etchison@unc.edu

India’s world experts on TBEvery three minutes, two people living

in India die of tuberculosis. Thisequates to approximately 370,000deaths each year, and a staggering

economic toll: an estimated US$300 million indirect costs and US$3 billion in indirect costs.

The Revised National Tuberculosis ControlProgramme (RNTCP), the world’s biggest TBcontrol programme, has made Indianhealthcare officials world experts in thediagnosis, treatment and public healthmanagement of this disease. The Programmewas launched in October 1993 as a pilotproject after the World Health Organisation,the Swedish International DevelopmentAgency and the Government of India haddetermined that existing TBcontrol/treatment initiatives neededoverhauling.

The RNTCP pilot achieved such impressiveresults that it became a permanent nationalprogramme starting in 1997. Ten years later,RNTCP has achieved a 70% case detectionand a treatment success rate of more than85%. By 31 December 2007, more than 6.7million patients had been treated and over 1.2million lives saved. More than 100,000patients are currently treated each month.

The strategy utilised, the Directly ObservedTreatment Short Course (DOTS), overseestimely diagnosis, treatment with a full courseof drugs administered over a duration of sixmonths (18-24 months for multi-drugresistant TB) and aggressive patientmonitoring for the entire period of treatment.RNTCP has established bureaus throughoutthe entire country, involving local, regionaland national participation, including some ofthe patients themselves.

Indian radiologists have become experts inthe detection of both common and raremanifestations of TB. This disease was the

topic of ESR Meets India at the recent ECR2008 conference. Introducing the session, DrH Satishchandra, professor and head of theDepartment of Bangalore Medical College andResearch Institute in Bangalore, showeddiagnostic images of TB from X-rays, CT andMRI of TB symptoms that mimicked othermedical symptoms. TB in the lungs, forexample, can mimic a wide range ofconditions from pneumonia to malignancy. Inthe abdomen, it can mimic mass lesions andother inflammatory bowel diseases.

TB is rare in most European countries,although HIV patients are particularlysusceptible to it. The recent emergence ofdrug-resistant organisms, and the increase inthe incidence of diabetes and AIDS, have ledto TB being seen with protean manifestations.Ultrasound is used to detect abdominal

Numerous measlescases in Salzburg

T U B E R C U L O S I S

tuberculosis. Dr S S Doda, of Doda Imagingin New Delhi, explained how his privatepractice has experimented and improvised inits use. MRI can most efficiently delineatecommon patterns of involvement in spinaland paravertebral structures, and is veryuseful in monitoring the effect of treatment.Spectroscopy is being utilised to diagnoseintracranial tuberculosis.

Academic hospitals in India continue toundertake some of the most leading-edgeresearch in TB diagnosis and treatment. DrSatishchandra stressed that Europeanradiologists who may not recognise subtleforms of TB should turn to Indianradiologists as expert consultants for suchdiagnoses.Further details and statistics:www.eurotb.org and www.tbcindia.org

STUDY SHOWS PROMISING RESULTS

By Cynthia E Keen

With one fifth ofthe global TBincidence, India hasthe highest TBburden worldwide.Source: WHO Geneva;WHO Report 2006:Global TuberculosisControl; Surveillance,Planning and Financing

M E A S E L S

By Christian Pruszinsky