Centre supplement 12-PAGE EH@ESC EUROPEAN HOSPITAL THEEUROPEAN FORUM FOR THOSE IN THE BUSINESS OF MAKING HEALTHCARE WORK 2-7 Management 12-14 IT & Telemed ● ● Munich, Germany Migrant patients 1st tele-ultrasound 30 August to and staff via satellite ● Cultural attitudes ● Scots test 3 September ESC and care telemetry system 2008 ● Education and ● E-health in the news training Netherlands Berlin, 8–9 inside September 2008

VOL 17 ISSUE 4/08 AUGUST / SEPTEMBER 2008 Patients’ views on pay for their personal self control World’s first robot-assisted

USA – To reduce health costs as well as improve health, many large employers vascular surgery for aneurysm and insurers are introducing pay for the performance of patients (P4P4P). London, UK – A Hansen Sensei* reduced damage to the blood Led by Judith A Long, researchers in robot has been used to perform vessel wall as well as minimising Pennsylvania set out to assess the view of vascular surgery on a 78-year-old staff exposure to the ionising EHFG patients on P4P4P by surveying a cross- patient for an aneurysm that would radiation in theatre, surgeons section of patients in waiting rooms at have been thought too high-risk for report. ‘The Sensei robot has the celebrates first two university-based primary care clinics. conventional surgery. potential to treat extremely decade 1–4 October 2008 Asked for their opinions about paying During the operation a robotic complex aneurysm cases that have The programme for this year’s European smokers to quit smoking, obese people to catheter was manipulated by the been considered inoperable until Health Forum Gastein (EHFG) – its 10th lose weight, hypertension patients to con- surgeon at a console outside the now – reducing the risk of death by gathering – covers a far broader range of trol their blood pressure, or diabetics to operating theatre, using a steerable rupture.’ topics than before. During over 20 plenary control their blood sugar, 36–42% of tip through the blood vessels. The operation took place at St sessions, forums and workshops, with respondents thought it a good/excellent Viewing the blood vessels Mary’s Hospital in Paddington, about 120 lectures, key topics that embrace idea. However, 41–44% of participants European and the national health politics onscreen, a stent was accurately London, which is part of the of EU member states will be presented and thought paying them is a bad or very bad fitted in the aneurysm. Blood then Imperial College Healthcare NHS idea. discussed by experts. To be included: flowed through the stent rather Trust. Professor Nick Cheshire, ● Europe on the way to a standardised Smokers and obese patients were more than through the aneurysm, Consultant Surgeon and Director of healthcare market? The new EU guide- in favour of P4P4P to stop smoking and reducing the risk of rupture. Imperial’s Circulation and Renal line on patient rights and trans-national lose weight, respectively, than the non- This procedure with a stent is an Sciences Group, said: ‘Using this healthcare smoking and non-obese respondents. ● More coordination and integration: The researchers conclude that accep- advanced type of minimally robotic technology will take us Modern information technology tance by the public of paying patients for invasive surgery (MIS) which closer to our goal of treating every improves the care of the chronically ill performance is equivocal and add that offers all the advantages over BENEFITS vascular patient with minimally ● Increased patient safety and improve- establishing the value of P4P4P pro- conventional surgery as other MIS invasive endovascular techniques ment in the quality of care as central gramme may help such a programme to procedures: surgical incision, Shorter procedure time, to improve patient outcomes. challenges for healthcare in the 21st minimal blood loss, shorter These technologies are proving to century gain wider acceptance. reduced blood vessel wall ● Why social and economic disparities The study was published online in July for hospital stay and quicker recovery. be safer and more cost effective can prevent better health for all and registered users of the Journal of General However, the robot takes this damage and minimised than open surgery and this project what we can do against this Medicine (www.springer.com/ process a step further; it can staff exposure is a perfect example of how our ● The responsibilities of positions in the medicine/internal/journal/11606 potentially offer patients an even Trust, as the first Academic Health healthcare profession in a changing [doi:10.1007/s11606-008-0739-1]) shorter procedure time and to the ionising radiation continued on page 2 healthcare environment ● Smoking bans, food labelling and alco- hol abuse: How more prevention and EU initiatives can prevent the develop- ment of diseases at an earlier stage ● Rare diseases and orphan drugs: EU £50,000 fine proposed for measures help to improve the health- care for people with rare diseases ● Health and innovations – biotechnolo- breach of hygiene code gy, new vaccines and their financing The EHFG has initiated a new European UK – Although outbreaks of nosoco- Quality Commission (CQC), which Health Forum Award, to promote health mial infections, e.g. Clostridium dif- will replace the Healthcare policy initiatives that have contributed sig- ficile and MRSA, have dropped by Commission, the current NHS su- nificantly in Europe to meet healthcare almost a third since last year, and pervisory body, in 2009. As well as challenges, such as the inequality and dis- parity in health status, access to services many hygiene measures have been regulating hospitals, the CQC will and the provision of treatment within initiated and improved, there are become responsible for overseeing Europe. (Entry is now closed.) now proposals for an even more general practitioners’ (GP) surg- Details: www.ehfg.org stringent measure to control eries, care homes, and private facili- hygiene: the possibility that National ties, all currently regulated by sever- Health Service (NHS) Trust hospi- al different organisations. contents tals that break hygiene regulations The maximum fine of £50,000 could be fined up to £50,000 in the would be issued for the most serious News & management . . . . . 1-7 future. In addition, inspectors may offences, e.g. not carrying out Competition ...... 4 also be empowered to close unhy- advised improvements after an Lab & Pharma ...... 8-9 gienic wards or clinics. infection outbreak. The proposals Diabetes ...... 10-11 The hygiene code covers infection also include fixed penalty notices IT & telemed ...... 12-14 control, decontamination and clean- with fines up to £4,000, issued Radiology ...... 15 liness. However, recent data has against Trusts that do not meet min- Cardiology revealed that, although there has imum hygiene standards. Further, if ESC insert, Centre ...... 1-12 been a considerable improvement in a Trust obstructs a CQC inspector, or hygiene standards in hospitals, fails to provide documents or data, it Ultrasound ...... 16-18 about 25% of NHS Trusts, which could be fined £1,250. Urology ...... 19-20 govern their area hospitals, have Although these draft measures, Neurology ...... 20-21 failed to meet at least one of these which will further govern hygiene Russian pages ...... 22-25 standards. control, have met with opposition, Weighing scales ...... 26 These are part of new measures they are now under consideration. Events ...... 27 that come under the new Care See page 2: Advice on MRSA control MANAGEMENT

unt Biobank, Norway’s Thermo Fisher reports that partici- biggest research biobank, pation from the population has is using Thermo Fisher been successful in large part Pioneering software to HScientific Inc’s Nautilus because every participant receives LIMS in its HUNT 3 study, to gather, the feedback document reporting store, manage, track and retrieve their health status, facilitated by the biological data of approxi- Nautilus LIMS. The system also pro- protect patients’ privacy mately 100,000 people from Nord- vides clinical follow-up, data han- Trøndelag County. dling and quality control following Information in patients’ records To test the and Bioengineering, sponsor of HUNT Biobank studies provide data collection and distributes could benefit biomedical research new software, the work, the information in insight into disease status and pro- coded data files to various research in terms of understanding diseases the researchers patients’ medical records is a gression, particularly in relation to groups. Additionally, the LIMS has and their treatments. The used it on 1,836 ‘largely untapped treasure trove’ quality of life measures such as become the means of linking infor- drawback is that those records nursing notes that the biomedical research contain confidential information (containing community could use to increase that could identify patients. If that 296,400 words). understanding of diseases and data has to be removed manually, Using multiple their treatments. ‘The automated Nautilus LIMS used the task is not only painstaking Prof Roger G Mark experts and de-identification software and therefore expensive, but also additional algorithms, they developed under the guidance of not foolproof. replaced all personal data with Dr Mark is a big step forward in in Hunt Biobank Now a computer programme ‘fake’ information. They report that permitting the widespread sharing that can automatically delete the software successfully deleted of patient information without the confidential data from medical over 94% of the confidential risk of compromised privacy and records, yet leave their vital information, but only 0.2% of the confidentiality,’ he pointed out. population study medical information intact, has medical content was wrongly * This research was published in been developed by researchers at deleted. ‘This is significantly better journal BMC Medical Informatics the Massachusetts Institute of than one expert working alone, at and Decision Making (24/7/08). Technology (MIT). ‘We’ve least as good as two trained Other research team members: Ishna developed a free and open-source medical professionals checking Neamatullah; Margaret M. Douglass; software package to allow each other’s work and many, many Li-wei H. Lehman, an HST research researchers to accurately de- times faster than either,’ they engineer; Andrew Reisner, an HST identify text in medical records,’ pointed out. visiting scientist; Mauricio explained Gari D Clifford, a The free, open-source software Villarroel, an HST visiting engineer; principal research scientist in the package (labelled de-identified William J. Long, a principal Harvard-MIT Division of Health data together with the software) research associate in MIT’s Sciences and Technology (HST) will enable other researchers to Computer Science and Artificial who led the research* with improve their systems and allow Intelligence Laboratory (CSAIL); Principal Investigator Professor adaptation of the software to other Professor Peter Szolovits of the Roger G Mark, of HST and MIT’s data types with different qualities. Department of Electrical Department of Electrical According to Dr Zohara Cohen, Engineering and Computer Science Engineering and Computer programme director at the National and HST; and George B. Moody, HST Science. Institute of Biomedical Imaging sponsored research staff.

environment, education and occu- mation from the extensive HUNT ADVICE pation. Spanning almost 25 years, database to each study partici- Nosocomial and HUNT Biobank now represents an pant’s personal identity number, as integrated family and personal well as to end-point national database. The HUNT 3 study, part of health registries. The Nautilus LIMS one of the largest population- installed base of biobanking community MRSA infections based health studies ever per- organisations also provides a net- formed, incorporates over 130 sub- work of shared user experiences. Professor Wolfgang Witte PhD of the Robert Koch Institute, Wernigerode, studies, including status in subjec- ‘Being totally configurable, the tive health, diabetes, lung, cardio- system has been very easy to Germany, urges tests to be carried out on emergency or ambulatory care cases vascular, thyroid, muscle and skele- implement right out-of-the-box First emerging at the beginning of The preva- perform bacteriology when treat- tal diseases, mental diseases, and has delivered superior data the ‘60s, Methicillin-resistant lence of caMRSA ing deep seated infections of skin prostate complaints, urinary incon- capture, integration and automa- Staphylococcus aureus as a noso- infection in and soft tissue in emergencies or tinence, female reproductive disor- tion capabilities,’ said Thor Gunnar comial infection – healthcare asso- Europe is still ambulatory practice. In a case of ders and gynaecological diseases. Steinsli, LIMS Manager of HUNT ciated MRSA (haMRSA) – has low compared demonstration of caMRSA, not only Initiated to support epidemio- Research Centre and Biobank. become an increasingly prevalent to the USA, the affected patient should be logical, clinical and preventative ‘The unique security capability infection control problem in many where increas- checked for nasal colonisation, medical research, it is due for com- of Nautilus LIMS has allowed HUNT countries. ing frequencies with the consequence of eradica- pletion this June. Biobank users to keep regulated Nosocomial MRSA infections are are recorded. tion when positive, but also family The Nautilus LIMS interfaces data separate from unregulated usually associated with a number Professor Nearly half of members and comparable associ- with the laboratory’s existing processes, to ensure maximum of risk factors. As a consequence of Wolfgang Witte infections treat- ates. robotics, import files from the hos- data authenticity, integrity and shortening of hospital stay and ed in the emergency departments Clusters of nosocomial infections pital laboratory, and then return traceability,’ Thermo Fisher points treatment in specialised ambulato- of US hospitals are caused by with caMRSA not only require care- results for every participant. out. ry facilities, a number of MRSA caMRSA. Meanwhile, clusters of ful measures of in-house infection infections is acquired in healthcare nosocomial infections with control but also information to the institutions but becomes manifest caMRSA have also occurred. This is general practitioner (GP) in the Worlwide first robot-assisted vascular surgery for aneurysm in the community – healthcare mainly associated with spread of case of patients discharged and associated community onset MRSA the so called ‘USA300’ strain (char- needing further ambulatory care. continued from page 1 (hcaMRSA). acteristics in molecular typing: Science Centre in the UK, has The Vascular Unit at St Mary’s During the past 10 years, the MLST ST8, spa-type t008, PVL +, Livestock literally taken research from the Hospital, part of Imperial College emergence of MRSA infections in arcA +). As can be expected in a Additional attention should also be bench to the bedside.’ Healthcare Trust, is a leading the community, in previously globalised world, caMRSA USA300 paid to individuals with profession- Annually, 5,000 people in the European centre for endovascular healthy individuals lacking the risk has also be arrived in a number of al exposure to livestock in agricul- UK die from abdominal aortic treatment with the largest number factors known for ha and hcaMRSA European countries. Although risk ture. Mainly pigs, but also other aneurysms, which occur in 7% of of endovascular thoraco- have been reported worldwide. For factors favouring the spread of animals, are frequently colonised men over the age of 60. At abdominal aneurysm repairs pathogens causing this kind of community MRSA, such as low (nasal) with a particular MRSA Imperial College Healthcare NHS worldwide. The Imperial College infections the term community social conditions associated with strain, namely MRSA ST398. As for Trust 60% of patients receive Endovascular Group has associated MRSA (caMRSA) has minor access to healthcare com- other groups of patients with risk endovascular repair with a stent undertaken prize winning been introduced. pared to the USA, frequent histo- factors for MRSA colonisation, compared to a national average research into vascular robotics. CaMRSA have a pronounced ries of incarceration and high sexu- these patients should be subjected of 20%. With the new robot the The Group won the 1st prize capacity for causing invasive infec- al promiscuity (in both MSM and to admission screening when Trust hopes to be able to provide (scientific session) from the tions of skin and soft tissue, a heterosexuals) may be less fre- entering hospitals and barrier pre- this treatment for up to 100% of British Society of Endovascular minority of patients affected also quent among urban communities in cautions should be applied. cases. Therapy in July 2008 (Riga CV, develop necrotising pneumonia Europe, nevertheless the presence Eradication of nasal carriage is Celia Riga, Vascular Research Bicknell CD, Hamady M, Cheshire and necrotising fasciitis. Although of caMRSA needs particular atten- advisable in case of elective surgi- Fellow, said: ‘The combination of NJW). A similar robot to the its role in pathogenesis is not real- tion and preparedness. cal measures. It is not sensible in innovative technology and Sensei is being used by the Trust ly understood, formation of Although caMRSA infections are general due to frequent recolonisa- clinical excellence within the to treat arrhythmias in cardiology Panton-Valentine leukocidin is a not notifiable in European coun- tion when being in contact with Trust has enabled us to translate patients. characteristic of caMRSA. tries, so far, it is highly advisable to livestock. cutting edge research into * Robot details: practice.’ www.hansenmedical.com

2 EUROPEAN HOSPITAL Vol 17 Issue 4/08 MANAGEMENT UK Polyclinic proposals meet opposition he relationship between patient care, and 42% were not GP and a negotiator with the will be,’ he added. ‘We need Darzi’s report include hospitals England’s GPs and convinced they would improve BMA’s GP committee, said the more details from the publishing death rates for hospitals is currently at a access to treatment. More than problem with the plans for government on this before we various conditions; the old and Tsensitive stage, with a 70% said they would destabilise polyclinics and GP-led health really know.’ terminally ill to have the right to review of health services across hospitals and GP practices. centres is that they are The matter is the latest in a choose to die at home instead of the country set to impact on the Under England’s current something of an unknown series of issues that has in hospital; greater scope for way the two groups work and system, hospitals are paid per quantity and the details of how brought UK GPs into conflict private health care firms to liaise with one another. patient treated and there is a they would operate are not clear. with the government. Recently, supply primary care services, and The issue has been brought growing concern that, if ‘It is also unclear how GPs and the BMA led opposition to a new NHS constitution that will into focus by the review of polyclinics take the simple cases, hospital doctors will work plans to extend the opening enshrine rights to confidentiality, healthcare in England by health they may deprive hospital trust of together through the polyclinic hours of surgeries into evenings control of patient records and a minister Lord Darzi. income. proposals and what the financial and weekends. second opinion. While the proposals are wide- Dr Chaand Nagpaul, a London transactions of the partnership Other proposals in Lord Report: Mark Nicholls reaching, one of the higher profile areas is the creation of GP-led health centres, or ‘polyclinics’. Lord Darzi, a surgeon, initially proposed these under a review of London’s healthcare, but now wants a separate network of 150 GP-led health centres across England. Polyclinics (common in Central Double the utilization of your and Eastern Europe), or ‘super- surgeries’, provide a wide range fluoroscopy room? of medical services and are staffed by teams of GPs, dentists, nurses, midwives, therapists and hospital doctors offering X-rays, blood tests and diagnostic tests. Ministers claim polyclinics will improve patient care by offering a wider range of treatments and staying open from 8am to 8pm daily. They say the clinics will be able to offer quick appointments and reduce waiting times for

Health Minister Dr Chaand Nagpaul Professor Lord Darzi diagnostic tests that are currently only provided in hospital. Doctors’ leaders and patient groups fear polyclinics will end the personal relationship between a patient and their general practitioner (GP). Additionally, the British Medical Association, which represents doctors, claims some existing GPs will be forced out of business. However, a Department of Health spokeswoman said: ‘We are not imposing super- surgeries or polyclinics, or replacing existing services. The 150 health centres will complement existing GP practices and serve as an extra way to see a doctor.’ The King’s Fund, the healthcare think tank You bet. With AXIOM Luminos dRF. organisation, warns that the proposal could backfire if GPs d and other healthcare staff end As a fully digital, 2-in-1 solution for radiography and fluoroscopy (R/F), AXIOM Luminos RF is exceptionally versatile and up being concentrated in a fast. Thanks to its 43 cm × 43 cm flat detector, time-consuming cassette handling is a thing of the past. The system easily single building and make it accommodates the full range of R/F applications as well as various interventional procedures – all in one room. more difficult for patients to What’s more, with its low table height of 48 cm, AXIOM Luminos dRF is also tremendously comfortable for patients and visit their GP, especially those convenient for staff. Outstanding image quality, fully digital workflow, exceptional ergonomics – when you add it all up, living in rural areas. you have optimal resource allocation and improved utilization. Similarly, NHS consultants www.siemens.com/answersforlife +49 69 797 6420 have raised doubts about the merits of polyclinics. In a BMA Answers for life. poll, which received 1,587 responses, 60 % either disagreed or strongly disagreed AX-Z1083-1-7600 that polyclinics would improve

90184_Z1083_A4_eng.indd 1 23.06.2008 9:51:02 Uhr EUROPEAN HOSPITAL Vol 17 Issue 4/08 3 Centre supplement 12-PAGE EH@ESC READERS’ COMPETITION

CARE WORK OSPITALNG HEALTH H emed E BUSINESS OFITMAKI & Tel IN TH 12-14 nd FOR THOSE ● 1st tele-ultrasouite atell Berlin, 8–9 0 0 8 via s ber 2008R 2 st MBE NFORUM ts te m P T E EA Management ● Sco syste SE UROPEANients SeptemST / 2-7 UROPEAN OSPITAL tpat metry GU an tele he A U ● Migr E H EEEUROP ff ealth in t ta TH and s des ● E-h nds attitu etherla ● Cultural N care and n and Munich, Germany ESC ● Educatio 30 August to training 3 September 2008 news inside d 8 bloo 4/0 the ising age to inim EHFG ISSUE dam as m 7 ced ell ng pean OL 1 redu as w ionisi Euro V all the ns celebrates1–4 first Octoberar’s 2008th ssel w re to geo is ye its 10 orld’s first robot-assistedve posu , sur the for th G) – e of re F g ff ex eat t has decademme (EH r ran W sta in th obo ogra stein roade enary tients’ views on ion ei r pr Ga b pl Pa diat Sens mely e The orum a far er 20 th ra ‘The xtre t hav lth F overs g ov s, wi ort. eat e tha Hea g – c urin hop ace Reader Survey rep o tr ases til erin fore.D works br pay for their i* tial t sm c le un gath n be and hat em ics Sense oten eury erab by s tha s pics t polit sen p x an inop ath topic orum ey to alth nd well as ascular Han orm surgery form pleaneurysmred of de ions,f res,k al he ted a rf e s u n v – A o pe co nsid e risk ses lect natio sen t ld o pre personal self control sed ar-o en c ing th out 120 d the ill be ed: he en u 8-ye ld be duc t St ab n an es w nclud uce healthy costslarge asemployers London,a UKs be n a 7 wou – re ce a ropea r stat be i rdised – To red ay for t ot h ry o that r now k pla Eu embe rts.To nda e- USA alth, man ducing p rob urge rysm sk fo re.’ too ton, EU m expe a sta guid he tro in ular s neu gh-ri ptu ation ding of d by ay to w EU al 4P4P). vasc an a hi ru per Pad cusse the w he ne -nation improve s (P archers t for ht too The o al in f the dis on t? 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E en a ndard rusts e ill et w ratio be sta S T , hav hich w ve m nside iene NH itals e w ha er co trol hyg of osp hes trol, und A con t 25% a h e of t con ow MRS bou r are t on re n ce on a thei eas they a Advi ern et at l res 2: gov me easu ee page ed to w m re S fail s. f ne Ca dard art o ew stan are p he n To participate, simply fill in this coupon and fax to: e r t Thes nde ome u that c +49 201 87 126 864 No fax? No problem. Simply post your coupon to: seca quadra 808 European Hospital Publisher, Theodor-Althoff-Str. 39, 45133 Essen, Germany Or, for even quicker entry, please visit our website: www.european-hospital.com ENTRY COUPON Enter today! Simply fill in the COMPETITION QUESTION How many memory buttons does the seca quadra 808 have? Readers Survey (left) and send it in Your answer

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4 . WHAT SUBJECTS INTEREST YOU IN YOUR WORK? scales is handsome indeed. and thus also easy to clean. Surgical innovations/surgical equipment Radiology, imaging/high tech advances However, the winner will not only receive a (ITO is highly conductive and ensures Clinical research/treatments/equipment Intensive Care Units/ management/equipment fine looking accessory for his or her bathroom, uninterrupted skin contact during Ambulance and rescue equipment Pharmaceutical news but also a highly practical machine. Using the measuring.) Physiotherapy updates/equipment Speech therapy/aids shock-proof seca quadra 808 you can Nursing: new aids/techniques Laboratory equipment, refrigeration, etc. Technical data ● Analyse body fat and body water, for better Hospital furnishings: beds, lights, etc. Hospital clothing and protective wear ● Capacity: 150 kg/330 lbs/23 sts Hygiene & sterilisation Nutrition and kitchen supplies health control. Linens & laundry Waste management ● Division: 100 g/0.2 lbs ● Use the BMI function to determine your Information technology & digital communications Hospital planning/logistics ● Personnel/hospital administration/management Hospital Purchasing nutritional status. Dimensions scale (WxHxD): 300 x 46 x 330 mm Material Management Medical conferences/seminars ● Use the memory buttons (4) and your seca EU political updates quadra 808 will recognise you. ● Weight: 2.8 kg Other information requirements - please list ● Functions: BF/BW measurement, BMI, Auto-HOLD, automatic switch-off ESPECIALLY FOR DOCTORS: Please complete the above questions and we would like you to answer the following additional ● Parts to be delivered: 4 AAA questions by ticking yes or no or filling in the lines as appropriate. batteries, 4 extension feet for carpets What is your speciality? The full range of seca products can be In which department do you work? viewed at: www.seca.com Are you head of the department? Yes No Are you in charge of your department’s budget? Yes No

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4 EUROPEAN HOSPITAL Vol 17 Issue 4/08 MANAGEMENT

In hospitals all over the world peo- ple of very diverse cultural back- grounds come together, whether as employees in various roles, or as The needs of migrant patients patients. This means that hospital teams must deal with diverse state was good. The most common rioration of health, high occurrence ly to be solved, particularly as in- needs, cultures and languages. complaints were headaches, back By Heidi Heinhold of sickness, increasing numbers patient stays are increasingly short- In 1963, Virginia Henderson in and joint pains, circulation prob- retiring early due to ill health, occu- er; for other problems that occur the US determined the 15 basic lems, cardiac trouble, nervousness pational diseases and problems consistently and repeatedly (e.g. the human needs in her Theory of and other ailments, such as identified as contributors to the after occupational accidents. need for a room for religious ritu- Basic Principles of Nursing Care. bronchial infections and ulcers (in development of illnesses. These Conclusion: In- and out-patient als) in time there will be a solution These are internationally acknowl- stomach, duodenum, which can practices are very different to the nurses cannot solve the issues acceptable to all. edged as the lowest common have psychosomatic elements). way that people had previously alone. Apart from voluntary train- *Source: Pförtner-Hüttner, Renate: denominator for patient care. Working practices in western worked in their own countries, ing, they need professional support Study on the care of foreign patients: Nurses are responsible for the industrial nations, e.g. working in where they may have been agricul- from reliable individuals who medi- How important are cultural differ- basic needs of patients, which large scale industries, industrial tural workers, craftsmen or ate between the hospital and the ences. Pflegezeitschrift 1/99 59-61, include rest and sleep, cleanliness production, shift work etc. were traders, leading to premature dete- patients. Many problems are unlike- Kohlhammer, Stuttgart and personal hygiene, the expres- sion of emotions, distress, and their fear or feelings about dealing with others. Transcultural nursing care About 10 years ago Renate Pförtner-Hüttner*, then a nurse at the Nuremburg Hospital, examined the situation regarding foreign hos- pital patients as part of her Professional Care training course. ● Expectations: It transpired that these patients did not expect or demand that the staff should know much about their cultures – expec- tations were very low. Patients from Eastern Europe and Turkey consciously tried to assimilate into the daily life on the wards without any problems. ● Religious needs: Patients accept a hospital’s particular organisation and adapt their individual needs to those expectations. However, Muslim patients did state that they missed a room where they could carry out their religious rituals, par- ticularly cleansing before prayer, which should always be carried out with running water. This, however, is not possible for bedridden patients. There is one comfort – Islam permits making up for missed prayers at a later time. ● Religious diet: Patients were not worried about something as obvi- ous as mistakenly being served pork. However, they were con- cerned about whether, in a large hospital kitchen, there was suffi- cient care to keep different foods apart, e.g. in the preparation of sauces. Some patients preferred to use their own cutlery and crockery to avoid possible contamination. ● Language barriers: There were fewer than assumed and these mostly occurred among Muslim women whose lives were focused around their families and who only communicated in their mother tongue. ● The generation gap: Muslim patients of the so-called first gener- ation were a lot less forthcoming with their wishes and demands than those of the second genera- tion. Younger patients were very well informed about their rights and opportunities in a hospital. To summarise: It could be said that foreign patients acknowledge the singular situation they are in and so put their individual needs on hold. Are foreign patients ill in a different way? Twenty years ago the German Red Cross examined this question in their project: Older migrants – the promotion of social commitment by younger people to help older, foreign fellow citizens in Germany. Visit us at Medica 2008 62.1% of men and women polled Hall 12 • B 34 stated that they felt sick rather than healthy, whereas 37.9% reported that they felt their current physical

EUROPEAN HOSPITAL Vol 17 Issue 4/08 5 MANAGEMENT

ritain is a primarily Christian Medical students and staff dress: Muslim woman – doctor, medical some ladies simply felt they could another across our different faith country. It is also home to Although Muslim women medical student, nurse or patient – should not wear the normal gown which, as traditions.’ people with various reli- students were allowed to wear be forced to bare her arms below we know, can show parts of us we Representatives of Christian, Bgious beliefs who have the full-face veil for lectures and the elbow.’ The problem continues. do not want on show. We have had Muslim, Hindu, Jewish and Buddhist migrated here from many parts of on the campus, Birmingham Patients’ gowns: In 2005, a hospital examples of people not showing up faiths attended its July opening. the world, or are British born. In a University School of Medicine gown, called the ‘inter-faith gown’, for operations. This can only help.’ Candles were lit and sacred texts 2001 census, 72% of the population banned this in hospital clinical was designed to comply with rules In November 2006, the inter-faith and other religious artefacts were identified itself as Christian. The areas and in GP surgeries, on the on women’s dress, in Muslim, gowns went on general sale, costing donated by the religious groups. next biggest religious faith was grounds that it could prevent good Hindu, Orthodox Jewish and about €16 per set. Drugs: There is concern that, Muslim (2.7%), followed by Hindu communication between them and Rastafarian faiths. Gender of patients and doctors: although Muslims must avoid (1.0%), Sikh (0.6%), Jewish (0.5%) their colleagues – as well as Made by the UK company The preference among Muslims is to porcine and alcohol derived drugs, and Buddhist (0.3%), and the rest patients. It was said that regulation Interweave Textiles (www.inter- be seen by same sex doctors. followed other religions, had no surgical masks provide adequate weavetextiles.com), one of the However, if no female doctor is faith, or stated none for the census. face covering in the operating the- biggest suppliers of textiles to available, some women may agree to In terms of numbers, seven in atres. Headscarves worn as part of healthcare and contract markets, be seen as long as another woman every ten people in Britain claimed to be Christian; the Muslim popula- tion equates to 1.6 million people; Hindu to 599,000; Sikh to 336,000, Jews to 267,000, and so on. In August, the statistical research Muslims and healthcare body Eurostat released projections that suggest that the current UK population of around 61 million could increase steadily to about 77 million by 2060. Healthcare and in the United Kingdom social care may account for a huge Garment made for Muslim female patients increase in numbers – particularly By Brenda Marsh of old people. religious observance were to be these jade green polycotton gar- (e.g. a nurse) is present. Others may possibly objectionable drugs may not These figures are not just of inter- allowed. ments come in five pieces, which refuse to be seen. Mixed wards also be labelled as such, nor advice given est; they also reflect Britain’s A recent Department of Health include trousers and a choice of cause stress to female Muslims, but on alternatives. changing way of life. guidance stipulates that all doctors head pieces, to cover the head, this is also disturbing to women Catering: Some outside catering ser- With its long history of Empire must be ‘bare below the elbow’, to neck and body, leaving only a gap patients of any faith. vices in Britain can provide not only and Commonwealth, Britain has help prevent infections. Various for a patient’s eyes. They also Beds to face Mecca: Last halal food, but also the necessary long prided itself in welcoming and hospitals have received objections have elasticated cuffs to ensure December, the Mid-Yorkshire NHS equipment for their hygienic handling. assimilating immigrants. However, from Muslim women trainees who women’s arms are not revealed. Trust proposed that Muslim Ramadan and Hajj: Recognition of change is not easily accepted by all. do not wish to remove arm cover- Inspired by Karen Jacob, linen patients’ beds should be turned to their importance has been advised, Thus, when Muslim groups began ings in the operating theatre and to services manager at Lancashire face towards Mecca five times a day. for example not to book hospital to request that various religious roll up their sleeves when hand Teaching Hospitals, the gowns Running water should also be pro- appointments for Muslim patients needs should be met within the washing. In terms of hygiene, this is were tested for a 12-month period vided for these patients to wash during these events. National Health Service (NHS) vital. However, it is a problem for at Lancashire Teaching Hospitals. before and after their prayers, and During Ramadan, the holiest of these have been met with a mixture some Muslims: one university hos- ‘The use of the gown at our Trust for many other purposes. Islam’s four holy months, eating, of willingness and generosity but pital reported that some students produced some very positive feed- This was first implemented in the drinking and sexual relations are for- also consternation. The situation said they would rather give up their back from patients,’ she said. Dewsbury and District Hospital, bidden in daylight hours. Last year, is often controversial, not least studies than bare their arms. A Lancashire Teaching Hospitals Yorkshire, where there is a large the Scottish Executive and the because so many hospital practices Nonetheless, the Islamic Medical NHS Trust spokesperson said the Muslim population. A spokes- Scottish NHS issued a guidance are challenged. Association insisted: ‘No practising gown was introduced ‘… because woman for the Mid Yorkshire Trust that, during Ramadan, ‘consideration’ said: ‘This is all part of our holistic should be shown to Muslim col- approach to treating patients of all leagues and patients. Food should not faiths. Where it is safe and practical be eaten in front of them, and food we will move the beds of seriously trolleys kept away. ill patients so that they face towards Are separate faith-based Germany’s Muslim patients Mecca five times a day, should a patient request it. We are keen to hospitals the answer? Which doctor, physician or witch doctor? accommodate all faiths, for exam- Aziz Sheikh, professor of primary ple if a patient is Roman Catholic care research and development in A new Turkish patient is admitted. What would almost any nurse think? ‘The then we would try and ensure they the Division of Community Health whole family will always be there’, says health economist Fatemeh Pohl- can receive Holy Communion.’ Sciences, University of Edinburgh, Shirazi. ‘In Muslim cultures illness makes someone the centre of attention and However, critics of the ruling said and principal investigator on a the whole family wants to show compassion – which unavoidably changes it would be far better to create Scottish Executive supported grant to normal hospital routine. The patient’s room will always be full, with visitors Muslim-only wards, with all beds investigate the end-of-life care needs coming and going, and visiting times often re-interpreted. They will also bring facing Mecca, than to burden over- of South Asian Sikhs and Muslims in food for the patient.’ Here she outlines a few significant cultural differences worked nurses with this extra task. Scotland, advocates that doctors and and ways to better understand and therefore avoid awkwardness in care Religion: British hospitals generally health policy makers should realise house Christian chapels and many their needs and provide specific ser- Muslims are not a homogenous group: ferer is the centre of attention, and the have multi-faith prayer rooms. vices for them. Fatemeh Pohl-Shirazi, a German/Iranian, gained The Ashford and St. Peter’s It is even suggested that faith-based some are deeply religious, others more more severe the pain, the greater the a health economics degree at the University of or less so and more or less open attention. Applied Sciences for her thesis on Muslim Hospitals, serving a diverse popula- hospitals may improve the well-being towards Western lifestyles. However, Thus, the expression of pain may be patients and the German healthcare system – tion of over 400,000 people, have of Muslim patients. (Moscow’s first they all grew up in a culture very differ- increased if Muslim patients fear that with a focus on culture and ethics. provided a Christian chapel and private clinic based on Sharia law ent from that which has been dominant hospital staff will neither understand improvised arrangements for other opened last year. Among other things in Western Europe. In many regions and them nor take them seriously. This cian enquiring about the wellbeing of faiths. Recently, however, a Multi- it observes gender differences, sup- families, the hodscha (healer) is still an means the expression of pain may be the patient’s family. faith Centre was opened at St. plying female or male specialists important figure – and he may well more intense than the pain actually is. Mutual information and expressions Peter’s, and a similar project is according to a patient’s gender. The determine the ‘evil eye’ or some evil of empathy can build bridges, not only planned for Ashford. doctors show only their hands; female The Centre comprises the existing doctors wear headscarves or hijabs. demon to have caused an illness. Same disease, different because knowledge of Muslim per- Chapel, Multi-faith Prayer Room, In the prayer room a screen separates Additionally, the women are often shy perspective: In any culture spectives and rituals facilitates com- and consider undressing for a medical munication in the hospital and even Quiet Room and Ablutions Room men from women. Halal food is physicians strive to fight, examination extremely embarrassing. increases the probability of successful for ritual washing before prayer, and served.) mitigate and heal illnesses.But Although Christians and Muslims treatment, but also because we live in also provides a shoe rack for In Britain, although male infant appear to share everyday life in what is an illness and what is times of transition, in times when footwear. The ample Prayer Room circumcision is not approved by the Germany, they largely live in separate health? The answer can be very cost-efficiency is imperative, because floor has a simple compass design. National Institute of Clinical worlds and often do not know much different in different cultures. customer and patient-oriented work is Secure storage space is provided for Excellence (NICE), Professor Sheikh about the others’ customs and rituals. In So, who can help, doctor or vital to a hospital’s economic success sacred texts and religious artefacts. believes that male infant circumcision the microcosm of a hospital this separa- traditional healer? – and because Muslims are a target ‘Our vision was to develop the should be available throughout the tion cannot be so easily maintained. group. Not to mention the fact that a Chapel area to provide more fitting NHS. A few Trusts do provide this ser- Their worlds clash. Lack of knowledge, The behaviour of patient and physi- specialised service for this target facilities for all who wish to spend vice, but most Muslim parents must on both sides, can cause misunder- cian may also lead to misunderstand- group may attract a solvent clientele time in quiet, reflection, meditation resort to poorly regulated operators, standings with awkward results. ings: German doctors frequently dis- from the Middle East – a major bene- or prayer,’ explained Judith Allford, sometimes unhygienic and danger- The major, most immediate issue is tance themselves from patients. ficial economic factor. Head of Pastoral Care for both hos- ous. language. Many Muslims here speak lit- Diagnosis is brief, physical gestures are How can medics learn more about pitals. The new double doors, set Conclusion: There is a laudable com- tle if any German. Therefore family minimal. The physician should expect to Muslim culture that would not only with decorative glass, link the Multi- mitment to prevent racism or reli- members become interpreters. But do be observed critically by the patient help to solve stressful daily problems faith Prayer Room to the Chapel. gious prejudice in all public services. they – for whatever – reason tell the who may decide, without hesitation, to but also improve quality of care? An These, she explained, have both a Certainly, small advances have been truth? Sometimes the family member obtain second and third opinions. initial, simple step can be found in practical and symbolic purpose. made, but with so many issues wants to spare the relative the truth and What role does a Muslim physician workshops on communication with ‘Practically, they offer the option to involved, the way forward is by no consciously offers a wrong translation. play? He or she enjoys considerable patients from different cultural back- extend the space in both the Prayer means straightforward. Different expression of pain and respect, trust and authority. Physical grounds and further education of clin- Room and the Chapel when the * Should Muslims have faith based medical approaches gestures are welcomed as signs of a ical staff. need arises. Symbolically, they rep- health services? BMJ 2007; 334:74 In Turkish culture, expressing emotions trustful relationship. Most physician- * Workshop details: Pohl- resent the welcome and hospitality (13/1/08), doi:10.1136/bmj.39072. and pain is acceptable, because the suf- patient interviews begin with the physi- [email protected] which it is our desire to offer to one 347720.68

6 EUROPEAN HOSPITAL Vol 17 Issue 4/08 MANAGEMENT EDUCATION LEADERSHIP TOOLS FOR HEALTHCARE MANAGERS Essential: Training staff for sudden disasters Strong leadership is vital for healthcare management. your world, and a strong pair of legs for getting out of The doors of the accident & emergency structures are very different from hospital ‘Operationalisation’ of leadership is necessary in order to your chair and walking to where the action is. department fly open. An explosion to hospital individual risk analysis is learn, apply and evaluate leadership in healthcare facilities ● A funny bone.You need to be able to see something occurred at a nuclear power station. needed to build up a functioning crisis contexts, says Dr Eduardo de la Sota Guimón. to smile about even in the midst of trouble, because Severely injured workers, some scream- management system. But how is this best achieved? Although various authors laughter is often the grease that gets the wheels turn- ing, some unconscious flood are rapidly ‘The cost pressures that hospitals inter- ing again. arriving on trolleys pushed by para- nationally face are well known. For this suggest methods to attain effective leadership, their medics; doctors and nurses rush in. reason alone there should always be approaches are not always uniform. Here he reviews some ● The ability to delegate. And the ability to track per- formance and correct it before it’s too late. About 50 accident victims need care. customised advice for each individual of the literature and authors’ advice. Who should be treated first – and hospital, so that their effectiveness is not ● Curiosity.The burning desire to understand why things where? Primary treatment is extended impaired, and also to guarantee first- The Leadership Strategies for Evolving Health Care occur. to other wards. ‘I think the power sta- class medical care under normal condi- Executives Programme (Harvard University, 2008) focuses ● Financial intelligence.The ability to understand finan- tion reactor has also been affected,’ tions. Disaster medicine training sessions on leadership skills essential for achieving individual and organi- cial information. shouts a paramedic. The workers may be in healthcare institutions should be held sational objectives. Interesting highlights: ● Planning skills, including time management radioactively contaminated. ‘We can’t at least once a year, although it would be ● Develop creative problem-solving. Learn how to successfully ● Problem solving skills admit them to the hospital just like desirable to hold them more frequently. It implement your agenda during organisational change ● Risk management skills, especially Potential Problem that!’ someone cries. Too late! Suddenly, goes without saying that not every possi- ● Evaluate, diagnose, and build a high-performance team Analysis. everything eases up; everyone’s thinking ble scenario can be provided for with ● Attain a firm grasp of your organisation’s financial manage- ● An evidence-based approach to new ideas – healthy the same thing: ‘Just as well this was training exercises right down to the last ment controls in order to effectively bring organisational vision scepticism about the latest management fad. just a training exercise!’ detail, but we have repeatedly noted that Norman Hecker, Head of the Project participants in such simulations under to reality ● Measurement skills.The ability to devise measures for for Emergency Medicine at the German ● real conditions develop very creative cop- Learn how improving operational performance most things that matter in your organisation. Institute for Disaster Medicine, is well ing strategies.’ ● Balance organisational interests with those of professional ● The ability to know when and how to make versed in the effects of large scale inci- Efficient crisis management is charac- staff, patients, and the community decisions. dents, pandemics and mass accidents, terised by three big Cs: Command, ● Position and brand your services and products to prevent them ● Tenacity for he advises on and trains hospital Communication and Coordination, he from being turned into a commodity Interestingly, the fourth annual Leadership Tools for staff for worst case scenarios, so that explained. This means that a senior man- ● Learn legal and ethical responsibilities. Women Conference (New York, June 2008), has taken people can learn from the mistakes agement team should be appointed to Bryant Nelson has place under the banner ‘Changing the Power of Women’. demonstrated in the above scenario. take on the coordination of individual recently written the The conference is designed specifically for women ‘Planning or no planning,’ he said, ‘train- resources, and that organised reporting book (2007) ‘Leadership working in higher posts who wish to heighten their under- ing exercises or no training exercises channels guarantee the transfer of infor- can sometimes mean the difference Tools For Inspiration standing of the contemporary issues facing women as mation – if this is not done it can lead to between life and death. It is important situations where, for example, a contam- and Motivation’. He they move to assume leadership roles in their institutions. to practice processes through regular inated patient contaminates all sensitive maintains that inspira- The Leadership-Tools.com page, by Richard Gorham, training – that’s the only way to ensure areas within a hospital because there has tion and motivation are offers leadership tools and resources that will assist man- that in a real emergency everything runs been insufficient preparation and struc- musts for any leader agers in becoming more effective leaders in the work- smoothly. Well-trained staff and opti- turing of his transfer through the build- and that you can have place. mised alarm action plans can often pre- ing. In particular, the responsibilities and perfect structures, awe- Leadership-tools.com is devoted to researching, creating vent an escalation of a crisis. One of the distribution of executive functions should some communication, and loads of emotional intelligence, but and delivering high quality tools in five strategic cat- prerequisites for this is that the hospital be clarified before it is too late. ‘The inci- they are not worth much if your group is not inspired and moti- egories: continuously and critically checks its dent command team must be deter- vated. ● Business plan- concepts for their suitability for practical mined,’ he advised. ‘They take over the use. Many hospital action plans are out- K Blumberg (2007), points out 15 Essential ‘Leadership Tools’: ning strategic management and coordination dated and based around threats that no ● ● of the crisis on site. Although, in Strategic vision. Like an SLR camera with several lenses, you Leadership longer correspond with current reality. Germany, they are supported by the need to be able to think about the long-term (telephoto lens) development The terrorist attacks in the US on 11 super-ordinate danger defense organisa- and the short term (normal length lens). ● Sales manage- September 2001 and those in Madrid tions, such as the police and fire brigade, ● Automatic focus.A key leadership job is making sense out of ment and London showed the necessity of the hospital management can be, and is the mass of information in the world and focusing it down to ● Customer service preparation for large-scale events made, personally liable if a lack of prior the few key things the organisation needs to do. ● Team building through more efficient rescue strategies, planning is proved. Hospitals are ethical- ● A heart. Blumberg believes you lead best from caring for oth- As we can see, dif- and this applies to Europe as well.’ But, ly and legally obliged to ensure the best ers. ferent authors have their specific interpretations over he adds, internal crises such as hospital possible medical care for patients in the ● Input tools.These include a good pair of ears for listening leadership tools, but all of them pursue effectiveness and fires or power cuts are also underesti- case of catastrophes despite limited mated. As the sources of danger and the carefully to those around you, a clear pair of eyes for observing efficiency, through people. resources.’

ment level, for example hip replacement procedure, Courses for future Gerhard Polak MD DTMH outlines Efficient processes in the angioplasty, diabetes, etc. This is what we should do if the 2009 catalogue of courses we want to develop standard operating procedures for hospital managers commencing in Europe this October treatment of patient groups. However, there is a prob- Finnish hospital HUS Today hospital managers services as well as management for non- By Dr Janne Aaltonen, lem of high number of separate diagnoses and treat- have to meet varied and profit organisations (NPOs). ment options and in addition high variety between complex requirements. Examples of courses in Europe: Director R&D, HUS patients (acute vs. chronic, emergency vs. elective, etc.). Their field of activities Health Care Management, Dresden Administration Building, Therefore we wanted to study if there are process steps covers multiple disci- International University and subprocesses common to different patient groups plines and the decisions International Executive MSc in Helsinki, Finland and specialities. And, naturally, there are. A referral they make are of far- International Primary Health Care by process, diagnostic process, operation process or trans- reaching significance for Web-Based Distance Learning, fer process is similar between different patients and the future positioning and economic viabil- University College London (UCL) he Hospital District of Helsinki and Uusimaa (HUS) is the specialities. ity of their hospitals or hospital group. Master en Dirección Médica y Gestión It is therefore imperative to create a biggest of 20 hospital districts in Finland. It provides spe- By combining these two approaches we can form Clínica, Escuela Nacional de Sanidad, work environment that is attractive, Instituto de Salud Carlos III, Madrid Tcialised and university level health care services in and two-dimensional process matrix, elements that are com- despite the high workload. Economic suc- Master in Health Services Research, around city of Helsinki, with regional responsibility of 1.5 million mon to all patients at certain stage (vertical process) cess depends on the optimisation of Erasmus MC, University Medical Centre people. HUS has 23 hospitals, 21,000 employees (2,500 doctors), and elements which are common to all patients at cer- organisational processes, while medical Rotterdam Master of Arts in Hospital 1.4 million annual outpatient and 500,000 in-hospital visits, and tain diagnosis or treatment (horizontal process). care, diagnostics and interventions must Management, University of Leeds annual revenues of 1.4 billion EUR. Helsinki University Hospital is If we consider all medical care, we can find out, that be state-of-the-art. Quality management MBA Health Care Management, part of HUS. processes in emergency care and elective care are quite measures taken in hospital organisation Medical University of Vienna The HUS strategy was fully aligned in 2007. Our objective is to different. Elective care is scheduled; therefore we can must also focus on patient safety and com- MBA Health Care Management, SMBS - increase productivity 2–3% per annum, adoption of the purchas- utilise resources differently from emergency care. Also, fort and ensure the continuous improve- University of Salzburg Business School er/provider split, customer-orientated services and structures, and an elective patient has a diagnosis, while first step of ment of treatment outcomes. MBA International Hospital & Health Special training courses prepare (future) reform of operating models throughout the organisation. All of emergency care is to define diagnosis. Due to differ- Care Management,Frankfurt School of hospital managers for these tasks by offer- Finance & Management these objectives apart from purchaser/provider split call for ences in these processes we have concluded, that it ing broad business education that provides MSc in Health Services Research, process development. Actually, even before aligning the strategy would be reasonable to separate elective care totally them with the technical and methodologi- University of York the Ideal Hospital project was started, which aim is to develop a from emergency care. Similarly there are major process cal competence required for managing MBA Health Services Management, new process oriented concept for HUS. and resource optimisation differences concerning elec- hospitals. Danube University Krems The Finish healthcare system is relatively effective, if we use tive in-hospital treatment and elective ambulatory ser- The catalogue medicine & health 2009* The courses are described in abstracts, GDP proportion of healthcare costs as an indicator of efficiency. In vices where people flow anyway, i.e. in shopping centres gives an overview of courses offered in which facilitates their comparison. On 2005 Finland used 7.8% of GDP in healthcare (OECD health data). and city centres, not in the hospital environment. hospital management. The 19th edition of around 300 pages, the catalogue presents All people have access to public healthcare; there is also a small As a conclusion, there are two ways to define medicine & health presents a comprehen- seminars, courses, summer schools and private sector (about 10% of services). Primary and secondary processes in hospital: 1) customer processes (vertical), sive listing of and concise information on conferences taking place from October 2,500 flagship courses from 50 thematic care is currently disintegrated, although there is a legislation which allow optimising allocative efficiency (‘doing 2008 to June 2010. Each chapter starts areas structured in seven chapters. The with expert articles and includes addition- process to join these two. Specialised care is provided by Hospital right things’), and 2) production processes (horizontal), courses and conferences included are al short articles informing on training Districts, each municipality belong to one (of 20). Most districts which allow optimising technical efficiency (‘doing offered and held by over 750 universities, opportunities and career paths in the the- use DRG reimbursement system. things right’). Customer processes can be used in devel- higher education institutions and interna- matic fields covered. In addition, medicine The quality of Finnish healthcare systems is also quite high if we oping ICT, and for comparison of different specialties in tional organisations. & health 2009 offers comprehensive ask people who have used healthcare services. Finnish people one organisation. Production processes should be used Specifically for hospital managers and indexes, a guide to 150 selected websites regard our system third best in the EU (EurLIFE survey 2003). If we to standardise operating procedures, and for compari- healthcare executives, new and renowned and a directory of organisers. combine efficiency as a GDP share and quality as asked from peo- son of one unit in time, and same activity in different courses and seminars organised at the *Price: €39.90 (Austria and Germany), 42.00 ple, we can find Finland the number one OECD country in quality- organisations. regional, national or international level are (rest of Europe) and 51.00 (overseas, airmail). efficiency matrix. Low costs are mainly due to lower than average We expect productivity gain of 10–20% by standard- listed in an exemplary and clear fashion in Order through bookshops or directly from: the chapters on hospital management and www.goinginternational.org. personnel cost because of smaller number of doctors and nurses. ising customer processes, and 5–10% by standardising organisation, quality management, infor- E-mail: [email protected] We have described numerous processes in diagnosis or treat- production processes. mation technology, healthcare and health Phone: +43/(0)1 798 2527

EUROPEAN HOSPITAL Vol 17 Issue 4/08 7 LABORATORY & PHARMACEUTICALS

esearchers funded by the By 2010 India could capture clinical trials business of around US$ 1 billion, up from US$ 200 million European Union have devised in 2007, making the subcontinent one of the world’s preferred destinations for clinical trials ROptoLabCard, a system that pre- pares samples and performs DNA tests on bacteria in a portable, easily used, Cochrane Network, and a member cost-effective lab-on-a-chip. of the Scientific Advisory Group Within three years, this work will lead of the WHO International Clinical to commercially available hand-held Ethical concerns over Trials Registry Platform (ICTRP) devices that detect bacteria in the food and of the steering group of the chain and diseases as diverse as cancer, Clinical Trials Registry. hepatitis, AIDS and flu within 20–30 The latest developments in India minutes, replicating laboratory process- reflect a concerted effort on the es anywhere at any time. clinical trials in India part of the global public health OptoLabCards could also be used to As an increasing number of community to push clinical trials identify pathogens and pollution in international drug companies are issues to the fore in the wake of water supplies, says Dr Jesús M Ruano- moving their clinical trials several high-profile cases in which López, coordinator of the OptoLabCard business to India, the clinical trial pharmaceutical companies were project at the IKERLAN Technology industry has been raising shown to be withholding research centre, Arrasate, Spain. The concerns about the lack of information from regulators. In regulation of private trials carried September 2004, for example, the out there, including the uneven members of the International application of requirements for Committee of Medical Journal informed consent and proper Editors (ICMJE) published a joint Integration ethics review. editorial promoting registration of There is now a new urgency for all clinical trials. The ICMJE the reform of clinical trials stated that, from 1 July 2005, only of POCT registry in the subcontinent. registered trials would be eligible Dr Ambujam Nair Kapoor, a for journal publication. In 2007 the senior scientist of the Indian ICMJE stated that it would into the Council of Medical Research consider a trial for publication if it (ICMR), stated: ‘Unless we put in had been registered in any World place systems that ensure safety Health Organisation Primary clinical of patients and good quality of Registry. trials, people will get away with The WHO’s involvement in whatever they can get away with.’ clinical trial registration began in laboratory ICMR, a national body October 2003 with consultations responsible for the formulation, with different stakeholders to coordination and promotion of identify a potential basis for Unlike regular laboratory analy- biomedical research, is striving to collaboration to address complex ses, which is performed by clinical do just that with the Clinical issues related to trial registration pathologists and technicians in the Trials Registry of India, which and reporting. This culminated in

© MARY PARGETER© MARY www.pargeterdesign.co.uk clinical laboratory, Point of Care was launched in July last year. the establishment of the ICTRP Testing (POCT) are devices to per- This encourages the registration sometimes not publicised,’ she involving human subjects to Secretariat, which began form laboratory analyses in the of all clinical trials conducted in said, adding that information register their trials in the Clinical operations in August 2005. It is vicinity of the patient by the India before the enrolment of the about failures should also be put Trials Registry or any other committed to harmonising attending physician or nurses. first participant. Dr Kapoor, who in a publicly searchable database. primary clinical trial register. From standards within which trial POCT is essential in all hospi- added that the Registry is meant Working with the Indian Journal January 2010 these journals will registers and databases worldwide tals, either due to the instability of to bring transparency to clinical of Medical Research, early this consider publication of a trial can operate in a coordinated the analytes (e.g. in blood gas trials conducted in India, is very year the Clinical Trial Registry started in or after June 2008 only if fashion, providing a global trial analysis) or the necessity of imme- aware of the shortcomings of also brought together the editors it has been previously registered. identification and search diate reporting (e.g. glucose test- current trial publication practices, of 12 Indian biomedical journals ‘We are wearing down the capability, and promoting ing to adjust insulin doses) and including a tendency to publish to develop policy covering the resistance [to registration],’ says compliance. the very demanding logistics for trial results only when they are publication of clinical trials. The Dr Prathap Tharyan, professor of For a full report published in the the alternative, i.e. testing sam- positive: ‘Trials done earlier, editors issued a statement in April psychiatry at the Christian Medical WHO Bulletin in August, go to: ples in the laboratory. This has led where the drug has not been urging all those conducting and/or College, Vellore, India. Tharyan is www.who.int/entity/bulletin/volumes/ to the development of several found to be effective, are planning to conduct clinical trials the coordinator of the South Asian 86/8/08-010808.pdf devices specially designed for POCT. Not only is the location dif- ferent for POCT, but the levels of analytical expertise in the ward and the ease of testing are also dif- ferent. In general, POCT devices analyse unprocessed samples (e.g. whole blood) and can be run by personnel with only limited train- ing. The devices automatically check the integrity of the analyti- cal procedure and the necessary pre-analytical steps (replacing centrifugation for the separation of blood cells from serum/plasma) are generally performed within the devices. POCT carries several challenges: the immediate medical response to the results, and the tests in terms of medical analysis by a layperson, demand supervision by analytical experts. In Germany, for example, supervision by the central labora- tory is mandated by law and DIN EN ISO 22870 describes in detail the optimal organisation of POCT. The decentralised testing makes this supervision very demanding: a typical 800-bed hospital has about 50 patient sites for glucose testing and about 10 for blood gases; large university hospitals may have sev- eral hundred sites in which to per- form POCT. The high volume of POCT analyses – in general, about 50-100 tests are performed annu- ally per hospital bed – and the widespread use of electronic patient records (EPRs) should

8 EUROPEAN HOSPITAL Vol 17 Issue 4/08 LABORATORY & PHARMACEUTICALS Spanish researchers develop a new lab-on-a-chip improve the accuracy of detection, Ikerlan incorporated magnetophoresis The OptoLabCard for 20–30 minute tests. David Loshak reports and the polymerase chain reaction (PCR) technique to concentrate sam- company develops products that com- possible to put sensors, fluid channels thick photoresist – photosensitive ‘After all, to detect the presence of ples before testing, PCR being well- bine mechanical with electronic and and optical components into a tiny resin that loses its resistance to chem- bacteria you must have a reliable sam- established as a method of replicating software engineering. space, using components measured in ical etching when exposed to radiation ple.’ DNA to create higher concentrations. Clearly, the quick detection of dis- microns (millionths of a metre). and used in the transference of circuit Rubbing a swab across a chicken ‘In that way we can create more eases such as campylobacter and sal- But until now production costs have patterns to semiconductor chips when carcass, for example, might produce a concentrated bacteria samples,’ Dr monella well before they enter the food been prohibitive. What distinguishes making integrated circuits. sample containing as few as ten bac- Ruano-López explains. ‘And because it chain would greatly enhance food safe- the OptoLabCard is the material used The base unit contains all the elec- teria, an amount that could go unde- works with DNA, the same device can ty, especially as tests on farms or in food to manufacture the components and tronics and optics and the chip is dis- tected once transferred into the be used to detect many types of bac- processing and distribution require lab- the way in which samples are prepared posable. Incorporating sample prepa- device. teria and diseases.’ oratory testing that can take days. for testing. ration into the chip enables users to That inability to provide a represen- Campylobacter detection will be The notion of a device small enough The device integrates optoelectro- perform laboratory processes wherev- tative sample could mean the bird, or especially important, as the bacteria to perform tests normally needing lab nic, microfluidic and microbiological er they need. even the entire batch, being deemed are highly prevalent in poultry, leading facilities arose from the development in advances. Chips are simpler and cheap- ‘Sample preparation is the crucial clean even though covered with to gastrointestinal infections costing the last century of microelectromechan- er to produce because, for most compo- part but it was abandoned by earlier pathogens. $1 billion to treat in the USA and ical (mems) technology, which made it nents, the OptoLabCard uses a negative developers,’ Dr Ruano-López notes. To overcome that problem and Europe annually.

GE Healthcare

By Matthias Orth MD of the Institute for Laboratory Medicine in Stuttgart, Germany The end of disease mean an automatically transfer POCT results into the EPR. In starts at the beginning. general, different POCT devices are connected via Connector software with the laboratory information system (LIS). The sooner the better. Never did that phrase ring more true than Connector software is avail- when treating illness. From predicting and diagnosing to monitoring, able from the major vendors of treating and informing, GE Healthcare dedicates its resources to help POCT devices (e.g. Siemens, Radiometer, Roche) and from healthcare providers stay as many steps ahead of illness as possible. independent companies (e.g. Because the earlier the detection, the sooner we just might bring Conworx). This software allows disease to an end. Healthcare Re-imagined. supervision of quality controls and patient results. Depending on the level of compatibility, sev- To learn more, visit us at ESC booth number C520 & D500, Hall B2. eral functions of the POCT device can be monitored remote- ly and even some maintenance steps can be started and moni- tored remotely. Patient results are transferred to the LIS and are then transferred to the EPR. The communication between these systems employs standard protocols, such as HL7, HCM, ASTM Protokoll or POCT1A. While the connection of instru- ments, supervision of quality controls and managing the device status remotely are easy, the integration of patient reports into the EPR can be challenging. In general, the LIS first gener- ates an order and will then ask for the results. In the case of POCT, the POCT device gener- ates a result (including time stamp and patient data) which is transmitted to the LIS. However, few LIS can generate an order simultaneously with the trans- mission of results. From a legal standpoint, those responsible must be indicated on each laboratory report. This is challenging, particularly for POCT results: a high number of people perform these tests (i.e. essentially all nurses and doc- GE imagination at work tors) and the full responsibility for the results is in the depart- ment where the analyses have been performed and not in the © 2008 General Electric Company GE Medical Systems, a General Electric company, doing business as GE Healthcare. central laboratory. Taken togeth- er, POCT with supervision by the central laboratory can be a very efficient tool for the quick and reliable treatment of patients in the hospital.

EUROPEAN HOSPITAL Vol 17 Issue 4/08 9 LABORATORY & PHARMACEUTICALS Laboratory Outsourcing: DIABETES Arrays Chromosomal rearrangements leading to genomic What next? By Mary Black disorders are often mediated by low-copy repeat A quiet revolution is occurring in clinical laboratory services. In any regions of the genome (e.g. segmental duplications) business model, laboratory services are cost centres, and cost centres can be moved around, services out- sourced, amalgamated, contracted out. Globally, diagnostics and labo- ratory outsourcing are following the already trodden path of infor- mation technology. Two types of work are involved in the move overseas – diagnostics and patho- logy testing, and clinical trials/ research. There are three ways of handling the sample materials themselves: ● Clinical materials can be sent overseas for direct testing toes in the market, attracted by director of the global CRO firm ● Photomicrographs of lab tests costs that may be considerably Chiltern international, expects the can be sent for review and lower than a local laboratory. The Indian market to hit the $1-1.5 bil- reporting by experts. Time zone use of telepathology services are lion mark by 2010. Most of their differences can be used to increasing in Europe and the US, work comes from Europe (70–80%) advantage, with reports sent but also in countries such as West and the remainder from the US overnight to be picked up on the Asia, Sri Lanka, Africa, Nepal and (almost 20%). next business day. Bangladesh. Metropolis, a market New concerns are arising out of ● Testing on humans can be sent leader in diagnostic services this outsourcing shift, including overseas (as in clinical trials) and nationally in India, also provides how to deal with patient confiden- laboratory services simply hospital laboratory management tiality, regulatory barriers, and an follow. services with labs in the Middle ongoing debate on quality and the Roche reports that, using its nonallelic homologous This really is big business. 20 East and South-East Asian coun- minimisation of reporting errors. NimbleGen CGH arrays, recombination (NAHR) between years ago, in the USA diagnostics tries, including Thailand, Indonesia These have been ongoing concerns researchers* have identified a low-copy repeat regions of the was a highly fragmented industry. It and Vietnam. They process more for laboratory services for years; recurrent reciprocal genomic genome and occur in approximately is now annually a $50 billion indus- than 10 million sample tests in the difference now is that debate rearrangement of chromosomal 1 in 1,000 live births. The try, with 50% coming from the top their global chain annually, but crosses not just organisational but region 17q12 in foetal samples phenotypes of many of these known five chains. This pattern is replicat- only 1.0% is classed as outsourc- international boundaries. We can with congenital anomalies that is genomic disorders include ing across the world and chains of ing. This is set to rise. predict that lower prices alone will also associated with paediatric developmental delay and mental consolidated super labs, providing Clinical Research outsourcing has not drive the industry, but that renal disease and epilepsy. ‘The retardation. Therefore, screening services on a contracted basis, are moved faster, driven by lower costs quality will come to the fore. results emphasize the importance for novel genomic disorders has becoming well established in and access to clinical subjects. Public awareness of laboratory of evaluating de novo structural largely focused on patients with Europe. The next business trend An estimated 30 Global Clinical outsourcing is still low, but as the variation events in paediatric cognitive disability and/or will be transnational outsourcing. Research Outsourcing (CRO) com- industry develops, patient and diseases other than mental peripheral nervous system defects. National health services and indi- panies are involved in India alone. other advocacy groups will enter retardation and the importance of Previous studies reported on the vidual hospitals are dipping their Dr Umakanta Sahoo, a managing the debate. duplication architecture as a development and use of a BAC- predisposing factor for disease,’ based microarray targeting 130 Roche points out. ‘rearrangement hotspots’, defined as Genomic disorders result from regions of the genome with an develop a ‘sample-to-result’ sys- tem that meets the needs of the UPDATE UniCel core laboratory.’ Market expansions Bayer’s new Contour Talking about the growth in integrated systems health care infrastructure invest- ment in emerging markets, he meter and This summer, California-based said: Beckman Coulter Inc. began gener- ‘This is one of the key factors al distribution of its UniCel DxC for growth of the entire industry. Microlet 2 devices 880i’s integrated system in Europe. We have made significant invest- The new Contour blood glucose meter from ‘The company’s technological ment in our operations outside Bayer HealthCare Diabetes Care promises achievement with the DxC 880i has the United States to take advan- enhanced testing features that can be per- been to devise a way to integrate tage of this trend. For example, in the testing process by running India, we established a direct sonalised to meet diabetics’ individual treat- chemistry and immunoassay tests ments. The firm has also redesigned the Marc Meyer Scott Garrett sales office. And growth in China in parallel and to do this without continues in the double digits as Microlet 2 lancing system. removing sample caps and expos- meet those needs. Market analysis we invest in our operations there.’ The new updated Contour includes Bayer’s ing the blood to contamination,’ today tells us that integrated sys- The group’s former EMEAI No Coding technology, small sample size and explained Marc Meyer, Beckman tems are the fastest-growing seg- (Europe, Middle East, Africa and fast testing time, but is also reported to be Coulter Europe’s new clinical diag- ment of chemistry system sales.’ India) region has been split into the only meter that will provide diabetics nostics marketing director. ‘Since it He followed this with announce- two: Europe (Western); and with a choice of ‘basic’ or ‘advanced’ set- was first featured at EuroMedLab ments that included the launch of Emerging Markets (covering tings, i.e. either for simple diabetes manage- 2007, customers have ordered the three more integrated systems by Eastern Europe, Eastern Med- ment or to make it more specific. individual elements, the UniCel DxI the end of 2008 – the UniCel DxC iterranean, Africa, Russia, the In the advanced setting, test reminders can 800 immunoassay analyser and 860i; DxC 660i and DxC 680i. Middle East and India). Both oper- UniCel DxC 800 clinical chemistry ations are still managed from be programmed in, and pre- and post-meal markers can provide Molecular diagnostics system, planning to connect them the group’s European head- information on how a meal can affect blood glucose – particularly with Beckman Coulter’s second Unveiling plans for expansion into quarters in Nyon, on Lake Geneva, helpful for self-adjusting insulin users. In this mode they can also generation closed tube aliquotter the US $2.1 billion molecular diag- Switzerland. set their own high and low blood glucose targets. The setting also (UniCel CTA) to form the DxC 880i.’ nostics market with the launch of a provides 7, 14 and 30 day testing averages. Scott Garrett, the firm’s Chair- random access analyser, the UniCel Pre-eclampsia markers The Microlet 2 lancing system, which will be included with the man, President and CEO, empha- DxN, Scott Garrett explained: The company is also focusing on new Contour system, has been redesigned to simplify testing. ‘It sised how it relies on customer ‘Molecular diagnostics is one of prenatal testing; prostate cancer, also has a large release button, smooth silicone-coated lancets and input to help define laboratory the most important technological anaemia; reproductive endo- reduced puncture force. Plus it enables easy lancet ejection,’ Bayer requirements. ‘Before the begin- advancements in clinical diagnos- crinology; and cardiac testing. In adds. ning of this century, customers tics, but it currently operates out- terms of pre-eclampsia, for which were indicating the value they side the core laboratory. We will currently there is no diagnostic These new devices soon will be launched in selected European placed on integrating chemistry use our expertise in laboratory test, the company is working on markets, first in Germany and Nordic countries. and immunoassay testing, so we instrument design and our diverse the development of two markers started development of systems to intellectual property portfolio to to help diagnose the condition. See clinical laboratory events: Page 27

10 EUROPEAN HOSPITAL Vol 17 Issue 4/08 DIABETES

early-onset type II diabetes in children. Therefore, the evaluation of this microdeletion should be considered early in the diagnostic workup for children with renal to detect genomic disorder pathology. In addition, the authors architecture suggestive of a maturity-onset diabetes of the gene were analysed using a focal cortical dysplasia. advocate generalised screening of susceptibility to recurrent young type 5 (MODY5) and both custom oligonucleotide array In summary, the analysis revealed genomic hotspot regions of both microdeletion and/or duplication. paediatric and prenatally (NimbleGen, 385K, average probe novel microdeletions and parents and offspring for other Employing this array, novel detectable cystic renal disease. In spacing 53 bp). Four of five duplications in a series of foetal paediatric diseases for which the genomic disorders associated with one study, one third of MODY5- paediatric and all three of the samples with congenital anomalies genetic aetiology is not well mental retardation and affected individuals exhibited MODY5 patients showed other than mental retardation. The understood, including developmental delay (MR/DD) deletion of the entire TCF2 gene microdeletions nearly identical to 17q12 deletion is the first genomic schizophrenia, asthma, and were discovered. Surprisingly, and surrounding sequence. the foetal case. In addition, Roche disorder identified that results in cardiovascular disease. many of the predicted 130 hotspot Five patients with paediatric NimbleGen custom fine-tiling diabetes and the identification of * Mefford HC et al.: Recurrent regions have never been renal disease without diabetes array CGH was used to identify this recurrent microdeletion will reciprocal genomic rearrangements of associated with copy number and three patients with MODY5 the reciprocal microduplication in have a significant impact on 17q12 are associated with renal variants in either apparently previously shown to have patients with mild-to-moderate diagnosis, prognosis, and disease, diabetes, and epilepsy Am J normal individuals or patients deletions encompassing the TCF2 mental retardation, epilepsy, and management of renal disease and Hum Genet 2007; 81: 1057-1069 with MR/DD. To address the hypothesis that genomic rearrangements mediated by many of these regions affect gene pathways other than those involved in MR/DD, and to broaden the spectrum of diseases www.bayerdiabetes.com caused by genomic disorders, H C Mefford and colleagues analysed Bayer (reg´d), the Bayer Cross (reg´d), CONTOUR, the NO CODING logo, DNA samples from prenatal and the SIMPLEWINS logo are trademarks of Bayer HealthCare LLC. autopsy specimens from 155 foetuses with one or more congenital anomalies, no known cytogenetic anomalies, and detailed pathology data were analysed by BAC array CGH. THIS TIME According to the data, nine individuals (6 %) showed evidence of microdeletion or microduplication and eight were identified with potentially IT’S pathogenic deletions or duplications. Fine-mapping using a custom oligonucleotide array (NimbleGen, 385K, average probe spacing 53 bp) revealed that three PERSONAL, of the individuals harbour microdeletions with breakpoints mapping to flanking segmental DIABETES. duplications. One foetus with bilateral multicystic dysplastic kidneys contained a deletion Testing with Bayer’s improved region of 1.8 Mb at 17q12 that involves 19 known genes. CONTOUR™ meter is always simple. Mutations in one of these genes, And new features allow easy TCF2, has been shown to cause personalisation of its functions to fi t individual needs.

ALWAYS SIMPLE EASD s.O#ODING˜TECHNOLOGY for easy accuracy s2ESULTSINJUSTSECONDS 2008 s4INYBLOODSAMPLE—, Rome, Italy, NEW CUSTOMISABLE FUNCTIONS 8-11 September s"ASICORADVANCEDOPERATINGLEVELS s0ERSONAL(),/BLOODGLUCOSE Massimo Porta target range The 44th annual meeting of the s0RE ANDPOST MEALAVERAGES European Association for the Study of Diabetes (EASD) will focus on scientific research into diabetes mellitus. From 2,498 abstracts submitted, the Scientific Programme Comm- ittee, chaired by EASD Honorary Secretary Professor Michael .OTETHATTHEENVISAGEDFIRSTLAUNCHOFTHISPRODUCT Stumvoll, selected 1,402 for pre- IN%UROPEWILLBEIN'ERMANYIN3EPTEMBER sentation. 0OSSIBLEFUTUREAVAILABILITYOFTHEPRODUCTISTOBE ASSESSEDONACOUNTRY BY COUNTRYBASIS!SKYOUR In his invitation to attend the LOCAL"AYER$IABETES#AREREPRESENTATIVEIFWHENTHE event, Massimo Porta, PRODUCTISWILLBEAVAILABLEINYOURCOUNTRY Chairman of the Local Organising Committee and member of the Abstract Review Committee, promises it will be unforgettable and, of course, Rome is a great venue: ‘Do come to enjoy the outstanding EASD scientific pro- gramme, and a bit of dolce vita.’ Details: www.easd.org

EUROPEAN HOSPITAL Vol 17 Issue 4/08 11 IT & TELEMEDICINE

Scots test Report: Anja Behringer telemetry system The 1st tele-

The world’s first installation of Cisco’s telemetry system HealthPresence has been completed at Aberdeen Royal Infirmary in Scotland. The system combines video, audio and call centre technology with medical information in a high- security network. ‘By integrating the video conferencing solution Tele- Presence it allows a virtual French and Cypriot face-to-face conversation members of MARTE 2 although physician and patient SAPPHIRE mission may be miles apart,’ Cisco explains. ‘HealthPresence interfaces with diagnostic equipment such as stethoscopes, otoscopes and to a monitor that displays blood pressure, temperature, pulse rate and pulse oxymetry. An attendant operates the equipment at the patient site and monitors it.’ In partnership with the Scottish Centre for Telehealth and the National Health Service Scotland, Cisco has been live testing, since earlier in the year, the efficacy of the solution as well as patient and caregiver satisfaction. Further international tests are planned. Telemetry delivers healthcare to even the most remote areas, bringing with it the value of distant medical specialist involvement in a case. The system can be installed in an office building, community centre, hotel or school, also bringing easier access to the elderly. A satellite link is envisaged that will make the IT platform the ideal partner for short-term use, for example in disaster areas or during the outbreak of epidemics.

FEATURES BENEFITS • Based on Cisco TelePresence and a secure • Enables access to care anywhere, anytime. networking infrastructure. • Can be configured to deliver primary care, specialty care, and chronic • Combines state-of-the-art video technology care management services. with physiological data captured by an •Facilitates new care delivery models, extending the service delivery area. array of medical devices. • Uses an IP communications platform; clinical providers can be co-located or distributed; can be serviced from call centres, medical offices, hospitals, and clinics.

• Can be located anywhere there is • Provides better and more convenient access to healthcare. broadband access; integration with satellite • Can be placed in retail and office locations, schools, industrial parks, communications is expected in the future. planned communities – anywhere services are not easily accessible. •Patients can access remote specialists without travelling.

• Based on industry-leading audio and video • Replicates the in-person experience for both patient and provider, with technology offering high-definition images. life-size images and no voice delay.

• Supported by attendants. • Does not require expensive health personnel. • Assures a safe and pleasant experience for patients.

• Can be integrated with Electronic Medical • EMRs used over a secure network provide the best enabling technology Records (EMRs) and can access other for continuity of care and efficient care delivery. hosted services.

• Will be integrated with IP-based call centre • Optimises use of scarce clinical resources technology. • Can organise resources by region, type, specialty, gender, or any other organising principle

12 EUROPEAN HOSPITAL Vol 17 Issue 4/08 IT & TELEMEDICINE ultrasound via satellite Robot Estele probes patient onboard ship and transmits images to France France – The first robotised tele- Several robots equipped with applications. assistance for the elderly and it can also be licensed to robotics ultrasound examination has been preliminary versions of the Beyond professional handicapped, etc.) integrators and manufacturers performed by participants in the robuBOX have already been applications, Robosoft believes the To bring these applications to for mass production. European Mobile And Robotised deployed: Estele, the tele- era of personal robotics is life, Robosoft already integrates According to the Japan Tele-echography (MARTE) project, ultrasound robot; robuCAB, an approaching fast and that its 80% of programming complexity Robotics Association’s in collaboration with Robosoft, autonomous GPS-guided vehicle, service robots, called robuters, will into the robuBOX, a module predictions, the world market for specialist in the development and and general-purpose mobile be part of everyday life within five programme using the Microsoft service and personal robotics production of service robot platforms such as the robuLAB10 years (i.e. they will not only be Robotics Developer Studio. will reach 17 billion dollars by systems. for domestic help or the robuROC utilised for amusement, education, Although robuBOX is incorporated 2010. Using Robosoft’s Estele, a tele- for security and military culture and healthcare, but also for into the heart of Robosoft robots, Details: www.robosoft.com operated robotic system, an expert clinician can perform remote echographic diagnosis as if in the same room as the patient. The system is based on a 3 kg, 4- axis ultrasound Probe Holder Robot, which can be positioned on a patient by any on-the-spot medical assistant, is controlled by the distant specialist at the Remote Master Controller. Via the bi-directional ‘visio’ conferencing system, the specialist receives the ultrasound images and can see and communicate with the patient. Two in one

Multi-screen video conference between Sapphire team and Bourges Communication can be via ISDN (known as RNIS in France) or a specific communication link, such as satellite, as used in this the first tele-ultrasound examination of a patient who was on the ship Saphire, owned by Cyprus-based Louis Cruise Lines. Researchers at PRISME – a new multidisciplinary research institute that includes some 170 university researchers, engineers, technicians and doctoral students at several locations (Bourges, Orléans, Chartres, Châteauroux, Paris) – initially spent a month becoming familiar with the software in the Estele robot, which is entirely controlled by the robuBOX, a universal robotics engine adapted for the growing service robots market. The team then developed and implemented software for internet communication via satellite between the Remote Master Controller in France and the remote Probe Holder Robot on the ship, which was sailing in the Mediterranean. ‘These kinds of projects show the soundness of the generic approach used in the robuBOX,’ said Vincent Dupourqué, CEO of Robosoft. ‘The standard tele- ultrasound robot was originally The new Evita XL - the combination of delivered for use in a classic video- excellence in invasive and non-invasive ventilation conferencing system over phone lines. Thanks to the robuBOX Smooth and comfortable - whether you’re ventilating adults, pediatrics or even development toolkit, included with premature babies. www.draeger.com the standard robot, a customer can add his own functionalities, and can also integrate the robot into a larger system.’ For the project the PRISME Dräger. Technology for Life® Institute team adapted Estele’s software using Microsoft Robotics

Developer Studio (see http://www. 0170-2008 microsoft.com/robotics)

EUROPEAN HOSPITAL Vol 17 Issue 4/08 13 IT & TELEMEDICINE

n 2005, the Dutch Ministry of Health bang’ replacement. Healthcare provi- embarked on a journey to imple- ders have invested heavily in HCIT over ment a national Electronic Health the last years. The Netherlands has one Software aids medication dosing decisions IRecord for all Dutch citizens. Its goal of the highest penetrations of practice is to improve the effectiveness and management and HIS/CIS solutions. The drug information system AiDKlinik developed by Dosing provide information quickly and precisely at the point quality of care through the optimal use Additionally, 100% of hospitals have GmbH is a software solution for the server-based intranet for where medical decisions are being made are decisive for of ICT. Though the Dutch efforts may chosen digitised radiology (PACS). The medication dosing. Dosing reports: ‘It is used to maximise the the quality of care. ‘For all aspects of the prescription of not often be cited in international con- EHR approach assumes the principle of safety and efficiency of drug therapy qualitatively and quanti- drugs, AiDKlinik is the tool that makes it possible to find texts, progress over the last years has autonomous healthcare providers. In- tatively and to prevent errors with medication by running the best possible drug reliably, quickly and economically been impressive. formation ‘stays at the source’, creating database checks on individual patient data prior to drugs and to avoid interactions with other drugs. It is therefore a being prescribed.’ valuable tool for all doctors.’ Among users of the software is Professor M Dominik ‘It’s as simple and efficient as using Google,’ adds Alscher MD, Head of the Centre for Internal Medicine at the Dosing, which has worked closely with University Hospital E-health in the Netherlands Robert-Bosch Hospital in Stuttgart, who said that, given the Heidelberg, where digital medication prescriptions have increasing complexity of medication, any tools that help to been provided since 2003. The Dutch E-health initiatives have made remarkable progress in recent years, writes Marcel Swennenhuis, President of Topicus HealthCare. Many solutions, such as online medication services, Latest SurgiMedia to be launched at MEDICA 2008 patient portals and web-based disease management initiatives, France – Isis* will unveil the latest version of SurgiMedia, the company’s integrated display demonstrate the success of the country’s EHR approach. system for operating theatres, at the MEDICA trade show (19–22 November, Dusseldorf) The Dutch follow both a top-down as a ‘virtual’ record whereby healthcare SurgiMedia is a multimedia digital-display station designed installed by the operating area. This control system then pow- well as a bottom-up approach. On the providers can access information from for use in operating theatres. It can be used for managing, ers the display on remote monitors, ensures the recording of one hand, work is being done to estab- other systems online through secured checking and recording patient data. Isis reports: ‘The latest data in a variety of formats, as well as the broadcast of this lish a countrywide infrastructure (called connections, one-time login, etc. version is fully integrated and modular, offering users greater data via video-conference. This system can be customised by AORTA) including elements such as an Everything is based on patient consent. flexibility. SurgiMedia is now available in two ranges of digi- Isis according to each hospital’s specifications.’ electronic healthcare provider card, a And it works. tal-display stations – a free-standing version and a hub ver- ‘With both systems, data can be retrieved directly from countrywide patient registry, security Experience shows that involvement sion.’ other devices in the operating theatre (such as microscopes, standards and legislation for one unique of healthcare providers in regional ini- The free-standing SA range is a fully integrated all-in-one endoscope cameras, computers and imaging devices), from countrywide patient ID. tiatives (covering 500,000 – one mil- system that displays, records and transmits patient data in CDs, or from the PACS via the network. SurgiMedia has an In parallel, local and regional initia- lion patients) provides a good basis for the operating theatre (including radiological images, videos intuitive touch screen based on pictograms, which is easy to tives have resulted in many implementa- success. Using existing regional coop- of surgery and expert opinions). It can be adapted to fit any use.’ tions of solutions. Local software compa- eration structures, it creates a better operating theatre setup. It is modular via its optional func- * Based in Saint Martin d’Hères (near Grenoble), Isis designs nies, e.g. Topicus HealthCare, were understanding of the needs/benefits of tionalities and also offers the flexibility of multiple configura- computer-based surgical equipment and provides technical involved in these initiatives from the the individual healthcare providers. The tions: it can be wall mounted, or attached to a surgical arm maintenance for its products. start. Topicus was instrumental in the mutual trust stimulates willingness to or a wheeled trolley. Isis will also exhibit at Zdravoochraneniye in Moscow (8-12 overall architecture and technology solu- share information. The implementa- ‘The hub-system SC range is a complete solution for the December) and Arab Health in Dubai (26-29 January 2009). tions for the leading EHR regions. tions are done faster with greater entire theatre. It is based around a control centre that is Details: www.isis-robotics.com Solutions were deployed varying from an acceptance. Fast and iterative software electronic medication service (showing development approaches complement all of a patient’s medication), a web ser- this flexible organisational approach. Emergency first aid advice via mobile phones vice for weekend/evening doctors in duty The open competition model stimu- (allowing them to access a specific view lates HCIT providers, such as Topicus, to Austria – Only 28% of the public would give first aid ‘no take. ‘I don’t know a single case where a first aider was taken to the patient’s record during out-of- work continuously on the cutting edge matter what’; 32% would be ‘very likely’ do so, according to a to court for making a mistake,’ says Red Cross solicitor office hours), and integrated solutions of e-health solutions. Using standards study by the market research institute Market. However, the Bernhard Schneider. for disease management such as dia- like IHE and HL7 discourages lock-in to Austrian Red Cross warns that those figures may be overly The Austrian Arbeiter-Samariter-Bund (ASB) has developed betes. Web-based patient portals have specific vendors. At the same time, co- optimistic: their observations at accident sites indicate that Samariter, a mobile phone application that can be down- been introduced, allowing patients to existence with older de facto standards significantly fewer people are prepared to administer first aid. loaded (the mobile must be Java-enabled, as are most cur- schedule appointments, re-order medica- and even proprietary protocols enable ‘The most important measures that every student driver rent models). On the phone display, this shows how to put a tion and have e-consultations. A web- a gradual and smooth introduction and should learn are recovery position and cardiopulmonary resus- person in recovery position, how to perform CPR and how to based referral service has been intro- transition into the new e-health world. citation (CPR),’ advises Wolfgang Schreiber, Medical staunch bleeding. ‘The system is intended to help a first aider duced, allowing referring physicians to In the coming years regional initia- Director of the Austrian Red Cross. to use the time sensibly until the emergency medical service create and manage their referrals. This tives are expected to cover the entire In another recent study 73% of the participants reported arrives,’ explains Franz Schnabl, President of ASB Austria. shows availability, waiting times, etc. It country, whilst, in parallel, all regional being scared to do the wrong thing in an emergency. 40% had To date, about 4,000 people have installed Samariter, also allows hospitals and clinics to solutions will connect to the country- first aid training over a decade ago. Only 3.5% could identify which is network-independent, enabling use even in poor define their services interactively and wide infrastructure. The solution space the correct sequence of emergency measures at an accident transmission zones, e.g. mountains. add them to the referral service. is now being extended to new services, site. Yet, greater knowledge could save lives. The Austrian Red ASB points out that the instructions are only to help in an The Dutch approach strongly supports for example other disease manage- Cross also points out that failure to render assistance is legal- emergency, it is no substitute for full first aid training, which a gradual integration and co-existence ment solutions, home care, youth care ly considered a misdemeanour; it’s better to make a mistake it strongly recommends. with existing HCIT solutions. Not a ‘big and more. than not help at all. No one need fear punishment for a mis- Samariter details: www.dersamariter.at PACS: Netcentric clinic services based ADVERTORIAL Sponsored by NUTRITION AND HEALTH their own hardware and software.’ on JiveX product line The system is already successful in Obesity in adolescents leads the market, Visus points out. Currently, Visus and T-Systems are to metabolic syndrome taking over external long term Children are not born overweight. Dramatic weight gain in some children and archiving for three hospitals within adolescents tends to start only during school, puberty and after. The reasons the Evangelischen Stiftung Augusta are known: unhealthy diet – too much, too fatty, too sweet – and lack of in Bochum, Germany, starting with a exercise. data amount of more than ten ter- According to estimates by the EU Commission 22 million children in Europe are abyte. ‘A user hotline comes with the overweight; five million of these are classed as obese.An EU Commission study offer of T-Systems and Visus. published in mid-2008 showed that almost every third boy and every fifth girl Also included in this service is the aged between 13 and 17 years are overweight. necessary data and/or hardware Nowadays, overweight children tend to suffer illnesses formerly only seen in implementation within the scope of adults: type 2 diabetes, high blood pressure, elevated blood lipids and uric acid the stipulated term of safekeeping,’ levels. In short, these children are developing metabolic syndrome. As adults Visus adds. they are at higher risk of heart attacks or strokes. Severe obesity in particular ‘The digital long term archiving – which goes hand in hand with an increased waistline (abdominal obesity) – solution has been developed accord- increases the risk of cardiovascular diseases. ing to the regulations of the IHE As yet there is no standard definition of metabolic syndrome in children that is From left: Axel Fromm, Senior Business Consultant in Business Centre Healthcare, T-Systems; Jörg recognized across Europe. However, Italian researchers at the University of Holstein, Managing Director of Visus; Andreas Dahm-Griess, Director Business Centre Health (Integrating the Healthcare Enter- Care, T-Systems; and Peter Rosiepen, Visus Sales Manager prise). Verona have recently shown that overweight five to 15-year-olds in whom the It aims at unifying data exchange ratio of waist to body height is larger than 0.5 have an eightfold increased risk Hospitals must digitally keep med- vices for the necessary systems. in using standards like Health Level of developing metabolic syndrome compared to those with normal weight. ical documents audit proof, which ‘Customers can rent Services on a 7 (HL7) and DICOM (Digital Imaging Here, losing weight is necessary. Precise scales, such as those manufactured by involves a lot of material and per- flexible basis,’ Visus explains. ‘They and Communications in Medicine). seca gmbh & co. kg. in Hamburg, Germany, help to document even the small- sonnel efforts. Following the princi- will pay per examination respective- With that the development, awarded est success. ple ‘Software as a Service’, Telekom ly per data unit (e.g. Gigabyte) or a prize by the State of North-Rhine To fight obesity in children across Europe, in summer 2008 the European subsidiary T-Systems, together with they simply pay a fixed price for each Westphalia, a high degree of invest- Commission suggested a programme that envisages free fruit and vegetables Visus, offers a solution that covers year of archiving. ment security for customers is for schoolchildren aged six to ten years.The programme is due to start with the installation, maintenance and ser- So they do not have to invest in ensured.’ school year 2009/2010 and is aimed at teaching children about a healthy diet.

14 EUROPEAN HOSPITAL Vol 17 Issue 4/08 EUROPEAN HOSPITAL@ Munich, Germany 30 August to 3 September ESC2008 2008 THIS SPECIAL CARDIOLOGY SUPPLEMENT IS A EUROPEAN HOSPITAL PUBLICATION www.european-hospital.com AUGUST / SEPTEMBER 2008

Every summer the European Society of Cardiology (ESC) holds Europe’s biggest annual meeting of specialists in cardiovascular medicine, inviting and drawing in top international medical professionals. Karoline Laarmann asked Professor Kim Fox, President of the European Society of Cardiology and Consultant Cardiologist at the Royal Brompton Hospital, and professor of clinical cardiology at Imperial College, London, UK, about the most relevant HOT TOPIC issues and highlights planned for this year’s programme. cardiovascular imaging Last year’s key focus was on diac CT scanning, and of course not is: Who should execute the proce- heart failure. What will be forgetting to mention all the dure? The demarcation lines for this year’s hot topic? invasive techniques: cardio-angio- that are changing currently and KF: ‘This year we decided to go for graphy and cardiac catherisation.’ they differ from country to coun- cardiovascular imaging because Which of the current imaging try. In the UK, for example, the any cardiovascular condition that modalities is making the radiologist will lead on cardiac CT, will be discussed during our con- strongest progress? most of the others by cardiologists euHeart gress always involves imaging in ‘The gold standard is multimodality but with special expertise in imag- some form. Imaging is the corner- imaging, because although a single ing. I assume that coronary CT will Aiming to personalise CVD stone not only for diagnosing a tool may be sufficient, patient eval- probably remain the area of radiol- condition but also to assess prog- uation is often best when used in ogists just now. nosis and tailoring individual treat- conjunction with other techniques. What will be the biggest diagnosis and treatment ment, too. By imaging we are talk- Every imaging technique has its challenges for cardiology in ing about procedures from the sim- individual strengths and weakness- the future? Royal Philips Electronics is to lead heart disease patients. plest form such as the electrocar- es; they all give a different piece of ‘Heart transplantation is a fantas- ‘euHeart’, the new European Union The newly created ‘euHeart’ consor- diogram to the most complicated information, so it depends on what tic technique but we clearly need (EU) funded research project that aims tium aims to improve the diagnosis, non-invasive imaging techniques you intend to measure. to think about some form of alter- to improve CVD diagnosis, therapy therapy planning and treatment of – MRI, nuclear imaging, echocar- Therefore one of the hot ESC native technique, which may be planning and treatment. CVD by developing computer models diography and, more recently, car- topics will be to discuss which are stem cells or a form of artificial By targeting the diagnosis and treat- that simulate the normal and disease- the right imaging tools to use for a heart. Better still, of course, would ment phases of the care cycles for related behaviour of each individual special problem. Of course we have be better implementation of pre- heart conditions such as heart failure, patient’s heart and aorta. Professor Kim Fox considerable hopes in molecular vention. We probably could deal coronary artery disease, heart rhythm Supplied with information about is the acknow- imaging. It may be the tool to iden- with most of the cases of heart fail- disorders and congenital heart defects, how specific CVDs affect heart func- ledged European tify different forms of heart muscle ure if prevention would be better, the euHeart project complements the tion at molecular, cellular, tissue and expert in the diseases that may respond to differ- which brings me to obesity, which recently announced HeartCycle project organ level, these computer models understanding, ent therapies and, in particular, causes an increasing number of (also led by Philips) which focuses on have the potential to allow doctors to investigation and may respond to stem cells. If it heart diseases. Last year, at the the long term management of chronic contined on page 2 treatment of were to be shown that stem cells ESC opening ceremony, I empha- angina. His major Professor Henning Sass (left) and Guy Peeters MD (right), chairmen of the Boards of Management were to be beneficial, then to deliv- sised my dislike of smoking. Now of the Aachen and Maastricht university medical centres, respectively, with Dr Henk van Houten roles in many er the stem cells will require I see child obesity as a major issue (centre), head of the Healthcare Research Programme at Philips Research, together for the signing significant sophisticated imaging. The second to take care of. But it is much of a letter of intent for a joint cross-border medical research programme for CVDs international hope we nourish in molecular tougher to handle because you clinical trials include EUROPA, imaging is to identify vulnerable cannot legislate what people eat. HPS, and ASCOT etc, which have plaques. We’ve just started to get The trouble is that fast food is revolutionised the treatment of this some imaging information by using much cheaper than a healthy diet. condition. He also chairs the task intravascular ultrasound of the It will take huge educational pro- force producing the European Angina coronary artery.’ grammes to accomplish a change Guidelines as well as the committee What form does work sharing of thinking. responsible for the audit for the take between cardiology and ‘Finally, it would be very helpful management of these patients in radiology imaging? to identify the 20–30% of patients Europe. Nowadays the management of a benefiting from treatment with Prof Fox has published over 400 patient is multidisciplinary, to drugs, because this would lead to papers in leading scientific journals, achieve the best quality of health- enormous cost savings and allow lectured to national societies care. As a cardiologist I think that access to medicinal treatment for worldwide, and has given the radiology is extremely important in people who truly need it. What we Finlayson Lecture to the Royal College particular cases where physics is are doing now is treating the of Surgeons in Glasgow, the St Cyres involved – radiation in particular. whole population with a drug or Lecture to the British Cardiac Society Radiologists need to be involved in procedure from which only a few euHeart Consortium membership (alphabetical order) Academic Medical Centre Amsterdam (Netherlands); Berlin Heart (Germany); Deutsches and the Andrea Cissalpino Lecture to ensuring that proper safety is taken profit. But the most important the Italian Society of Cardiology. Krebsforschungszentrum (Germany); HemoLab (Netherlands); Hospital Clínico San Carlos de into account. However, when it thing to do in cardiology is prevent Madrid Insalud (Spain); Institut National de la Santé et de la Recherche Médicale (France); For his services to cardiology he is comes to actually deciding which ischaemic heart disease. We have Institut National de Recherche en Informatique et en Automatique (France): King’s College an elected honorary member of the imaging tool should be used for a to identify the people who show an London (United Kingdom); Philips Healthcare (Netherlands, Spain); Philips Research (Germany); French Cardiac Society and the patient, the cardiologist must be aggravated risk to optimise our PolyDimensions (Germany); Universitat Pompeu Fabra (Spain); University of Karlsruhe Japanese Circulation Society. (Germany); University of Oxford (United Kingdom); University of Sheffield (United Kingdom); the person to make the decision. strategies of prevention and treat- Volcano Europe SA/NV (Belgium). The most controversial issue here ment based on the individual.’

EH@ESC 2008 ESC 1 EH@ESC

Dr Tomasz Zdrojewski, Dept. of Hypertension and Diabetology at the Medical University of Gdansk, Hypertension worldwide Poland Generally we can say that, with the political Social and cultural differences affect risk factors for cardiovascular diseases transformation in Poland over the last 15 years, Countries vary widely in their capacity to manage hypertension, but globally the majority of diagnosed the risk factors for CVDs have dramatically changed, some of them significantly decreased hypertensives is inadequately controlled. Not treated it can cause cardiovascular disease (CVD), myocardial (e.g. smoking) and some increased (e.g. psy- infarction and stroke. According to the WHO, hypertension is estimated to cause 4.5% of the current global chosocial factors). With regard to hypertension disease burden and is as prevalent in many developing countries as in the developed world. Here, three the consumption of too much salt is our main national problem. The recommended daily experts from three continents comment on risk factors and hypertension management in their countries. allowance is 7g but every Pole eats 10–15g, in poor families it is even 15–20g. The government began to take Dr Fiona Turnbull, George Institute for Dr Yackoob Kassim Seedat, Nelson R Mandela action last year with an information campaign on Polish TV and International Health, University of Sydney, School of Medicine, Faculty of Health Sciences, radio. Additionally, there are attempts to convince industry to Australia University of KwaZulu-Natal, Durban, S. Africa replace sodium by potassium. ‘Education is the crucial factor in prevention and control of arteri- Blood pressure-related disease is a major glob- Sub-Saharan Africa (SSA) contains a diversity al health problem and is responsible for nearly of ethnic groups, cultures and countries (54 in al hypertension. One step to increase public awareness was to make eight million deaths annually. About half of all all) of vastly different socio-economic status. primary physicians measure BP during every patient visit. stroke and coronary heart disease is attribut- Data from many parts of sub-Saharan Africa The place of residence is also a major indicator for prevalence and able to non-optimal blood pressure (BP). are poorly explored because of financial con- a starting point for the control of hypertension. One can say that Furthermore, about 50% of these major cardio- straints. South Africa is one of the few coun- Poland, especially during the early and very rapid phase of political vascular events occur in people who are so- tries where data are reasonably accurate. and economic transformation, has been separated into two sec- called ‘normotensive’. Therefore major health Available data focusing on black groups indi- tions: large cities and small cities (county boroughs) and villages. gains can be achieved by lowering BP, even in cate that hypertension seems more common People in large cities have had much better access to the best med- people who are not hypertensive according to traditional threshold with increasing acculturation, with a group of truly rural dwellers ical treatment, so we have many more cases of severe heart failure values. Obviously obesity and nutritional factors, especially salt con- still being relatively protected. However, it is not known what in the countryside, for example. Consequently, the hospitalisation sumption, play a major role in blood pressure. With the rapid epi- proportion of the African population lives in truly rural condi- rate of the rural population has been much higher in the last 15 demiological transition occurring in low-middle incomes, such as tions, relatively immune to the advances of civilisation versus years. ‘China and India, CVD attributable to BP is becoming increasingly‘those succumbing to urbanisation either rapidly or gradually. However, we have made significant progress in recent years, prevalent in developing as well as developed countries. The prevalence of hypertension according to rural studies due to huge investments and the long term and complex health Although lifestyle factors are important, drug therapy remains the undertaken in the 1970s, 1980s and 1990s has generally been policy project – National Cardiovascular Diseases Prevention and mainstay of blood pressure control and, given the millions of people low: 4.1% in Ghana, 5.9% in Nigeria, 7% in Lesotho and 9.4% Treatment Programme (POLKARD 2003-2008). For example, Poland increasingly prescribed therapy, it is critical to be able to discern in the rural Zulu. The migration of people to urban settings led to now has a tight nationwide network of interventional cardiology even small differences in the benefits of different drug classes. an immense increase of BP due to change in diet of new arrivals and cardiac surgery centres. Access to these procedures dramatical- A major component of my activities has been the leadership since in the cities and higher pulse rates due to psychosocial stress and ly improved and large inequalities significantly decreased. For 2003 of the Blood Pressure Lowering Treatment Trialists’ hard work. example, in 2002, 2,300 coronary angiographies were performed Collaboration (BPLTTC). This is an international collaboration of the Salt intake and lack of potassium due to inadequate fruit and per million people, and almost 900 percutaneous coronary revascu- principal investigators of major trials of blood pressure-lowering vegetable consumption are also main causes for hypertension larisation interventions (PCI), the respective numbers in 2007 were regimens. The collaboration seeks to provide clinicians, patients and here. Other factors are obesity, particularly observed in black 3,850 coronary angiographies and 2185 PCI. policy-makers with the most reliable information about BP drugs females, whereas alcohol excess is a problem particularly in I hope this improvement in access to best procedures, changes in and their effects on major cardiovascular events, such as stroke and black males. population awareness, healthier diet and less smoking are the most coronary heart disease, by conducting meta-analyses (pooled analy- Because SSA is the world’s poorest continent, only low cost important factors responsible for a 30% reduction in CVD prema- ses) of these trials. hypertension programmes can be afforded. The healthcare ture mortality in our country.This year we want to check this hypoth- The work of the Collaboration is conducted at the George Institute expenditure in many SSA countries is around US$10 per person esis and calculate the importance of each factor using the IMPACT for International Health in Sydney,Australia. This international initia- annually in contrast to between US$2,000 and $5,000 in indus- model elaborated and published in most prestigious medical jour- tive is based on information from more than 30 trials collectively trialised Western countries. The major health challenge is still nals by Prof Simon Capewell from the University of Liverpool. including nearly 200,000 patients from the UK, Europe, US, China, HIV/AIDS which takes a large portion of healthcare resources. One side effect of the transition to a market economy was that we Japan and Australasia.The collaboration brings together not only the There is a lack of adequate financing for research, but a compre- lost our national industry and the drugs to treat arterial hyperten- data from the largest BP trials but also the expertise and experience hensive CVD programme is absolutely necessary. Furthermore, sion became more expensive. Furthermore, primary care was priva- of the principal investigators of these trials, who are leaders in their there is inadequate financing for researchers who need to be tised which, in the beginning of this process, especially in small respective fields. To date, the Collaboration has provided important trained in excellent research centres so that they can learn tech- cities and villages, made access to basic medical care more difficult. information about the effects of newer compared with older classes niques in research methodology. It would be helpful if However, over the last five years we have observed an opposite of BP-lowering drugs and about their effects on stroke, coronary researchers from the developed world could provide expertise trend and social and medical awareness of arterial hypertension is heart disease in patients of different age, sex, and disease status. and engage in collaborative work. We need administrators and increasing again. At the moment about 66% of the population who These findings have informed major international BP guidelines as politicians in sub-Saharan Africa to be convinced of the value of have arterial hypertension know about it. well as clinical practice. A major challenge to this research is to research on risk factors in CVDs. Inadequate funds, inexperience Another important problem is the very poor control of people who ensure continually that the research is translated into practice. Huge and lack of infrastructure remain important barriers to hyperten- already had a stroke or myocardial infarct. I am the coordinator of gaps between evidence and practice exist and large proportions of sion diagnosis and therapy. an international study for Poland, Ukraine and Russia. This shows the global population at risk of blood pressure-related disease con- To sum it up: The effects of urbanisation which influence the that very few patients receive adequate post-myocardial infarction tinue to remain untreated. Part of the problem is that doctors persist prevalence of hypertension and CVDs in SSA are decreased phys- or post-stroke treatment. My most recent project is the 400 Cities in using outdated models of treatment based on managing individ- ical activity, increased energy and fat consumption and increased Programme, a very large-scale educational and prevention project to ual risk factors rather than consideration of the patient’s ‘absolute psychosocial stress. This leads to obesity, dyslipidaemia, diabetes fight CVDs. We focus on the smaller cities, where the epidemiologi- risk’ of experiencing a major cardiovascular event. and an increase in blood pressure. The future approach to CVD cal situation is worse than in large cities and, for example, offer spe- As new drug classes and new indications for treatment evolve, the prevention should be a population focus on societal change and cial classes in primary schools or special training for the nurses, doc- work of the BPLTTC will continue to be a valuable source of reliable not only individual focus on high risk factors. This should include tors and administrative staff responsible for healthcare in their information about the effects of these important drugs. primordial prevention, salt restriction and physical exercise. cities.

continued fom page 1 modelling and image processing, clini- physics, anatomy and physiology – a treatment therapies and improve ther- gist may be able to test the results of investigate the effects of different cal experts, and engineers in the task that will be facilitated by the use apy planning. In addition, the models destroying different tissue areas therapy choices on a virtual model of device and imaging industries.’ But, he of standardised mark-up languages could lead to improvements in the before actually operating on the the patient’s heart and aorta, before adds: ‘In the euHeart project we are such as CellML and FieldML to development and programming of patient. going ahead with the option that confident that we have brought describe them. implantable devices such as pacemak- In addition to RF ablation therapy offers the best clinical outcome. The together the necessary expertise,’ Patient-specific ers, left ventricular assist devices, and for arrhythmias, other clinical focuses availability of clinical decision support which could, he says, make a real con- Most importantly, the resultant com- endografts. for the euHeart project include heart tools that utilise these personalised tribution to improving cardiac treat- prehensive model will be adaptable to Therapy planning failure (cardiac resynchronisation ther- heart models could therefore improve ments. reflect the condition of a specific Because of the need to build the apy and congenital cardiac surgery the outcome for patients with life- From molecules to organs patient’s heart, using anatomical and model over time, particularly in rela- and left ventricular assist devices), threatening conditions such as heart A characteristic of biological complexi- functional information obtained via tion to incorporating molecular-level coronary artery disease, and dis- failure, coronary artery disease, heart ty is the intrinsic interaction of physio- diagnostic techniques such as medical to organ-level disease pathologies for eases/defects in the heart valves and rhythm disorders and congenital heart logical behaviours across a range of imaging (CT, MRI, ultrasound, etc.), diagnostic purposes, the first applica- aorta. defects. time scales and anatomical levels. The blood flow and blood pressure mea- tions are likely to be in therapy plan- Work packages However, as Henk van Houten, computer models developed in the surements or electrocardiograms. At ning for pre-diagnosed conditions, e.g. The euHeart project is broken up into senior vice president of Philips euHeart project will therefore relate the intra-cellular level, the model heart arrhythmias, sometimes treated a number of work-packages that Research and head of the Healthcare what happens at cellular and could even take into account specific by radio-frequency (RF) ablation. include database management/valida- Research programme, said: ‘The devel- microvascular levels to what happens gene defects in individual patients. During this procedure, the cardiologist tion for individual (sub-) models and opment of computer models that inte- at tissue level, and what happens at By having an accurate personalised relies on experience to decide which their coupling together into larger grate structural and functional infor- tissue level to what happens at organ model of the patient’s heart to work areas of tissue to destroy, a task com- structural/functional models; the mation of the heart and then person- level. This will require the integration with, doctors may be able to gain a plicated by the fact that each heart’s development of appropriate mark-up alise it to individual patients is a and interconnection of existing and deeper understanding of the patient’s electrical activity is subtly different. languages and communication infra- mammoth task that will require the future models from many different disease. This could allow them to Aided by a computerised model that structures for model description/ multi-disciplinary effort of researchers areas of biological research, including make more accurate diagnoses, pre- reflects the patient’s unique heart exchange; the personalisation of with strong know-how in biophysical molecular biology, biochemistry, bio- dict the likely effectiveness of different structure and function, the cardiolo- anatomical models from image data;

ESC 2 EH@ESC 2008 EH@ESC

Recent studies have shown that with the development in overweight and obesity during Colombia of audiovisual content childhood and adolescence have a that focuses on healthy life negative impact on the habits, designed to be used by functioning of the internal walls CHILDHOOD OBESITY health and education of the arteries (vascular professionals and to enable the endothelium), paving the way to New strategies to prevent obesity and sedentary lifestyles later evaluation of their impact the development of an message properly,’ Dr La Greca development of audiovisual of cardiovascular disease, said on both children’s and parents’ arteriosclerotic disease from an pointed out, adding that teachers materials that encourage pre- Dr Shahyar Sheik, President activities. Six out of the 27 increasingly early age. They also are the proper vectors to convey school children (aged between of the World Heart Federation, audiovisual materials initially prove that, regardless of age, life quality concepts to children. three and six years) to take who added that it also aims to planned have been broadcast in race and sex, child and The World Heart Federation in regular physical activity and eat ‘…identify those elements of the 2007 within the Plaza Sésamo adolescent obesity affects the Colombia also has a project to a healthy, balanced diet, and to programme that are cost- show, which is broadcast virtually vascular endothelial functions. promote healthy life habits in promote the importance of effective in order to reproduce all over the American Continent ‘The evidence that the risk childhood and adolescence. instilling healthy life habits in them; and to develop an through the cable TV channels factors of cardiovascular ‘Healthy Habits For Life’, children among their carers. association with Plaza Sésamo Discovery Kids, TeleFutura and diseases that reveal themselves presented through the television Along with this the project that can be spread to other Televisa, and others. New in adulthood begin in childhood show Plaza Sesamo (Sesame encourages multi-sector countries.’ episodes are being broadcast or adolescence makes it Workshop), consists of the collaboration for the prevention This project began in 2006, during 2008. imperative that prevention strategies be planned from a very early age,’ said Dr Héctor Trungelliti, President of the Paediatric Cardiology Committee of the Argentine Federation of Cardiology (FAC), speaking this May at the World congress of Please visit us at the ESC Munich, Cardiology, held in Buenos Aires. 30th August to 3rd September 2008, Booth no. A2-B402 ‘These risk factors, such as overweight and obesity, as well as a sedentary lifestyle, nicotine addiction, dyslipidemias, hypertension and type 2 diabetes, share a common element that cannot be denied: the adoption of poor health- MAGLIFE light related habits characteristic of western societies.’ MRI monitoring for all Released at the congress were the preliminary results of the Educando (Educating) Plan, a project, developed by the Argentine Federation/Foundation of Cardiology, and launched in 2001. The plan aims to prevent cardiovascular disease from childhood, and is targeted at primary school teachers, to encourage healthier lifestyles by providing information about the disease and prevention. ‘Its clear and didactic message can be easily communicated to children,’ explained Dr Rodolfo La Greca, co-director of the plan. Since the programme began in 2001, around 8,000 primary school teachers, in charge of about 100,000 children between four and five years old, have photo courtesy of Siemens AG MAGNETOM Avanto, received training. ‘We will try to convey the Argentine experience because, due to its characteristics the Educando plan is unique as regards the centralised and unified management of the plan, addressed to teachers and not directly to children, who sometimes do not receive the

and the biophysical (structural and functional) personalisation of the MAGLIFE light models. The clinical relevance of the Ideal patient monitor for your routine MRI examinations:

project will be ensured by additional s Display of SpO2, pulse, heart rate and non-invasive blood pressure application work-packages that will values (Sys, Die, MAP) focus on specific model development Saving and display of latest NIBP values for each of the clinical focus areas list- s ed above – tailoring the model to spe- s Large colour screen

cific diseases. s SpO2 as bargraph depending on the selected model Funding s Mains and battery power supply The euHeart consortium comprises public and private partners from 16 s Visual and sound alarms research, academic, industrial and s)NTEGRATEDMAGNETIClELDDETECTOR medical organisations, from six s Operates at up to 400 Gauss (40 mT) European countries. Planned to run for four years the budget is around euros 19 million; 14 million of this provided by the EU as part of the EU 7th Framework Programme. The project forms part of the Virtual Physiological Human (VPH) initiative – a collabora- tion aiming to produce a computer model of the entire human body so Headquarters: SCHILLER AG, Altgasse 68, CH-6341 Baar, Switzerland, Phone +41 (0)41 766 42 42, Fax +41 (0)41 761 08 80, [email protected], www.schiller.ch that it can be investigated as a single complex system.

EH@ESC 2008 ESC 3 EH@ESC

he ageing population and grow- donor hearts, significant numbers ing risk factors have made a of patients die while waiting for Tsignificant impact on driving up a heart transplant. However, EuroPRevent 2009 the number of registered heart fail- cardiac resynchronisation therapy, ure (HF) cases. Existing pharmaco- mechanical circulatory support 6–9 May 2009 Stockholm, Sweden logical strategies are improving the devices and other alternative survival rates of acute and early- technologies have demonstrated Heart This year sees the fifth anniversary of EuroPRevent. stage HF patients, ironically provid- promising results, and the The growing HF population This international gathering of scientists, clinical ing a growing body of patients with continuing rapid technological The number of HF sufferers is cardiologists, health workers and others, provides progression of the disease to HF. developments in this area suggest expected to climb to epidemic pro- an opportunity to exchange experiences, upgrade With no new drug therapies we may only be a decade away portions. Worldwide, HF affects skills and knowledge and propose strategies addressing advanced HF and from eliminating the reliance on nearly 23 million people. In the heart transplants, according to a to provide the best preventive cardiology. existing pharmacological strate- United States, HF affects approxi- gies failing to compensate for a new report* by Datamonitor, an mately 4.7m persons with approxi- Deadline for abstracts: 19 November 2008 weakening heart, alternative so- independent market analyst that mately 550,000 incidences of HF Details: European Society of Cardiology, France. lutions have to be found. In view of provides online data, analyses diagnosed annually. Estimates of the Phone: +33 (0)4 92 94 76 00 long waiting lists for heart and business forecast platforms prevalence of symptomatic HF in the transplants and the growing lack of (www.datamonitor.com). general European population are similar to those in the United States and range from 0.4 to two percent of the total population. Existing gold- standard pharmacological strategies are able to provide superior compen- sation of acute and early-stage HF patients, increasing their survival rates without ensuring a full recov- ery. This results in an increasing long-term shift of such patients into the advanced HF group. With no new drug therapies addressing advanced HF and existing pharmacological strategies failing to compensate for a weakening heart, alternative, non-pharmacological solutions have to be found, reports Dr Sergey Ishin, Datamonitor’s senior cardiovascular analyst. ‘Cardiac transplantation continues to be the gold standard for the treat- ment of end-stage HF. However, the number of potential transplants far exceeds the number of donors. In the US, about 2,500 heart transplants are carried out each year and research has suggested that up to 100,000 patients have advanced heart disease that would benefit from transplanta- tion. This leads to 30% of patients on the waiting list dying annually.’ Cardiac resynchronisation therapy (CRT), through multiple randomised clinical trials, has demonstrated promising results in terms of both safety and efficacy, improving left ventricular efficiency and, subse- quently, improving functional class. ‘However, one of the greatest limita- tions of this technology is the fact that existing CRT devices, similarly to pharmacological treatment, can only temporarily improve symptoms and to some degree delay the pro- gression of myocardial deterioration. Unfortunately, neither can prevent, stop nor reverse it. This unfortunate situation eventually brings advanced HF patients back to the heart trans- plant waiting lists,’ Dr Ishin points out. Improving survival with alternative solutions Although advances in surgical tech- niques and immunosuppressant ther- apy make it possible to perform suc- cessful heart transplantations even in the most critically ill patients, the rapidly growing end-stage HF popu- lation creates a tremendous gap in the number of patients waiting for new hearts and the number of organs that actually become available, Dr Ishin adds: ‘In view of this, in addi- tion to avoiding the immunosuppres- sion and rejection complications of transplantation, mechanical circula- tory support devices work as the only promising option which can help resolve the issue of organ avail- ability and save more patients.’ The idea of finding a mechanical alternative to donor transplants is not new, Datamonitor points out. Mechanical circulatory support devices and total artificial hearts have been under development since

ESC 4 EH@ESC 2008 EH@ESC Can technology diminish reliance on heart transplants? reported device malfunction in 9% one of the most frequent complica- nificant increase in the chance of * Datamonitor’s report Stakeholder of all reported implantation cases. tions of ventricular assist device an infection, leading back to the Opinions: Heart Failure; When drugs failure Factors that affect the probability placement. Infections are reported problem of external power supply do not work: Treatment of advanced the 1950s, but only recently, with of device malfunction are directly to occur in no less than 13% of and longer lasting batteries. heart failure with medical device advances in technology, have they related the number of individual cases, Dr Ishin points out. ‘Although at present we can not therapies (Report author: Dr Sergey started demonstrating some serious components and moving parts in ‘Although device-related infections completely eliminate the need for Ishin) provides in-depth analysis of potential in completely eliminating the system. Hence, simplification can involve any aspect of the heart transplantation, rapid techno- the current status and future potential the need for heart transplants. With of design and reduction in the num- device: the surgical site, the drive- logical developments indicate that of treatment opportunities in advanced many different design concepts ber of components and moving line, the device pocket, or the we are not that far away from sort- stages of HF. It includes an overview of tested throughout the decades the parts should improve long-lasting pump itself, and more than half of ing mechanical issues, coagulation existing and emerging technologies new face of mechanical circulatory performance and durability of all device-related infections include control and device-related infec- including cardiac resynchronisation support technology started to devices. multiple sites, the existence of tions with serious breakthroughs therapy and mechanical circulatory emerge. Bulky, immobile systems In addition to device malfunc- external components, such as driv- expected within next five to 10 support devices. have gradually been replaced with tion, device-related infections are elines and batteries, leads to a sig- years,’ Dr Ishin concludes. Details: www.datamonitor.com more portable and even fully implantable solutions providing full patient mobility. Even though scientists initially desired to create a complete artifi- cial heart the lack of technological solutions at the time prevented rapid development in this area. Further research subsequently showed that it is more feasible to create a device that supports only the left ventricle. Presently, Dr Ishin continues, ventricular assist devices are the most well researched and technologically diverse area. ‘The biggest advan- tage of ventricular assist devices over a complete artificial heart is the ability to instantly provide suffi- cient cardiac output to the patient, possibly for a very long period of time, and at the same time avoid any irreversible surgical modifica- tions and keep an albeit weak, yet still functioning patient’s heart working while potentially improv- ing its functionality. Originally most of these devices were designed just to provide the neces- sary support while a patient is wait- ing for the donor heart. This is so called bridge-to-transplantation approach. Technological progress, however, made it possible to implant these devices for a signifi- cantly longer period of time, creat- ing an opportunity for the so-called destination therapy approach, when the device can be left implant- ed permanently, eliminating the need for heart transplant.’ Miniaturisation of the compo- nents is one of the most important keys in the developmental process. New, totally implantable solutions, such as Jarvik 2000 and BerlinHeart Incor, may not only eliminate the need for the heart transplantation, but also allow full patient mobility and a return to normal life. Still far from complete replacement of transplants In spite of rapid technological developments and successful clini- cal trials there are still a consider- able number of issues associated with this technology Dr Ishin says. ‘Among them are material biocom- patibility and coagulation control, mechanical reliability of internal components, smaller device size allowing implantation into smaller patients and children, power sources, size of the batteries and device energy consumption, which would allow for fully implantable solutions with better infection con- trol and patient mobility. Even the most advanced devices allow fully independent device operation for no longer than 20 minutes before it has to be connected back to its external batteries, which can be rather bulky and heavy.’ In 2007 the Interagency Registry for Mechanically Assisted Circ- ulatory Support (INTERMACS)

EH@ESC 2008 ESC 5 TRENDSEH@ESC IN IMAGE-GUIDED THERAPY

For the fourth article in his series of articles for European Hospital, Professor Stefan Schönberg of the Institute of Clinical Radiology and Nuclear Medicine (IKRN), University Hospital Mannheim, Medical Faculty of Mannheim, University of Heidelberg, invited his colleague from Mannheim, Henrik J Michaely, and experts from the David Geffen School of Medicine at UCLA for a round-table discussion on:

ly resolved 3-D images that display the first-pass transit of contrast through the vascular system. Time- Advances of vascular MRI resolved MRA can provide addition- al functional information and requires only very small doses of contrast. For many applications, in- plane resolution can be preserved while through-plane resolution is at higher field strengths commonly traded for rapid tempo- ral sampling. Stefan G Ruehm, Kambiz Nael, Derek Lohan and Henrik J Michaely* describe impressive images that benefit patient treatment Clinical Applications Contrast-enhanced MR angiography in combination with parallel imag- gadolinium agents is increased. In many institutions 3-D CEMRA (CEMRA) has evolved as an increas- ing techniques. This technique This is based on an increase of the has found its role as the method of ingly competitive diagnostic modali- allows for a reduction of MRI mea- longitudinal relaxation time (T1) of choice for the evaluation of the ty challenging both catheter angiog- surement times by using spatial background tissues with higher craniocervical vasculature. raphy and CT angiography (CTA) for information from multiple surface field strengths, which allows the Indications include a variety of con- imaging of nearly all vascular terri- coil elements at the same time to use of smaller volumes of paramag- ditions such as atherosclerotic dis- tories. Over the recent years, substitute for the overall number of netic contrast agents. ease, aneurysms, and arteriovenous improvements in gradient technolo- phase-encoding steps which deter- With recent advances in scanner malformations, presurgical assess- gy, pulse sequences, and postpro- mine the scan length. With the Stefan G Ruehm Derek Lohan gradient performance, fast data ment of tumours as well as post- cessing algorithms, combined with appropriate coil arrangement and acquisition times for isotropic treatment surveillance. The ability dramatic improvements in radiofre- receiver chain, it is possible to three-dimensional (3-D) data sets to time-resolved contrast-enhanced quency (RF) technology, have accelerate an acquisition manifold. for 576 matrix acquisitions have 3-D MRA with high spatial resolu- enabled the current status of In this context, a specific number become possible enabling high spa- tion is particularly valuable for the CEMRA applications at 1.5T. Lately, called ‘acceleration factor’ charac- tial-resolution 3-D imaging during a characterisation of arteriovenous whole-body 3T MRI systems have terises the increase in data collec- comfortable breath-holding period. malformations and allows the dif- been introduced, with the promise tion speed. However, the penalty for An additional feature of MRI is ferentiation between high versus of greatly improved signal-to-noise the increased speed of parallel the capability to generate temporal- slow flow lesions. This may play an Henrik J Michaely ratio (SNR) compared to 1.5T. With acquisition is a drop in SNR. Since Kambiz Nael 3T imaging it appears feasible to there is more SNR available at 3T, it Table: Benefits of 3 Tesla CEMRA for improved therapeutic strategies obtain almost double the available is possible to use higher accelera- SNR compared to 1.5T. tion factors at SNR values still ade- Technique Problem Solution However, the move from 1.5T to quate for diagnostic image quality. High-resolution MRA Stenosis quantification Improved accuracy for 3T involves more than just increas- Therefore with identical acquisition determination of significant ing SNR: For some pulse sequences, times, images can be collected with stenoses many of which are now routine for higher spatial resolution or greater imaging at 1.5T, there are substan- anatomical coverage compared to Fibromuscular dysplasia Better detection of distal renal tial trade-offs at 3T such as so- 1.5T. artery involvement by string-of- called dielectric resonance effect, Contrast-enhanced MRA is based beads changes which can result in bands of signal on the use of T1-weighted fast loss on the MR image, particularly spoiled 3-D gradient recalled-echo Time-resolved MRA Occlusion Detection of collateral flow when RF intensive techniques (e.g. sequence in combination with the High-grade stenosis Improved visualisation of altered steady state free precession T1-shortening effect of gadolinium- haemodynamics sequences) are employed. based contrast agents. As an attrac- T1 morphologic imaging Activity of vasculitis Improved detection of subtle High field imaging at 3T has tive feature of contrast-enhanced proven to be particularly beneficial MRA at 3T the sensitivity to injected vessel wall enhancement

Fig 1A Fig 1B Fig 3 Fig. 3:Time-resolved MRA in a patient with left- sided foot ulcer and PAOD. In the dynamic time- resolved-echo shared MRA at 3.0T (TREAT, 1.5 x 1.4 x 1.5 mm spatial resolution, 3s temporal resolution) after administration of 7ml of gadofosveset (Vasovist) a regular run-off of the right lower extremity can be appreciated while on the affected left side no patent arterial vessel can be seen. There are only small collateral branches excluding interventional revascularisation. Fig. 1: 1.5T high resolution MRA (A) and time-resolved echo-shared MRA (B) of a patient with pulmonary Fig 4A Fig 4B AVM. With both techniques an aberrant feeding vessel originating from the abdominal aorta can be Fig. 4 (a+b): Conventional renal angiogram (a) and appreciated. The time-resolved technique additionally demonstrates the dynamics of the blood flow. corresponding 3-D high-resolution contrast-enhanced MR angiographic oblique maximum intensity projection (MIP) Fig 2A Fig 2B (b) from a female patient with fibromuscular dysplasia of the right renal artery. This is evidenced by beading and irregularity of the distal third of this vessel on both imaging techniques. While of inferior spatial resolution to conventional radiographic techniques, CE-MRA at 3 Tesla maintains high diagnostic accuracy, while precluding the requirement for arterial puncture and ionising radiation exposure.

Fig 5A Fig 5B Fig. 5 (a+b): High-resolution 3-D contrast-enhanced MRA full-thickness MIP (a) obtained at 3 Tesla with injection of 12cc of Magnevist (gadopentetate) in a patient with Giant Cell Arteritis. An aberrant right subclavian and conventional left subclavian artery are occluded, with resultant arterial collateralisation. Dynamic time-resolved Fig. 2: 20mm thin MIP of the 3T-MRA (A) and 3T-phase-sensitive inversion recovery (PSIR) images of a images acquired with a TWIST sequence using a relatively patient with giant adrenal carcinoma. The carcinoma can be well depicted on the coronal MRA images (star, diminutive dose of 5cc Magnevist, confirms delayed A) which was acquired after the administration of 15ml of Gd-BOPTA (Multihance). There is also tumour bilateral upper extremity perfusion due to the attenuated growth into the inferior vena cava and reactive dilatation of the azygos system (arrow). In the cardiac exam size of these collateral vessels. the extension of the thrombus into the right atrium is well demonstrated. As the MRI demonstrated that the thrombus was not attached to the atrial wall a surgical resection of the tumour was performed.

ESC 6 EH@ESC 2008 EH@ESC

important role for determining ade- assessment of tumour extent. In or perfusion MRI, the accurate early diagnosis since there is a good contrast-injection protocol, and quate treatment strategies which addition, MR venography is a rapid- characterisation and quantification respond to balloon angioplasty. flexible table movement, venous include conservative treatment, ly growing application in chest, of the severity of stenotic renal FMD usually affects the mid and contamination can be minimised or embolisation therapy or surgery. abdomen, pelvis and lower extrem- artery disease plays an important distal artery segments. These seg- avoided. The procedure is feasible With a critical stenosis level of ity which benefits from high spatial role for planning revascularisation ments may be missed on conven- and holds promise for screening 70% as determined by the NASCET resolution and the potential reduc- strategies. High-resolution MRA at tional MRA at 1.5T due to limited applications. study to be the threshold for treat- tion of contrast volumes. 3T may help to limit the over-esti- spatial resolution. It is expected In summary, a wide spectrum of ment of patients with thromben- Indications for renal MRA include mation of the degree of stenotic dis- that CEMRA at 3T increases sensi- vascular diseases may benefit from darterectomy, improved spatial res- the diagnosis of atherosclerotic ease and may therefore avoid tivity and specificity for the early imaging at 3T. Our experience sug- olution for accurate stenosis grad- renal artery stenosis, fibromuscular unnecessary renal revascularisa- detection of FMD. gests that CEMRA at 3T is robust ing of carotid arteries appears dysplasia (FMD), renal aneurysms, tion procedures which may further Similarly to single station MRA, and besides providing spectacular mandatory. Similarly, high spatial dissections, as well as the evalua- increase the risk of patients with multistation peripheral or whole- images holds promise to improve resolution imaging for improved tion of patients pre- and post renal borderline renal function. body imaging can be performed at patient care by improved diagnostic characterisation of vascular wall transplantation. In combination FMD represents the second most 3T yielding high spatial-resolution accuracy which may positively invasion can play an important role with functional imaging techniques common cause of renal artery dis- data sets with isotropic submillime- affect therapeutic strategies. to determine resectability of neck such as ultrasound, nuclear medi- ease. It tends to affect younger ter voxel size. With the combination *Henrik J Michaely is a consultant to tumours. Craniocervical contrast- cine imaging, phase-contrast MRA patients. Patients benefit from of parallel imaging, an appropriate BayerHealthCare enhanced MRA can be used to eval- uate patients following treatment for vascular disease, for example to assess re-stenosis after endovascu- lar treatment following stent place- ment or for follow-up of patients with vessel dissection in order to detect possible progression of stenosis or occlusion which may mandate invasive therapy such as surgery or stenting to prevent ischemic cerebral complications. Does the left ventricle know what Applications in the pulmonary circulation include evaluation of pulmonary embolism, pulmonary the right ventricle is doing? hypertension, and congenital heart disease. Pulmonary venous MRA plays an increasing role for accu- rate planning and follow up of radiofrequency ablation therapy in patients with cardiac arrhythmia. For the abdominal vasculature, clinical applications include the assessment of atherosclerotic arter- ial disease, aneurysms, and dissec- tions, as well as the preoperative Atrial and ventricular contraction is differentially regulated Beta-3-adrenergic receptor activation increases human atrial tissue contractility and stimulates the L-type Ca2+ current France – The contraction of the atria and ventricles is differentially regulated, according to a study by Rodolphe Fischmeister and colleagues, at INSERM UMR-S 769 in Châtenay- Malabry. The contraction phase of the heart beat is controlled by several path- ways, including one initiated by stimula- tion of cell surface proteins known as beta-adrenergic receptors. At the mole- cular level, the flow of Ca2+ through protein channels known as L-type Ca2+ channels has a central role in the regu- lation of the contraction of the heart by beta-adrenergic receptors. Previous data have indicated that stimulation of beta-3-adrenergic recep- tor (beta-3-AR) decreases the contractil- Bring a new rhythm to cardiology workflow with Siemens ity of tissue from human ventricles and decreases the activity of ventricle L-type portfolio of advanced imaging, laboratory, and IT solutions. Ca2+ channels in various animal mod- els. In contrast, Dr Fischmeister and You now have access to a wider breadth of cardiology solutions that span the entire continuum of care. So you have team have found that beta-3-AR stimu- more options. Options that expand your possibilities so workflows can quicken. The clinical picture can sharpen. lation increases the activity of L-type And revenues can rise. With Siemens, the beat goes on. Preview the latest additions to the cardiology portfolio that Ca2+ channels in heart cells isolated from human atria and increases the gives you more options. www.siemens.com/cardiology +49 69 797 6420 contractility of the atrial tissue. The finding that beta-3-AR stimula- tion has opposing effects on human Answers for life. atrial and ventricular tissue could lead to the development of therapies that target beta-adrenergic receptors to CC-Z1078-2-7600 treat CVDs. Details: www.inserm.fr

90054_Z1078_A4_e.indd 1 21.08.2008 10:14:10 Uhr

EH@ESC 2008 ESC 7 EH@ESC HIFU surgical ablation Echocardiography acquires NEW instantaneous, non-stitched products gain CE Mark full-volume images in a single St. Jude Medical, Inc. has received European CE Mark approval and US Food and Drug Administration (FDA) clearance for its Epicor LP cardiac ablation system, a cardiac beat second generation technology that uses HIFU (high ture delivers vastly more information than intensity focused ultrasound) for surgical ablation of today’s conventional systems and is strength- cardiac tissue to disrupt abnormal cardiac electrical ened by Siemens patented Coherent Volume impulses. Formation technology. Coupled with the sys- The first patient to undergo treatment with the tem’s high-volume acquisition rate, Coherent Epicor LP System was a 73-year-old male with coro- Volume Formation moves away from serial line- nary artery disease and atrial fibrillation (AF). The pro- by-line acquisition towards simultaneous, mul- cedure was performed by cardiac surgeon Malcom tiple beams, delivering excellent image resolu- Dalrymple-Hay FRCS PhD FECTS, at Derriford tion,’ Siemens reports. Hospital in Plymouth, UK. The patient, who has suf- NEW ‘The proprietary 4Z1c transducer features fered persistent AF for over three years, had a normal OF ST JUDE MEDICAL,COURTESY INC revolutionary, patented active cooling technolo- heart rhythm upon completion of the ablation proce- gy, enabling full output power within regulato- dure. Ablation System when used concomitantly to correc- ry limits. This results in improved penetration, ‘An increasing volume of published literature is tive heart surgery. The investigators reported that reduced noise and high-volume acquisition demonstrating the benefits of treating pre-existing AF more than 83% of all patients, followed for at least six rates when compared to conventional 3-D in patients who are undergoing valvular or coronary months after surgery, were free from AF. In addition, Acuson SC2000 transducers. The 4Z1c is a single transducer artery bypass surgery,’ explained Dr Dalrymple-Hay. 86% of the patients followed for at least 18 months solution for adult echo applications that pro- ‘The Epicor LP System provides a technology that is remained free from AF.The investigators reported that vides all the modes needed: volume imaging, 2- flexible enough to treat AF patients during either stan- there were no device or ablative procedure-related D, M-mode, colour Doppler, and spectral dard open chest procedures or minimally invasive sur- adverse events and specifically noted an absence of Doppler. This breakthrough technology show- gical procedures.’ oesophageal, coronary or phrenic nerve damage. cases Siemens acoustic mastery and delivers on ‘In surgical ablation performed with a HIFU energy The 2007 results confirmed the findings of an earli- the long-awaited promise of true volume imag- source, energy is focused from outside a beating heart. er European multi-centre trial published in the The Acuson SC2000 volume imaging ultra- ing for every patient.’ This treatment has been designed to create precise September 2005 Journal of Thoracic and sound system – reported to be the first system Better outcomes through workflow- and complete lines of cardiac tissue ablation to block Cardiovascular Surgery. The investigators in the in the world to acquire non-stitched real-time driven examination sequences chaotic electrical impulses. The patient does not need European clinical trial reported an 85% freedom-from- full-volume 3-D images of the heart in one The Acuson SC2000 system is designed to sup- to be placed on a heart-lung bypass machine nor is the AF rate at six months post-procedure - the study’s pri- single heart cycle – will be launched by port advanced cardiovascular applications. The heart stopped. Because HIFU energy is directed from mary efficacy end point - in patients concomitantly Siemens Healthcare at the European Society of knowledge-based workflow software uses outside the heart inward (instead of from the inside treated for AF with the Epicor cardiac ablation system. Cardiology (ESC) meeting in Munich. Referred learned pattern recognition technology and an out as is sometimes the case in ablations performed St. Jude Medical acquired Epicor Medical in 2004 to as ‘Echo in a Heartbeat,’ this new technolo- expert database of real clinical cases. This with other energy sources), the risk of unintended and worked closely with Dr James Cox to develop the gy marks the greatest paradigm shift in ultra- enables the system to recognise anatomical peripheral damage is minimised,’ St Jude Medical Epicor Medical HIFU ablation system and its related sound since the introduction of 2-D imaging in patterns and landmarks, as well as to perform explains. surgical procedure. ‘Dr Cox is the developer of the the late ’70s, Siemens explains. ‘Instantaneous, automatic measurements streamlining clinical ‘In contrast, the traditional surgical approach Cox-Maze surgical procedure for the treatment of AF non-stitched, full-volume imaging comes 55 workflow. requires that patients be placed on a heart-lung and is acknowledged by his peers as a pioneer in the years after echocardiography pioneers Inge ‘The system automatically derives reference bypass machine with their hearts stopped while a car- field. Since the acquisition, St. Jude Medical has been Edler und Hellmuth Hertz acquired the world’s plane images from the full-volume cardiac cap- diac surgeon cuts maze-like patterns in the atrial tis- committed to improving the manufacturability and first cardiac ultrasound recording using ture dataset and offers automated full-volume sues and then sews the incisions to encourage the for- performance of the HIFU surgical ablation technology,’ Siemens technology in 1953.’ contouring for fast qualitative and quantitative mation of lesions, or tiny scars. Surgeons may also use the company adds. The company is continuing its pur- Klaus Hambuechen, CEO of Ultrasound, analysis. Customisable, programmable, and pro- alternative energy sources, such as radiofrequency or suit to expand clinical data, as well as additional tools Siemens Medical Solutions USA Inc. added: tocol-driven workflow sequences deliver cryothermy, to create lesions in heart tissue.The lesions to facilitate minimally invasive procedures, for the ‘The system has unparalleled capabilities in repeatability for better outcomes: greater effi- disrupt the abnormal electrical impulses that cause AF. technology. information rate processing that allow us to ciency, accuracy, consistency, and care – from ‘The Epicor LP system has a lower profile (smaller The first generation Epicor System gained regulato- acquire a full volume of the entire heart with data acquisition to diagnosis,’ Siemens adds. ‘To relative to the first generation technology) as well as ry approval for the treatment of AF in Europe in 2006. 90 degree pyramids.With a high-volume acqui- further enhance efficiency, the offline worksta- other features designed to facilitate easier device In the US, the first generation Epicor System and the sition rate like this – in one second, every sec- tion enables reporting as well as complete introduction and placement around and on patients’ Epicor LP System received clearance from the FDA for ond – acquisition time is dramatically reduced, review and processing of the acquired volumes.’ hearts,’ St Jude Medical continues, adding: ‘The Epicor the surgical ablation of cardiac tissue but have not improving the overall workflow in the echocar- The company has also addressed the LP System is equally suited for use in both closed-chest been indicated by the FDA specifically for the treat- diography suite.’ ergonomics of the system to meet and exceed procedures performed through a single incision, and in ment of AF. Next generation system architecture today’s recommended ergonomic guidelines to open-chest procedures.’ St. Jude Medical has over 12,500 employees world- and transducer technology reduce work-related stress injuries and to In the December 2007 edition of The Annals of wide and is headquartered in St Paul, Minnesota. The The Acuson SC2000 cardiology platform is accommodate the varied work environment of Thoracic Surgery, the results of an independent inves- firm focuses on developing systems for cardiac rhythm expected to change the way echocardiography sonographers. The new system is expected to tigator clinical trial led by Mark Groh MD, showed management, atrial fibrillation, cardiac surgery, cardi- is currently practiced. ‘Its advanced architec- become available in Europe this autumn. that AF is effectively treated using the Epicor Cardiac ology and neuromodulation. Beijing Olympics research finds CVD specialists meet footballers Rolling out World’s first symposium on sudden death syndrome enlarged hearts can be good hearts among European athletes ScanCath Cardiologist Dr Malissa Wood, of the Massachusetts General Spain – The world’s first symposium on the molecular analysis of sudden Hospital, Boston, USA, has reported that a study of Olympic athletes, death syndrome (SDS) among athletes drew in leading cardiovascular USA – With the recent using GE Healthcare’s Vivid I cardiac compact ultrasound researchers and several top Spanish footballers. Sponsored by Applied opening of its new technology, has allowed the medical research team in Beijing to Biosystems, and held in the Madrid’s Hospital Clinico San Carolos, the I headquarters in Newark, identify healthy patterns of heart enlargement that can differentiate it Symposium de Prevención en el Futbol aims to initiate the development of California, NovaRay Inc’s from hypertrophic cardiomyopathy. new tests to identify sports players at SDS risk. CEO and President, Jack Previously, it was believed that heart size is indicative of risk of This syndrome, most common in men under 40, generally causes Price announced that the Sudden Cardiac Death (SCD); however, Dr Wood’s research with the USA immediate cardiac arrest during strenuous exercise. Reports of unexpected firm will now ‘scale-up Weightlifting and US Men’s Rowing teams has shown that it is the health of the deaths of young men participating in marathons, cycling races and football and roll-out with the systolic or blood-pumping action - not the heart size - that is the distinguishing factor matches are not unusual. Sudden death can be caused by a variety of development of our first of a healthy heart. ‘As a result of these findings, we are in the process of developing a diseases or genetic factors. Genetic causes usually have no symptoms, so clinical product, the cardiac fitness index to be released later this year that will help trainers and coaches professional athletes at risk of the syndrome can appear to be in peak ScanCath cardiac understand how cardiac conditions impact performance of high-endurance athletes,’ physical condition during routine medical and fitness checks. Currently catheterisation system.’ Dr Wood said. ‘Our work also will provide healthcare professionals with insight into available CVD tests are usually insufficient to detect an individual at risk of NovaRay, which new, more effective ways of assessing and treating heart disease for the general SDS – only a genetic test will provide the required accuracy and reliability. develops digital cardiac public.’ A roundtable discussion ensued on methods to identify specific molecular X-ray imaging Based on Dr Wood’s findings, Dr Patrick Schamasch, Medical and Scientific or genetic changes in people at risk. Applied Biosystems points out that Director of the International Olympic Committee (IOC), has recommended routine these biomarkers could be used to develop a test panel for screening technology, explains that cardiac monitoring of Olympic athletes. ‘I fully support the action to have football players or other sportsmen to identify their risk of sudden death. the ScanCath cardiac preparticipation cardiovascular screening mandatory for elite athletes. This will There are several known genetic causes of sudden adult death, including catheterisation system evaluate athletes before participating in sports for the purpose of identifying (or abnormalities of the heart muscles, and malfunctioning of ion channels – provides advanced raising suspicion of) abnormalities that could provoke disease progression or sudden vital cellular structures through which ions (e.g. calcium, potassium or imaging capabilities cardiac death. Ensuring the well-being of all athletes is the IOC’s priority, and we feel sodium) pass in or out during a heart’s normal functioning. Malfunctions of coupled with reductions that the identification of the relevant diseases will allow clinicians to make decisions these channels can result in cardiac arrest. Several ion channel earlier on, of whether a player can stay in the game or not, but above all tailor their abnormalities have been identified that are known to increase the risk of in radiation. training programs to best meet their needs and ensure athlete safety. sudden cardiac arrest, including long QT syndrome and Brugada syndrome.

ESC 8 EH@ESC 2008 EH@ESC

As recession looms HeartVue 6S seeks in various countries, USA marketing Economic recession: so the effects of Pegasus/Heartview LLC has announced that clini- cal studies of its HeartVue 6S Heart Screening economic stress on System – which obtained CE Mark Approval in families may be Europe almost two years ago – have been com- pleted according to FDA guidelines, as a pre-mar- a cause of later CVD? passed on to the keting condition for release in the USA. Germany – Bad economic conditions, CV markers and predictors, and to children born during The HeartVue 6S Screening System, use as a e.g. a recession, at the time of birth expose those who have unfavourable screening tool, provides a quick, accurate assess- may lead to a higher risk of cardiovas- test values to preventive interven- such times, causing ment of patients with suspected coronary artery cular mortality much later in life, tions. Moreover, the results support a higher risk of disease in 1–2 minutes. according to a recent study published investments in nutritional quality and The clinical studies included testing 170 by researchers at the Institute for the health infrastructure in countries them developing patients of various ages, genders, races, weights Study of Labour (IZA) in Bonn. with a high degree of deprivation, as a fatal cardiovascular and health conditions. The results will now be The study showed that individuals means to reduce the cardiovascular analysed, interpreted and presented to the FDA in born in a recession on average live 15 mortality rate in future years. diseases in later life the form of a 510K Filing. months less than those born under better conditions and that this differ- ence can be mostly attributed to car- diovascular health risks. ‘What is sur- prising is that such effects may pop up 70 or 80 years after birth,’ said Gerard van den Berg, Economics Professor at VU University Amsterdam and Programme Director at IZA, who co- authored the study with Gabriele Doblhammer-Reiter and Kaare Christensen. In the intervening years no extraordinary health events may occur, until suddenly the fatal cardio- vascular problems arrive. The authors report that they do not find such long- run effects on cancer in general, although certain types of cancer have been linked to low birth weight, another marker of early-life condi- tions. The team used data on individuals born around 1900, as well as that of twins in Denmark, whose mortality causes have been systematically gath- ered for many years. The latter made it possible to check whether a twin pair’s health outcomes are more simi- lar later in life if they were born under adverse conditions than if they were born under good conditions. The find- ing was that they are more similar later in life if the starting position was bad. Conversely, if an individual is born under better conditions, then individual-specific factors dominate more. Why might a recession, for exam- ple, cause later damage to the cardio- vascular system? Dr Van den Berg said analyses carried out by the team for specific parts of Denmark suggest that long-run effects are particularly trig- gered by the combination of subopti- mal nutrition and a suboptimal health infrastructure early in life. Low house- hold income is less harmful for the baby’s future if the environment has good healthcare and hygiene facilities. In addition, stress is possibly a major factor. Parents who are economically stressed may produce offspring with features that make them more suscep- tible to CVDs at advanced ages. One may wonder whether the results are of significance for present- day birth conditions. Of course, we need another 80 years to know for sure. But there are signs that long-run effects are as important as ever. For example, birth weight studies among recent cohorts show effects on health and adult height that are as strong as ever. And with the advent of the fast food society, nutritional habits among segments of society may not be as good as they used to be. From this point of view, it may be worthwhile to screen young individu- als born under adverse conditions for

Source: Gerard J. van den Berg, Gabriele Doblhammer-Reiter, Kaare Christensen:Being Born Under Adverse Economic Conditions Leads to a Higher Cardiovascular Mortality Rate Later in Life: Evidence Based on Individuals Born at Different Stages of the Business Cycle IZA Discussion Paper No. 3635, Bonn: August 2008. http://ftp.iza.org/dp3635.pdf

EH@ESC 2008 ESC 9 EH@ESC

he diagnostic work-up of Heart sounds Karl Eberius MD, European syncope patients often raises The basic diagnostic physical the question of how much work-up often only requires a few Hospital’s new correspondent, Tdiagnosis is necessary and steps. ‘The first is auscultation of what examination methods are the heart, during which discussed advice for physicians really needed. To save time, pathological sounds of any kind specialists recommend focusing on must be assessed as warnings of with Professor Andreas determining whether the syncope cardiac syncope,’ Prof Schuchert may be caused by a cardiac emphasises. The neck vessels Schuchert, principal author of problem – a question answered should also be auscultated for quite easily in many cases. stenosis of the carotid artery. The the German Society of According to Professor Andreas physician should also listen very Schuchert, a basic diagnostic carefully for an irregular heartbeat Cardiology’s official work-up for every syncope case or a heart rate below 50 or above consists of three steps: the first a 100 beats a minute, which may statement on thorough anamnesis, followed by a indicate AV block or atrial brief physical examination and an fibrillation as the cause of syncope. syncope ECG. ‘Further measures are only ‘The most important alarm signals necessary either if no specific type are evidence of cardiac of syncope can be determined or if insufficiency – for example, the there are indications of their being legs are oedematous or there are Counter pressure caused by a cardiac problem.’ Only rattling sounds from the lungs or a SYNCOPE Diagnosis and therapy cardiac syncope shows a clearly congested liver is detectable more these cases is not a diffuse is clinically indicated. ‘In 99% of raised death rate (18-33% annually) than two finger widths below the sensation, like anxiety or pain, but syncope diagnoses no laboratory depending on the study, he adds rib cage,’ he reminds us. ‘The com- a clearly defined situation. tests are required.’ bination of cardiac insufficiency Furthermore situational syncope The same applies to carotid What is relevant in medical and syncope indicates a critically typically occurs more suddenly Doppler examinations, which are history? raised risk of mortality and and without any warning.’ only indicated when sounds of Syncope caused by cardiac therefore needs to be immediately Orthostatic syncope occurs stenosis can actually be heard on disorders can often be identified diagnosed.’ when standing up from lying down auscultation of the vessels of the during the anamnesis by asking or sitting. Unlike a vasovagal neck. ‘Otherwise the probability of just a few questions, importantly Vasovagal events attack, an orthostatic syncope syncope caused by carotid Karl Eberius Andreas Schuchert whether the syncope occurred If that basic procedure indicates typically does not occur after disorders should be ignored.’ during physical effort, which, the no cardiac cause, the physician can standing for a long period but who has problems when asked for a professor points out, is primarily focus on determining the actual immediately after the change in Therapy blood would be wise to lie down an indication of aortic stenosis or type of syncope – often possible by position. Vasovagal syncope can often be before the procedure,’ he advises, hypertrophic obstructive looking at the medical history. ‘A A drug-induced syncope should treated effectively by the simplest deploring the omission of these cardiomyopathy. Another question: vasovagal attack, the most be considered if the blood pressure methods. Counter pressure simple but important whether there was chest pain frequent kind of syncope, must (BP) has been too drastically manoeuvres are particularly useful recommendations. before or after the syncope, which always be assumed, for example, modified in hypertensive patients. in many cases, and in recent years Counter pressure manoeuvres are may indicate coronary ischaemia, when typical symptoms preceded On the other hand, if fainting have become a highly popular way in many cases a very effective aid, the professor explains. The the fainting attack: nausea, occurs when turning the head, for to prevent decreasing BP without widely used in clinical practice to physician should also check for sweating, dizziness, drowsiness, example while shaving or looking complications. counteract the fall in BP in a previous arrhythmia or other weakness, abdominal discomfort over one’s shoulder in a car, Before beginning treatment for vasovagal attack. Counter pressure cardiac disease. ‘If, for example, or blurred vision,’ he explains. carotid sinus syndrome should be vasovagal attacks, specialists manoeuvres require a hand size there has been a heart attack in the ‘Similarly when fainting followed a considered. recommend sufficient time is given rubber ball, simply carried in a past, cardiac syncope should be long period of standing tensely or to explain the therapy. ‘Patients pocket or bag. If a fainting attack assumed until there is evidence to the attack followed pain, emotional Additional examinations should know that fainting attacks approaches, in vasovagal attacks not the contrary,’ says Prof Schuchert, stress, anxiety or procedures like Depending on the results from the are not a symptom of a dangerous frequently heralded by typical who also considers the family’s having blood taken.’ basic diagnosis, various other disease of an organ,’ Prof symptoms, e.g. nausea, dizziness or medical history an important investigations may be Schuchert emphasises.’ When they drowsiness, one squeezes the ball as indicator. For example, the sudden Fainting during defecation recommended to clarify the type of know this they can then react hard as possible. As a result of death of a young relative from Situational syncope must be syncope. If the medical history more calmly to the fainting, which muscle contraction, the sympathetic cardiac causes may indicate assumed if loss of consciousness indicates an orthostatic syncope, for many is already a great relief.’ system is evidently activated, hereditary heart disease, e.g. occurs while urinating, defecating, for example, diagnosis can be During a consultation the typical producing constriction of the Brugada syndrome – rare but it coughing or vomiting. ‘Unlike the confirmed by the Schellong test, in trigger factors for syncope should peripheral blood vessels, thus often should be considered. vasovagal attack, the trigger in which the BP taken after five be addressed. ‘Someone who tends preventing the fall in BP causing minutes in the lying position is to have syncope attacks in narrow, syncope in the preliminary stage. compared to that taken after overheated spaces should avoid Alternatively one can perform the Treatments subsequently standing up. The department stores. And a person manoeuvre shown in the image. diagnosis is confirmed when the Orthostatic syncope – If loss of consciousness occurs directly after stand- systolic value after standing up ing up from having been lying down or sitting, this indicates orthostatic syn- falls below 90 mmHg or is more cope. The most important recommendation of Prof Schuchert is simply to than 20 mmHg below the stand up more slowly so that the cardiovascular system can adapt better to measurement taken when lying the body being upright. “Support hose, the sympathomimetic drug etilefrine down. Prof Schuchert points out EARLY DIAGNOSIS or the mineral corticosteroid fludrocortisone can also be helpful.” that, if the previously ascertained Situational syncope – Mostly occurring during micturation, defecation, medical history indicates vasovagal Hearing future heartbeats at ESC coughing or vomiting, in many cases this is not easy to treat and there are syncope, carotid sinus syndrome no proven evidence-based measures. ‘Any therapy that is also used for vaso- or situational syncope, the vagal attacks is worth a try,’ Prof Schuchert says, adding that many patients Schellong test is unnecessary. are helped by support hose or etilefrine. Moreover, tilt tests may be useful, Summation for example when vasovagal ● Diagnosis is the priority in vasovagal attacks. People affected should be syncope is suspected but the aware that the loss of consciousness does not indicate a dangerous dis- medical history does not ease of any organ. unambiguously indicate this. ● It is important to avoid factors triggering syncope. However, the predictive value of ● Counter pressure manoeuvres (e.g. squeezing a rubber ball or pulling tilt tests is increasingly challenged. clasped hands apart) have proved valuable to counteract fall in BP during vasovagal attacks. Laboratory tests of doubtful ● Lifestyle changes can be tried in motivated patients, e.g. increasing physi- benefit cal exercise, fluid and salt intake. The professor believes laboratory ● For vasovagal attacks, midodrine is the first drug of choice (3 x 10 mg/d). tests are almost always ● The benefits of selective serotonin re-uptake inhibitors have not been unnecessary for clarifying syncope definitively clarified. – particularly true for the ● Support hose, etilefrine and fludrocortisone can be useful for orthostatic determination of Hb levels, a test syncope. frequently performed due to a lack ● There is no evidence-based drug to treat situational syncope. of other ideas, but which is actually only necessary if anaemia

ESC 10 EH@ESC 2008 26 OCTOBER EH@ESC 2008 Simply clasp your hands together physical exercise. However, with arms at about chest height in scientifically, he points out their Experts gathering to front of your body and try to pull benefit has not been confirmed, your arms apart while not loosening which does not mean such changes Atrial fibrillation define future research your clasp. In both counter pressure are not worth a try in sufficiently manoeuvres muscles contract for as motivated patients. France – Seeking to set the agenda for urgent unresolved clinical issues in the diagnosis and long as it takes for the signals of the For many specialists, less atrial fibrillation (AF) research, European and treatment of AF. attack to disappear. recommendable is ‘tilt training’, in international cardiologists will gather this Among subjects for discussion: anticoagula- which patients stand leaning October at the European Heart House, in Sophia tion in patients at intermediate stroke risk; Medication against a wall, depending on the Antipolis, the headquarters of the European new concepts for rhythm control drug treat- Medication can also be useful to treatment plan, say for half an hour Society of Cardiology. ment; what to do if pulmonary vein isolation treat some vasovagal cases, daily, to train their circulatory A panel of international AF experts has been fails; relevance and intensity of ECG monitor- particularly when other therapies systems. Theoretically it produces invited by The European Heart Rhythm Society ing in clinical practice; relevance of clinically have failed and syncope continues good results, the professor says, (EHRA) and the German Atrial Fibrillation identifiable risk factors for AF progression; to occur. ‘The drug of choice is the ‘But it’s time-consuming and thus Network (AFNET) to their second joint conference alpha antagonist midodrine. At a compliance is very poor.’ what causes the first episode of idiopathic AF, dose of 3 x 10 mg/d this effectively to define new research perspectives and identify and novel therapeutic goals for AF treatment. raises the BP, and in almost all cases the drug avoids recurrence,’ the professor says. However, it is not suitable for every patient because it potentially increases the BP. This applies particularly to the elderly, whose BP compared to that of younger people is often already raised. Additionally, since this drug must be taken three times a day, many patients have compliance problems. If patients suffering vasovagal attacks are already hypertensive, beta-blockers can also be a useful alternative. Although not recommended by the ESC due to unproven benefit in vasovagal attacks, studies in recent years in patients aged 40+ indicate positive effects, so for this age group they are often to be recommended, he points out. Other drug alternatives, including selective serotonin re- uptake inhibitors, e.g. paroxetine, are being discussed, but Prof Schuchert recommends their very careful use due to lack of long- term data. Furthermore, in cases of vasovagal attacks the physician should check whether the patient is taking anti-hypertensive medication, which might cause the syncope and which could be reduced or discontinued. In some cases a cardiac pacemaker may be an option. ‘Such an implant is indicated if, for example, an event or loop recorder, which records the ECG over several months or even years, shows that asystoles are the cause of the fainting attacks,’ he points out.

Fluids and physical exercise Often, various lifestyle changes are also recommended to avoid vasovagal attacks: more fluid intake, more salt in the diet and more

Under the banner Hear today the heartbeats of tomorrow,at this year’s ESC meeting GE Healthcare will showcase its latest cardiology technology for the management of cardiovas- cular disease (CVD) as well as several new products. These include the MAC 1600 electro- cardiograph, which is based on Win CE5.0 to provide seamless communication to MUSE and CardioSoft and features auto- matic sync with a time server. GE points out that the device is scalable, to evolve as a depart- ment’s needs arise. * A GE sponsored satellite sympo- sium will be held on Tuesday, 2 September. GE at ESC: Booth C520 + D500 in Hall B2.

EH@ESC 2008 ESC 11 EH@ESC

Sample of website animated advice: NEW Website advice Implantable cardiac for HF patients monitors A new educational website specifically for heart failure patients, their fami- Syncope (fainting) is a leading cause of hospital lies and carers, has been set up by the Heart Failure Association of the emergency visits. In almost 10% of patients, European Society of Cardiology. On this site, host ‘Anna’, an animated How heart failure causes fluid accumulation syncope has a cardiac cause; in 50%, a non- woman who speaks in a friendly, matter of fact way, guides the visitor cardiac cause, and in 40% the cause of syncope through the website advice sections. is unknown. Syncope is difficult to diagnose There are also animated explanations covering how the normal heart as syncopal episodes are often too infrequent works, what goes wrong in HF, how the body compensates, an much else and unpredictable for detection with (example in illustration). conventional monitoring techniques. Cardiologists and physicians who wish to advise patients that they can Medtronic reports that its new Reveal learn more about their HF condition via their own computers, should pass on DX and Reveal XT can provide diagnostic this address: www.heartfailure.org How diuretics work in heart failure and monitoring insights into cases of syncope or abnormal heart rhythms,

including ventricular tachyarrhythmias (VT), fast ventricular tachyarrhythmias (FVT), bradyarrhythmias and asystole. ‘The Reveal DX continuously monitors the heart’s electrical activity to help physicians diagnose whether or not there is a cardiovascular cause for symptoms such as fainting, dizziness and unexplained seizure-like episodes.’ During a simple out-patient procedure, the Reveal DX monitor – weighing just 15g and about the size of a memory stick – is placed subcutaneously in the chest area using local anaesthesia. The monitor then records important cardiac rhythm data, which may help a physician to diagnose the patient and provide appropriate treatment. Unlike a pacemaker or implantable cardioverter- defibrillator, there are no leads (tiny wires) that extend from the device into the heart’s chamber(s). To store an electrocardiogram (ECG) at the time of an episode, a patient places a Every second counts. hand-held, pager-sized activator over Every choice matters. the device and presses a button. Every move deliberate. Later a physician analyses the stored information and determines if the episode was caused by an abnormal heart rhythm. Heart Failure Congress 2009 30 May - 2 Jun 2009

Among the many aims of the Heart Failure Association of the ESC is the establishment of MORE CONTROL. networks for the HF manage- ment, education and research. The HFA’s next annual meeting will be held next summer in the Palais Acropolis, Nice, France. LESS RISK. www.escardio.org/congresses/HF2009 Heart Failure 2009 Secretariat, ESC European Heart House, 2035 Route St. Jude Medical is focused on reducing risk by continuously des Colles, Les Templiers - BP 179 finding ways to put more control into the hands of those who save lives. 06903, Sophia Antipolis Cedex, France. Phone: +33 (0)4 92 94 76 00

EH@ESC 2008 is a supplement published in EUROPEAN HOSPITAL Experience Control. Visit sjm.com issue 4/08. Publisher: EUROPEAN HOSPITAL Verlags GmbH

St. Jude Medical GmbH Phone +49 61 96 77 11 0 Theodor-Althoff-Str. 39, ©2008 St. Jude Medical. All Rights Reserved. Helfmann - Park 1 Fax +49 61 96 77 11 177 45133 Essen, Germany The ST. JUDE MEDICAL logo is a trademark of St. Jude Medical, Inc. 65760 Eschborn - GERMANY Service +49 18 03 66 65 46 Phone: +49 201 87 126 853 www.european-hospital.com

ESC 12 EH@ESC 2008 CONTRAST AGENTS RADIOLOGY High risk of contrast-induced nephropathy refuted High-res cardiac images NEW USA – The belief that iodinated contrast nine changes in these patients was then agents can induce nephropathy has compared with the clinical data report- available at peak stress been held for many years, even though ed in previously published articles on most of the clinical literature has not the correlation of contrast media, serum USA – While treadmill exercise using a 12-lead electrocardiogram been able to distinguish contrast- creatinine levels and nephropathy. stress testing is essential to detect system, which is disconnected after induced nephropathy from other causes The Columbia team found that creati- cardiovascular disease, gaining clear exercise. Heart rate and rhythm are of the condition. nine levels rose as often in patients who cardiac images at peak stress level then monitored with a wireless, MRI- This August, however, Columbia had not received contrast material as in are not easy to gain using standard compatible electrode unit while University researchers published* the patients who did. testing procedures. Now, however, patients undergo a rapid, real-time results from their study of the clinical Over 50% of the 32,161 patients who researchers at the Ohio State imaging procedure that takes less allows us to better measure the data of over 32,000 patients that did not receive contrast material University Medical Centre have than a minute. presence and extent of heart disease spanned a decade. These suggest the showed a change of at least 25% in cre- designed equipment to provide Clinicians are excited about the with a clarity not previously possi- estimated risk from iodinated contrast atinine levels. Some two in five showed high-resolution cardiac images at a possibilities. ‘While current forms of ble,’ said Dr Subha Raman, associate media may have been grossly overesti- changes of at least 0.4 mg/dL. These critical testing stage, with results in stress testing have been helpful, professor of internal medicine in mated. ‘We don’t claim that IV contrast changes occurred in patients with nor- under one hour. combining exercise stress with car- OSU Medical Centre’s cardiovascular material never induces nephropathy, but mal and abnormal initial creatinine val- ‘In the past, we were constrained diac magnetic resonance imaging medicine division. it may do so less frequently and severe- ues and had been caused by a wide by the time lapse between the com- ly than previously thought,’ said princi- range of conditions, treatments and lab- pletion of exercise and capturing the pal investigator Dr Jeffrey Newhouse, oratory variations that may alter creati- images,’ explained Orlando director of the abdominal imaging divi- nine levels. Simonetti PhD, associate professor sion at Columbia-Presbyterian Medical Dr Newhouse said these changes of internal medicine and radiology. Cologne Centre, New York City. ‘If subsequent were not different from those published ‘We now have the ability to exercise by the clinical literature on patients who experimentation proves its safety, it patients to peak stress and obtain a could be used more frequently in underwent contrast-enhanced exams. 10 – 12 high definition image of their heart patients with renal failure.’ He advised a cautious interpretation The retrospective review involved of prior studies of the relationship within 60 seconds, which helps us October electronic records for radiology, cardiol- between iodinated contrast material more accurately identify exercise- ogy, and laboratory results stored in the and renal function, because serum crea- induced abnormalities. OSU Medical 2008 clinical data warehouse from January tinine levels change frequently in the Centre is the only place in the world 1995 to the end of December 2004. The absence of iodinated contrast media performing treadmill exercise stress researchers identified 32,161 patients material. Future studies need to incor- tests inside the MRI scan room.’ who had undergone imaging without porate appropriate controls. The standard design of treadmills iodinated contrast material. The fre- *Publication: American Journal of has made exercise stress testing a quency and magnitude of serum creati- Roentgenology (August 2008;191:376-382). challenge near the large magnetic th field generated by the MRI equip- 7 Management and ment. Simonetti and team, working Panel reviews safety of drugs with graduate students from Ohio State’s College of Engineering and Radiology Congress cleared for echocardiography faculty from the OSU Agricultural USA – Last October the Food and Drugs diagnoses have been improved through Technical Institute, modified a tread- Administration (FDA) added a ‘black box’ the use of Definity. Since October, the mill for use in close proximity to the for decision-makers in radiology warning on ultrasound (US) contrast FDA has approved labelling changes for MRI examination table. Magnetic from hospitals, agents used in echocardiogram imaging this contrast agent, which removed most components were replaced with examinations, around 200 reports of seri- of the warnings that had been added. non-magnetic stainless steel and private practices and ous allergic reactions were received. However, four more deaths in patients aluminium equivalents. Problems included cardiac arrest as well given Definity have been reported to the While patients perform the tread- healthcare management as breathing difficulty and seizures; seven FDA since October 2007. According to mill exercise test, they are monitored of the cases resulted in death. the Agency, one patient, suffering con- Following reports from doctors that the gestive heart failure, died within five New Molecular Imaging information resulting from the use of minutes of receiving the dose; another, contrast agents could be life-saving, the who suffered cardiac arrest minutes Techniques Aim at FDA warning was relaxed in May. after receiving a dose, was revived. ‘The Detection of Earliest Steps The only two FDA approved echocar- FDA remains concerned about the accu- Friday, 10 October 2008 diography contrast agents are Optison, mulating safety data pertaining to mar- of Disease Development Opening made by GE Healthcare, and Definity, keted ultrasound contrast agents, and An emerging discipline of noninvasive cardiac made by Lantheus Medical Imaging. the labels for these products continue to imaging, molecular imaging, has evolved con- So far, most of the reported problems contain a boxed warning that highlights stantly in the last few years and is increasingly involved patients given Definity. the risk for serious cardiopulmonary being translated from the preclinical to the clin- Saturday, 11 October 2008 According to the FDA, GE’s Optison was reaction,’ the Agency stated. ical level. Molecular imaging allows for unique 9.00 am – 11.00 am: not marketed from November 2005 to Calling for further studies to deter- insights into specific disease mechanisms and October 2007. GE Healthcare had volun- mine the safety and effectiveness of the holds great promise to change the practice of Scenario »Radiology« tarily withdrawn Optison after an FDA contrast agents, a panel of independent cardiovascular medicine by facilitating early inspection indicated problems with a medical experts was appointed by the disease detection, establishment of novel ther- 11.30 am – 12.30 pm: contract manufacturer. Optison was then FDA to review the safety of contrast apies, and selection of patients for treatment re-launched last year. GE has stated that agents used in echocardiography as well based on their individual disease biology (the Law and radiology: there have been no reported serious side as other experimental contrast agents paradigm of “personalized medicine”). the consequences of the legal reform effects. that are focused on other uses, e.g. to Several different imaging techniques can be In documents released by the FDA, detect liver problems. Initially, the panel used for detection of molecular probes, includ- 1.30 pm – 3.45 pm: Lantheus stated that there have been is being familiarised with the overall ing nuclear imaging, magnetic resonance imag- under 300 reports of serious complica- issues involved, before the FDA seeks its ing, ultrasound and optical imaging, although Controlling and financing: tions and that the mortality rate was advice in coming months. nuclear imaging techniques, and especially performance and cost control small compared to the number of doses The FDA is also working with the positron emission tomography (PET) are cur- given – around two million – since Optison and Definity producers to devel- rently most promising because of their superior 4.30 pm – 6.00 pm: Definity’s launch in 2001. The firm also op a risk assessment and management sensitivity for detection of small amounts of reported that results from recent clinical programme. This has prompted two new highly specific radioactive molecular probes in MARA Radiology Coopetition »RIS/PACS«: trials show that doctors’ ability to make clinical studies. the body.The new generation of hybrid imaging system, which integrate PET with X-ray com- user expectations and industry product offering puted tomography (CT) will further refine the Molecular imaging software tailors therapy application of molecular imaging probes, NEW because co registration with a high-resolution Sunday, 12 October 2008 planning and response monitoring CT will allow for better localization of the spe- USA – Atlanta-based Velocity Medical Solutions launched VelocityAI, its new mol- cific molecular signal from PET. 9.00 am – 10.20 am: ecular imaging software, at the 2008 American Association of Physicists Medicine Applications that are currently being tested Breast cancer screening (AAPM) in July.This platform can save clinicians significant time in creating today’s in early clinical stages include the identification more complex, yet more beneficial, treatment plans, the company explained. of individuals at risk for atherosclerotic plaque 11.00 am – 12.45 pm: ‘Incorporating leading-edge techniques for rapid and precise image fusion, rupture, identification of risk for development VelocityAI enables automatic registration of multiple imaging modalities including of heart failure and/or fatal ventricular arrhyth- Workshop »Communication« CT, MR, SPECT and PET.’ mia, and monitoring of novel therapies such as The firm adds that the software enables rapid plan creation using pre-defined stem cell therapy or gene delivery. 12.45 pm – 1.00 am: atlases, and advanced deformation methods support adaptive planning and com- The field is still in its infancy and strong Congress wrap-up plex re-treatment cases. ‘For enhanced patient follow up, VelocityAI allows volume translational efforts need to continue to make analysis of biologic uptake of FDGPET imaging so that a more quantitative assess- it a clinical reality in the next years. But there is ment of a patient’s progress can be made over time.’ a strong notion that, in the future era of per- Contact: Velocity recently received 510(k) clearance from the FDA to market v2.0 of sonalized molecular medicine, molecular imag- VelocityAI in the USA. VelocityAI v2.0 is an updated version of the VelocityAI v1.0 ing will play a key role for guidance of clinical www.krankenhaus-management.de product that received FDA clearance in March 2007, and added deformable image decision making based on individual disease E-mail: [email protected] registration and atlas-based segmentation to the powerful software’s capabilities, biology. the company explained.

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lmost 25 years ago spina bifida, even if it is not than the diameter of the ink and premature births. The longer twin’ transfusion syndrome the Michael Harrison of the treated with fetal surgery, actually cartridge of a biro. If left and more complicated the extent placenta vessels fuse together, University of California, rarely leads to severe mental untreated, a fetal diaphragmatic of the intervention, the higher the causing a life-threatening ASan Francisco (UCSF) disabilities. As the opening in hernia can lead to the internal risk. The main problems feared by exchange of blood between the operated on the bladder of an many children is quite low, organs shifting into the thorax and the surgeons are births occurring twins. Using a laser, Dr Kohl and unborn child. Almost eight years paralysis is less pronounced and can prevent the lungs from particularly before the 30th week colleagues close the vessels, in later, surgery was carried out on despite the characteristic clubfoot developing properly. of pregnancy. ‘Up to two years ago this way saving most of the the diaphragm of an unborn child. they can often walk well enough.’ Three further quantum leaps in this was a really big problem,’ he babies. His approach was controversial: a By surgically closing the back, medicine helped the further pointed out, but now around 80% Dr Kohl has now developed a paediatric surgeon opened the American fetal surgeons as well as development of this still relatively of the babies treated are born procedure for certain cardiac abdomen and uterus of the Dr Kohl hope to reduce the extent new specialty: The change from after the 30th week, and 50% are conditions that does not involve pregnant woman, lifted out the of palsy and improve the large, open surgical interventions actually born after the 34th week surgery. ‘Ultrasound scans can foetus, performed the surgery and concomitant malformations in the to minimally invasive procedures of pregnancy. sometimes show that the left side returned the foetus to the womb. brain so that an affected baby is from the beginning to mid-1990s To avoid very early premature of the heart is very small and the The disillusioning result: Almost main artery is very all these ‘open fetal surgery’ cases underdeveloped,’ he explained. In were born prematurely and most over two thirds of cases the baby died. needs cardiac surgery after birth, Harrison faced not only to widen the aortic arch. ‘My new criticism from experts and laymen, approach is to give the mother but also respect for his courage oxygen in the last weeks of and innovation. ‘Late one night, it Foetal surgery pregnancy. When this reaches the must have been before my baby the lung vessels open internship, I sat in my room in the births Dr Kohl tends to treat through reflex. This leads to more hall of residence in Essen Scanning and cutting problems that will only become blood flowing to the left side of Margarethenhöhe and flicked my life-threatening after birth, e.g. the heart, which can then grow way through the TV channels underdevelopment of the lungs in further.’ For some babies this when I came across a report on on a miniature scale the unborn with diaphragmatic completely eliminates the need for Michael Harrison and fetal hernias, ideally only from the 34th surgery after birth; for others surgery,’ recollected Thomas less disadvantaged through and, very topical, the ‘newly week of pregnancy. Up till then he doctors are at least able to Kohl, today Head of the renowned problems developing after its birth. developed anaesthetic procedures prefers not to disturb the baby’s improve the conditions for this German Centre for Fetal Surgery Thomas Kohl developed and developed at the DZFT, which development as far as he can. kind of surgery. Dr Kohl has now & Minimally Invasive Surgery practiced his technique on sheep, allow us to anaesthetize unborn Even at this late stage in dealt with 14 of these cases, and (DZFT) at the University Hospital operating on about 200 unborn babies safely and effectively pregnancy he achieves sufficient has five more already on his Bonn. ‘I’ve never been able to get lambs before he dared operate on without putting too much of a catching up in the development of waiting list. it out of my mind.’ a human. He also worked under strain on the mother’s the lungs in most of his patients How does he find time to Dr Kohl’s approach has little in renowned fetal researchers in San cardiovascular system, and finally treated in this way. develop such new procedures? common with that open surgery. Francisco, among them the pioneer the ability to close up holes in the However, there are some ‘The good thing about my special With a small group of colleagues Harrison, to perfect his technique. amniotic sac,’ explained Dr Kohl. fetuses that doctors try to save at subject is that I have he has paved the way for Today he is considered one of the A hole in the amniotic sac is a the earliest possible stage in comparatively few patients,’ the minimally-invasive fetoscopic fetal world’s leading fetal surgeons. problem well known from pregnancy. The most common surgeon explained, ‘therefore I surgery. These new interventions, ‘Around 70% of all babies who examinations of the amniotic cases treated at the Centre are have more time to refine my he says, ‘have fewer complications undergo fetal surgery survive these fluid: It can lead to amniorrhexis twin pregnancies. With ‘twin-to- approaches.’ by Edda Grabar than open fetal surgery and most interventions along with treatment importantly, put less pressure on once they are born,’ he said, ‘and pregnant mothers and their most can expect a normal quality unborn babies.’ Today a whole of life.’ range of diseases, e.g. twin The foetal surgery centre in transfusion syndrome, Bonn has operated on more than diaphragmatic hernia, spina bifida 200 unborn babies or treated them UNDER- OR OVER-UTILISED? and some cardiac problems can be with new, non-invasive procedures; treated in this way, as well as without these interventions, most By Dr Soenke H Bartling urethral rerouting. of them would have died or would Although ultrasound imaging is a Treating those with spina bifida have had to live with severe very powerful imaging modality it hold his particular interest. Spina disabilities. is mostly under-used bifida, in which part of the spinal The progress of fetal surgery Ultrasound combines several cord is exposed to the amniotic was significantly dependent on the very appealing characteristics. It is fluid and therefore damaged, can development of sensitive imaging among the non-invasive imaging be detected at very early stage procedures and the necessary modalities, indeed it is really non- pregnancy, using ultrasound and surgical instruments. Ultrasound invasive. Similar to MRI, no harm to marker protein determination has proved itself the most the patient can be caused by ultra- (alpha-1-fetoprotein- important tool. ‘Siemens offers a sound. concentration). Risk of paralysis machine that even allows us to Through the years it has wit- increases according to the level of capture images of the oesophagus nessed great developments: Reso- the affected parts of the spinal of an unborn baby with the help of lution increased, functional modes cord not protected by the a small ultrasound catheter. This is have been added and novel con- vertebral body. Moreover, the particularly suitable for monitoring trast concepts invented. It con- cerebellum and the brain stem are surgery with certain heart stantly served doctors during the displaced. problems,’ explained Dr Kohl. The last decades. Often, it can be used ‘Although children rarely die tube containing the ultrasound to replace more expensive and Ultrasound of a normal kidney (the intravascular blood flow, as measured through the from spina bifida, diagnosis can be transducer and the surgical more invasive (‘harming’) modali- Doppler effect, is colour coded) combining the structural as well as functional information fatal because most couples decide instruments measures only five ties. The latest developments have that ultrasound can derive to terminate the pregnancy,’ Dr millimetres. The diameter of the made ultrasound devices small and ties, ultrasound does not allow a While in many countries a wide Kohl pointed out. One reason is hollow needle he and his flexible so that they can even be profound documentation of the variety of doctors perform ultra- that parents are still being given colleagues use to treat a fetal carried in ambulatory or preclinical findings – at least not those find- sound – radiologists as well as the wrong kind of advice. diaphragmatic hernias measures medicine. Novel ultrasound probes ings that weren’t seen during the specialists and general practition- ‘Contrary to popular perception just under one millimeter, i.e. less were reduced in size and made 3-D, examination. An ultrasound exami- ers – in the USA the problem of a or better, 4-D imaging possible – nation cannot be looked at retro- declining reimbursement has most famously ‘baby-facing’, where spectively. In other words, there are been solved differently: radiogra- a mother-to-be can see the face of almost no consequences for a doc- phers perform very standardised her unborn child in 3-D. tor if he misses some findings. This scan protocols that are then read Ultrasound experts However, many still maintain that has led to ultrasound mostly being by radiologists. the power of ultrasound is under- used for screening and not the final Independent of widely dis- to meet in Davos utilised, whilst others say it is over- ‘elimination’. cussed local implementations, the utilised. To compensate for declining re- potential of ultrasound is not Switzerland – The 32nd congress of three national To explain this apparent discrep- imbursements for ultrasound, doc- used to its full extent – healthcare ultrasound associations – Swiss, German and Austrian – ancy one has to understand that tors increased (over-utilised) the politicians (adopting reimburse- ultrasound is an imaging modality number of examinations, which ment, assure quality examiners) will take place from 24–27 September, with a particular that is strongly dependent on the itself leads to a consecutive de- as well as the healthcare industry focus on ultrasound for mammography, paediatrics and training level of the operator. The crease in reimbursement, despite (make ultrasound less user neurology. probes give insight into parts of the the fact that a good ultrasound dependent, develop new probes, At this three-country-event manufacturers showcase new human body, but only those that examination takes time. So, to per- assure proper documentation) products and initiate new scientific partnerships. are looked at. Furthermore, in con- form a really good ultrasound have the potential to change this Details (German language): www.ultraschall2008.ch trast to all other imaging modali- examination no longer pays well. in the future.

16 EUROPEAN HOSPITAL Vol 17 Issue 4/08 ULTRASOUND

hat is the role of vascular could be referred to an experi- ultrasound in stroke pre- enced sonographer,’ the professor vention? Asked by concluded. Karoline Laarmann of * The DEGUM certification scheme W STROKE PREVENTION has three levels. ‘DEGUM Level I is a European Hospital, Professor tent vascular stenosis will be diag- sonographers. These are medical Christian Arning MD, Medical nosed or dangerous stenoses will technicians with extensive experi- qualified basic training, teaching the Director of the Neurology Depart- simply be overlooked.’ Ultrasound brings many ence in the modality but whose diag- user the principles as well as simple applications,’ Prof Arning explained. ment at Asklepios Klinik Wandsbek, These significant differences in nostic ability is hampered by the advantages, but trained ‘DEGUM Level II deals with more Germany, and Deputy Chairman of the quality of ultrasound instruction fact that they are not fully-trained sonographers are too few demanding applications and requires the German Society of Ultrasound in result in a large risk for the patient. physicians. several years of experience by the Medicine (DEGUM), gave an unequiv- Since currently there is no ‘warran- ‘Qualified diagnostic ultrasound sonographer. The level II certificate ocal answer: crucial – but only if the ty’ for a constantly high level of com- This ensures that the physician makes it possible to realise a new also includes the skills as an sonographer is properly qualified. petence in ultrasound, the DEGUM* treating the patient will be able to structure in diagnostic decision- instructor. DEGUM III, the third and ‘Without any doubt prevention is has developed a voluntary scheme solve the pertinent issues in a par- making. Currently, in the case of highest level of excellence, also not only the best but also the safest of certification that will make trans- ticular disorder.’ ambiguous findings, a physician not includes scientific research in treatment for stroke. It is precisely in parent the quality of the ultrasound The problems of specialisation well trained in ultrasound will refer ultrasound.’ prevention where ultrasound offers study. ‘For this certificate physicians are also seen in other countries: the patient to the radiologist. The homepage of the German Society of Ultrasound in Medicine has these enormous advantages over all will have to pass tests on specialised For example, in the USA and the However, it would be much better if a link to an open database listing of other modalities, and this applies not areas of application of ultrasound. UK ultrasound is performed by patients with ambiguous findings all sonographers certified by DEGUM. just to radiation exposure. Roughly 90% of all strokes are due to insuffi- cient blood supply to the brain due to vascular obliteration, including steno- sis of the carotid arteries. Since this part of the human anatomy is easily investigated by ultrasound, in 98% of the patients we can assess the status of the carotid arteries quite definitely, without having to fall back on any .artundwork designbüro

Hitachi Real-time Tissue Elastography: Discovering with all senses. Karoline Laarmann (European Hospital) with Christian Arning other modality. It is our overall goal that ultrasound will supplant X-ray studies, even in the diagnostic workup of stroke. In the case of catheter angiography, a modality with a certain inherent risk of side effects, we have already been successful: the standard modality up until recently, angiogra- phy of the cerebral arteries is uncalled for in 99% of cases,’ said Prof Arning. Since no other low-risk imaging modality exhibits such an excellent spatial resolution as ultrasound he also advises: ‘Patients at increased risk for stroke should undergo regular preventive ultrasound workup. The degree of stenosis is the most impor- tant criterion when assessing the risk of vascular obliteration. From this information alone the expert investiga- tor can infer the seriousness of the carotid artery stenosis.’ However, the safety and accuracy of the study requires proper training and extensive experience of the sonogra- pher. According to Professor Arning many German hospitals specifically lack these competent healthcare pro- fessionals. ‘The reason for this stems from the fact that although in Germany ultrasound is taught during residency, there are no uniform stan- dards in quality assurance and no min- imum standards for the teaching syl- Hitachi Real-time Tissue Elastography (HI-RTE) labus. Furthermore, not even the qual- ification of the teacher has been laid HI-RTE is an emerging ultrasound This unique HI-RTE modality... down in the residency regulations. modality for the assessment and real- · Extracts strain data ensuring that quantitative Therefore, quite often one resident time colour display of tissue elasticity. measurements are available from the Strain Ratio tool The value of this 2nd generation · Is easy to perform, fast, accurate and reproducible will pass on his/her partial knowledge ultrasound modality has been proven · Incorporates an adjustable colour transparency to the next. But for this modality the in a variety of different clinical areas, feature, enabling instant correlation between the operator’s experience is of paramount including breast, urology, endoscopy native B-mode and elasto image Mid-section of the prostate gland showing importance. A study on abdominal and many more. · Is a diagnostic tool that can reduce the financial and a carcinoma in the peripheral zone. ultrasound published in 2006 demon- emotional burden of further investigations strated that less experienced ultra- · Is available for the new range of HI Vision platforms sound operators came up with the cor- rect diagnosis in only 39% of cases, while for the experienced sonographer Visit us at Three Country Meeting in Davos, booth n° 205 this rate jumped to 95%. An accuracy or at DGU in Stuttgart, booth n° 3.01! of 95% is identical with that seen in other modalities, such as CT and MRI. Hitachi Medical Systems Europe Holding AG · Sumpfstrasse 13 · CH-6300 Zug www.hitachi-medical-systems.com When patients are studied by sonogra- Hitachi Medical Systems Europe Holding AG · Sumpfstrasse 13 · CH-6300 Zug phers who are not properly trained, www.hitachi-medical-systems.com time and time again either non-exis-

EUROPEAN HOSPITAL Vol 17 Issue 4/08 17 ULTRASOUND NEW Philips HD15 ultrasound system European debut for Acuson S2000 Philips has added a new platform to its provides sharper images and improved Siemens Healthcare will show its Klaus Hambüchen, CEO of Siemens HD ultrasound products – the HD15 – tissue uniformity throughout the depth of Acuson S2000, the first ultrasound Ultrasound Business Unit. which aims to provide small hospitals, field through application of new dynamic system in the new product series S, at Siemens is also preparing the clinics and private practices with receive lens tuning with five times more the ESC*. The system platform Acuson S2000 for Automated Breast advanced image clarity and broad appli- focal points than previous generation sys- includes integration of the newest Scanning (ABS). This method provides cation support for everyday use. ‘The tems,’ Philips explained. ‘Tissue Specific technologies to optimise workflow, automatically created, reproducible 3- HD15 brings capabilities that assure user Imaging presets and iSCAN one button e.g. comprehensive software D ultrasound volumes of the breast. simplicity and productivity to more clini- image optimisation can quickly provide applications such as new software for ABS is important for screening, early cians in a variety of clinical settings,’ clear images with little to no adjustment. breast imaging. The system is also detection, diagnosis and aftercare for explained Anne LeGrand, senior vice A broad suite of configurable patient equipped for future technologies: It breast cancer and complements president, Ultrasound, for Philips reports and exam storage options, such enables the implementation of mammography, especially for women Healthcare. as DVD-CD-R/RW, USB drive, and full ‘The system may be used as a primary DICOM capabilities, provide efficient innovative ARFI (Acoustic Radiation with dense breast tissue. Compared to system for some users, particularly those patient data management and colleague Forced Impulse) imaging and is manual breast ultrasound, ABS in emerging markets who require a fea- or specialist consulting.’ prepared for integration of new silicon shortens the examination time and ture-rich system but may not need all of Active native data allows clinicians to ultrasound technology, which is almost reduces user dependency. This makes the features of a high-end ultrasound manipulate examination parameters and ready for the market, Siemens points ultrasound imaging more reproducible solution,’ Philips added. Along with image settings even after a patient has out. ‘The Acuson S2000 is suitable for and provides more uniform results workflow improvements, the HD15 capa- left. ‘Images and Cineloops can receive internal medicine radiology imaging than before, Siemens explains. bilities include general imaging, cardiac, further investigation by manipulating the including vascular diagnosis and Innovative applications of the vascular and obstetrics/gynaecology original image to see new detail. Live echocardiography as well as Acuson S2000, e.g. ‘SieClear Spatial applications. Features such as contrast compare allows the clinician to compare gynaecology and obstetrics.’ Compounding’, also increase the enhanced ultrasound and PureWave a previous exam side-by-side with an ARFI ultrasound compresses tissue reliability of a diagnosis. ‘One push of transducer technology also allow real- active exam in order to see immediately using acoustic energy, enabling a button allows highlighting of time guidance and evaluation of mini- changes in structure or blood flow. This qualitative and quantitative evaluation anatomical boundaries and improves mally invasive treatments. can be particularly helpful in comparing of the stiffness of deep tissue. Current tissue contrast as a whole. The HD15 includes Philips QLAB quan- changes in cardiac and vascular anom- research indicates that this type of Simultaneous use of the Dynamic TCE tification software, XRES image process- alies, further documenting changes after evaluation can be helpful in technology reduces speckle patterns ing and PureWave transducer crystal interventional procedures, or evaluating differentiating abnormalities such as and noise signals and ensures technology. ‘New Microfine EX focusing foetal development.’ liver tumours, or quantifying the excellent image quality, even in advancement of fibrosis (development difficult cases. For the first time the ‘High performance systems need not be ● Flow 3-D:This function allows the of excess connective tissue), Siemens Acuson S2000 will use this 3D TCE large,’ says Aloka, manufacturer of the user to add 3-D colour flow informa- explains. with speckle reduction to acquire 3-D new compact ProSound 7, which pro- ProSound 7 tion to conventional 3D images of tis- images. The High Density (HD) probe duces high-resolution images yet can be sues. This makes it easier to appreci- technology also results in used in areas with little spare space. ate the complex vessel positioning, exceptionally fine signal levels for ‘Broadband Harmonics provides high sen- such as tortuous or tangled vessels, in excellent depth and contrast sitivity and penetration that is compara- relation to the surrounding tissue resolution,’ Siemens adds. ble to fundamental-frequency imaging which is harder to appreciate while The Acuson S2000 also integrates resulting in a significant improvement viewing standard with 2-D images. knowledge-based applications, for above standard harmonic imaging,’ Aloka ● Automatic Doppler Angle example the syngo Auto OB software, reports. Correction: Flow direction is tracked which creates semi-automatic The system also incorporates Directional using the colour Doppler image allow- biometric measurements of a foetus eFlow (D-eFLOW), Aloka’s unique tech- ing automatic adjustment of the angle and saves the operator up to 75% of nology that dynamically improves spatial correction cursor at a press of a but- the stages in a routine examination. and temporal resolution of blood flow. ton. Thereby minimising user input & Advanced-fourSight technology Aloka points out that it copes with the improving examination efficiency. provides improved functionality for ● full range of haemodynamic velocities Compatibility with 13 Additional volumetric acquisition, data rendering from fine blood vessels with low veloci- Probes e.g. and postprocessing. This software also ties in the tip of a finger to large vessels – Compound Array Linear Probe includes Amnioscopic Rendering, a with high velocities such as the Aorta. allows electronic focusing in two The Dual Dynamic Monitor (DDM) mode planes to generate images of a unique method of surface rendering to allows viewing of a fundamental B-Mode uniform slice thickness from show almost photorealistic and image and a contrast-enhanced image superficial to deep areas. detailed views of the foetus, Siemens simultaneously, side by side in real time. – 28 types of probes are now com- continues. The additional imaging with Aloka points out a range of ProSound 7 Aloka’s compact patible, expanding the system’s Foetal Heart STIC (Spatio-Temporal abilities: application range and enabling Image Correlation) acquires data over ● Adaptive Image Processing (AIP) for ultrasound system more specialised examinations in the course of several cardiac cycles speckle reduction: Speckle noise is respective fields. The Acuson S2000 is already and creates a 3-D volume of the foetal reduced while maintaining frame rate ● Edge Optimiser: Improves overall ● Flow Mediated Dilatation (FMD) designed for integration of future heart, which a physician can use to thus enhancing tissue differentiation edge definition of tissue boundaries to analysis is available by utilising the silicon ultrasound technology, the first view the heart in several layers. without affecting temporal resolution. improve diagnostic confidence. Thus Aloka eTracking function. Auto- groundbreaking development in Another feature is syngo eSie Calcs ● Image Optimiser: Instantaneous making measurements such as IMT & matically tracing the change in the probe technology in over 40 years. software, intended for boundary automatic optimisation of the live B- Nuchal Translucency definitive. diameter of vessels with a high accu- This uses the precise procedures of detection and segments it scans areas mode image freeing the user from indi- ● Multi-Slice Imaging:This is a racy of 0.01mm (at 10MHz) by track- semiconductor production and of interest, automatically calculating vidual image adjustments during exami- multi-planar sequential display func- ing the zero cross phases of RF sig- realises isotropic 3-D and 4-D all parameters of interest to the nations, resulting in enhanced patient tion of 3D volume data, which is a nals. Thereby providing an accurate ultrasound imaging for the first time, physician, Siemens continues. ‘The throughput & examination efficiency. popular display technique in CT and way to evaluate & quantify vascular which offers the same true-to-detail simple definition of a delimited area ● Spatial Compound Scan: Offers an MR. Multiple cross-sectional images of health. representation in every direction. allows the tracing of lesions and enhanced image processing technology arbitrary slice width can be displayed, Although launched only this year, ‘We believe that the ARFI and calculating either their volumes in 3-D by superposing images created by steer- Aloka reports that this compact making it easy to observe the extent of silicon technologies will change or surfaces in 2-D.’ ing the ultrasound beam in multiple a lesion or structure such as the foetal ultrasound system is reported to ultrasound imaging as extensively as (See EH@ESC supplement, centre 12 directions & user definable angles. heart for objective understanding of have already attained a successful Doppler imaging did in its day,’ said pages of this issue). Enhancing the definition of structures. anatomical location. reception.

At this year’s European Society of Cardiology (ESC) meeting, GE And now? Healthcare will celebrate a decade of GE celebrates a decade of Vivid memories The 10,000th Vivid 7 and the 5,000th achievements since it acquired sue tracking to the series. Amersham and contrast agent Optison compact Vivid system will be sold this Diasonics Vingmed Corporation. ‘To 2001 – Debut of Vivid 7 and informa- joined the GE portfolio. year. think about the achievements and tion management solution EchoPAC 2005 – Vivid 7 gained Automated IMT In both the console and compact strides we’ve made over the past ten PC. Vivid 7 became GE’s high-end PC- (intima-media thickness) measure- ultrasound lines, GE says it will intro- years is remarkable,’ said Business based ultrasound scanner and the ments and 9-slice imaging. Structured duce some significant new additions General Manager Anders Wold, who foundation for many future innova- findings came to EchoPAC and Image to the Vivid series. ‘In the console line, joined GE from Diasonics Vingmed. tions. Vault. they’ll share the promise of true 4-D ‘Perhaps even more remarkable, how- 2002 – Vivid 7 gained strain imaging 2006 – Vivid e, brought compact ultra- heart imaging, new 4-D quantitative ever, is to think of those achievements as well as new vascular and shared sound into doctor’s offices. Vivid & tools and open the door to enable full as a prologue to the endless possibili- service applications. Vivid 3 gained a gained 4-D real time colour flow and cardiac studies in a completely 4-D ties ahead.’ new transducer (the3S) and EchoPAC AFI (Automated Function Imaging). 4D environment. In the compact Vivid 1999 – GE introduced System FiVe, its connectivity. LV volume measurement came to product line, we continue to add new first cardiovascular ultrasound system. 2003 – TSI (Tissue Synchronisation EchoPAC. quantitative analysis tools and new This offered the then-breakthrough fea- Imaging) added to Vivid 7. Vivid 4 compact ultrasound market with the 2007 – Leveraging miniaturisation leading edge imaging quality tures of quantitative contrast imaging debuted with its 18 transducers. introduction of the Vivid i. GE’s first expertise gained from Vivid I and the enhancements, bringing even more and DICOM connectivity. 2004 – Vivid 7 picked up the compact cardiovascular ultrasound sys- performance of Vivid 7 and Vivid 4, diagnostic confidence into the equa- 2000 – GE’s new Vivid 3 became one of Dimension moniker based on its new tem brought the performance of 400- launched Vivid S6 and S5 cardiovascu- tion. The new introductions will take the first PC soft/hardware based ultra- real-time 4-D and multi-dimensional pound console systems into a light- lar ultrasound systems. Vivid 7 gained users and their patients in directions sound systems.The Vivid FiVe added tis- imaging capabilities. Vivid entered the weight, compact design. GE acquired ultra-definition imaging. they can only dream of.’

18 EUROPEAN HOSPITAL Vol 17 Issue 4/08 UROLOGY

Dr George Salomon: We are not yet standardised but there currently using sono-elastography are different ideas on how to with high-risk prostate cancer arrive at a standardisation. patients who underwent biopsy SONO-ELASTOGRAPHY Despite these positive results but show a high PSA value the method is not being used despite negative tumour results. A valuable additional method to improve diagnostic precision of prostate cancer widely in Europe. Why not? With these patients sono- On the one hand this can be elastography offers a complement attributed to the fact that the to conventional ultrasound since Martini Clinic, in the University Hospital Eppendorf (UKE) campus in Hamburg, industry has neglected this measuring tissue elasticity allows is one of the world’s major centres for nerve-sparing prostatectomy. The method for a long time. us to gather information on Martini physicians not only specialise in surgical intervention but are also at Promising approaches have been suspicious regions that were not around for a couple of years, but identified during biopsy. So far the cutting edge of diagnostics, being among the few in Germany to use sono- they were not followed through. the results have been very elastography, an innovative tool to detect prostate cancer. Today, as far as I know, the promising. As soon as we have We asked Dr Georg Salomon (GS), chief physician and head of diagnostics at Hitachi system is the only one identified a suspicious region we on the market that offers this can perform targeted biopsies, Martini Clinic, who has used sono-elastography for over a year, about this work diagnostic benefit. But things which increase diagnostic and his aims to improve the diagnosis and prognosis of prostate cancer. seem to be moving ahead as accuracy. other companies are We validate this method by ten In a previous study we were able data that we can analyse. Sono- to move the transducer precisely, increasingly interested in sono- biopsies thus working with the to show that sono-elastography as elastography is only an acceptable in order to generate the elasticity elastography – a fact which current gold standard. In a final such offers diagnostic benefits. We diagnostic tool for prostate cancer images. In a second step the proves that the method is indeed step we compare the results and compared pre-surgery ultrasound if it offers the same reliability as images have to be interpreted promising. use additional information from data of cancer patients with the the gold standard. At this point, based on their reproducibility. At the same time sono- our database, in which we save all post-surgical histological results of measuring tissue elasticity is a And finally the elastogram has to elastography is increasingly used the elastograms we have the removed tissue. Sensitivity and mere complement, which provides be compared with conventional clinically as an additional performed. specificity were about 76%, the additional information. ultrasound. If, for example, the modality. This will provide more How reliable is this method? positive predicative value was 87%, What would a physician need elastogram shows hardened data to work with in order to At this point our patient cohort and the negative predictive value to learn to use this? tissue, the ultrasound image can assess and optimise the method. counts approximately 100 patients was about 59%. That means the As with any other modality there is provide information on the In short: I’m convinced that with negative biopsy findings. We method is significantly better than a certain learning curve for sono- nature of the hardened tissue, for sono-elastography offers a have to analyse these data before conventional ultrasound. elastography. First, one has to example whether it is a valuable additional method to we can make valid statements on However, to assess the precise understand how the hard tissue is calcification. Currently, the improve diagnostic precision of the reliability of the method. diagnostic benefit we need more displayed. That means the user has criteria to assess elastograms are prostate cancer.

Laparoscopy is playing an increasingly important role in urology and centres of excellence have been established to provide training in urological laparoscop- ic surgery. However, increased Laparoscopy in urology patient demand for the latest minimally-invasive techniques Concerns are being means there is still a potential shortfall in urology laparo- raised across Europe scopists in Europe. Robot-assisted surgery may that not enough help ease the situation, though many leading urologists are not urologists are yet convinced either of its cost- effectiveness or ability to offer experienced in Per-Anders Frank Keeley outcomes better than regular Abrahamsson laparoscopy. laparoscopy to meet According to Per-Anders procedures the robot may be more Abrahamsson, Secretary Gen- growing demands of effective, especially with a radical eral of the European Association prostatectomy. of Urology, ‘There are more patients. Mark Advantages of robotic surgery demands from patients for mini- include the surgeon being seated mally-invasive and laparoscopic Laparoscopic urology surgery Nicholls reports. and having a three-dimensional surgery – with or without robot- view of the operating field. Robots assistance. That has been scopic surgery training co- there are clear advantages. consensus on the value of robot- are also effective for remote increasing exponentially in the authored by Dr Stephanie ‘Patient quality of life after ic surgery is that circumstances surgery being used by a surgeon in last few years in many European Kroeze of the University laparoscopic surgery is higher, differ from one European coun- one centre to operate on a patient countries.’ Medical Centre, Utrecht, con- and many patients now ask try to another. ‘In France for in another hospital. Laparoscopic urology surgery cluded that laparoscopic training whether their operation can be instance, this issue is not promi- But with the machinery costing began in the mid-90s in America needs to be improved but high- carried out laparoscopically,’ he nent because the pure laparo- millions to purchase and maintain, but was dropped because it was lighted laparoscopic virtual real- said. scopic surgeons are skilled Dr Ravery says this is another fac- considered too time consuming to ity simulation as helping meet ‘Once the surgeon reaches the enough to proceed without tor in deciding whether to go suit the needs of the US reim- that need in urological surgery. required level of expertise, he robots but in other countries, in down the robotic route: ‘To invest bursement system. In turn, Frank Keeley, a consultant should have more job satisfac- which regular laparoscopic pro- at this level we have to be sure French and German urologists urologist at Bristol Urological tion and fewer postoperative cedures are not as regularly car- that the oncological results are at took up the discipline and have Institute in England, said: complications.’ ried out, the robot is probably least as good as using other proce- become world leaders in develop- ‘Urologists have been slow to In urology, operations that more important.’ dures. So far, we are not sure.’ ing the role of laparoscopy in the develop laparoscopic expertise laparoscopy most benefit in- Urologists say the robotic At present the main robotic sys- treatment of urological disease because there is no procedure clude nephrectomy, adrenalecto- issue is often commercially dri- tem available is the da Vinci, but and tumours. Professor Abraham- which is relatively straightfor- my, and pyeloplasty because an ven with suppliers encouraging the Chinese are developing a sson, who is Chairman and ward. As a consequence, the upper abdominal or loin incision hospitals to take advantage of robot that could be commercially Professor of the Department of number of expert surgeons act- can be very debilitating. the technology, without any available within the next few Urology at Malmö University ing as trainers has been small.’ Although some centres are widespread clinical investigation years and, with greater choice Hospital in Sweden, said: ‘There He said urologists had to using robotic equipment for uro- of its effectiveness. through competition, the cost is an unmet need in many coun- develop their surgical expertise logical procedures, some sur- Dr Ravery added: ‘The issue is could decrease. tries in Europe and we have to ‘on the job’ and after they had geons have reservations about also driven by the patients who The da Vinci makers say there teach more urologists in terms of completed formal training, and whether the technology provides come to us asking for the robots are benefits of robotic surgery – laparoscopy.’ added: ‘The impact on hospitals better clinical outcomes than without any rationale but at this for the surgeon of magnified 3-D The EAU, through its European is fairly obvious: many surgeons regular laparoscopic surgery. stage we are not sure that robot- visualisation, increased precision, Urological Scholarship rogramme do not offer laparoscopic Dr Vincent Ravery, profes- ic surgery dramatically improves tremor filtration and improved (EUSP), and the British surgery; open surgery involves sor and chairman of the on the oncology and functionali- access to and manipulation of Association of Urological longer hospital stays and more Department of Urology, Bichat- ty of regular surgery.’ organs, tissues and nerves, and Surgeons (BAUS) have estab- blood loss than laparoscopy.’ Claude Bernard Hospital, Paris, However, urologists acknowl- for patients shorter hospitalisa- lished laparoscopy training pro- Laparoscopic surgery utilises and Chairman of the European edge having the option of robotic tion, reduced pain, faster recovery grammes for urologists. different skills to conventional Society of Oncological Urology, surgery makes it easier to attract times, and quicker resumption of A study of residents’ laparo- surgery, but Mr Keeley believes said that a problem in gaining a patients and for some complex normal activities.

EUROPEAN HOSPITAL Vol 17 Issue 4/08 19 UROLOGY NEUROLOGY

erry Shivo was 27 when she col- A compressed cranial nerve by blood vessels lines, but which for most other forms of dizzi- lapsed. Paramedics found nei- is responsible for numerous diseases. The ness is useless. However, success was not ther respiration nor a pulse. most well-known example is trigeminal neu- long-lasting. In just a few weeks, the adminis- Robot-assisted Almost three months later her ralgia, which is agony for many people affect- tration of carbamazepine led to a consider- T eyes had opened, but she was not con- ed by its sudden shooting pain in the face. able increase in liver enzyme values, where- scious. She has a sleep/wake circle and prostatectomy in Other examples are glossopharyngeal neu- upon the treatment had to be discontinued sometimes appeared to smile – she was ralgia, hemifacial spasm or even superior and the gruelling vertigo attacks returned in in a vegetative state. Up to her death in oblique myokymia in which, likewise, too full force. practical use the USA in 2005 her case caused a bit- close contact between a cranial nerve and a To end the suffering it was finally decided ter court battle for guardianship vessel is assumed to be the cause. to undertake surgery to widen the gap At the Medizin Innovativ 2008 between family members and a world- Medication or the extensively used posi- between the compressed cranial nerve and wide controversial debate began about congress (9–10 July, tional manoeuvre should not be the only treat- the artery causing the problem. Indeed the the quality of life following severe ments considered for effectively helping agonizing spells of vertigo disappeared com- Nuremburg, Germany) brain damage. Professor Jens-Uwe Reliable methods of diagnosis could Stolzenburg MD (right), Only surgery give more certainty about signs of Director of the Urology Clinic can provide awareness and chances of recovery. Simply operate Presently, the Functional Magnetic and Polyclinic at the University Hospital help for some Resonance Imaging (fMRI) is the most Leipzig, talked about his experiences with promising tool not only to provide bet- forms of ter diagnosis and predict outcome of the da Vinci robot. Used by surgeons at giddiness away? dizziness, brain injuries but also to communicate University Hospital Leipzig since last writes with the patient. October 2007, they performed 40 In Europe only two research centres Karl Eberius MD perform this imaging technique on operations in the first two months. coma patients: the Cambridge Neuroscience Centre in the UK and the The da Vinci technology has been under develop- Coma Science Group from the ment since 1995. Over the last three or four years, Compressed cranial nerve Cyclotron Research Centre at the robot-assisted surgery has replaced the open as the cause of vertigo: University of Liège, Belgium. The latter retropubic prostatectomy as standard surgical In disabling positional is led by Professor Steven Laureys, procedure for prostate cancer in the USA. In 2007, vertigo an artery near the brain stem presses on Head of Clinics in the Department of 68% of all radical prostatectomies in the US were the eighth cranial nerve. Neurology. performed using da Vinci. This percentage has Surgery can provide a Asked why coma research is so been increasing and is expected to rise even fur- cure. Lasting two to three important, the professor said that, due ther. hours the operation requires making a hole of The da Vinci technology, which is a significant about 2.5 cm diameter in further development of laparoscopy, offers a num- the skull* ber of advantages. From a workstation, the sur- Adiposity is not geon controls the laparoscopy instruments in the patient body via three-dimensional optics. Patient-side sterile procedures are no longer nec- factor for stroke essary and the ergonomically designed worksta- Professor Tobias Back ‘tion reduces the physical stress for the surgeon. cases of dizziness. Surgery can also be useful pletely after the operation, which took some MD is medical director The instruments of the da Vinci robot can be for some forms of dizziness as shown by the two to three hours and required a hole of of the Clinic for moved in six increments. Thus, the movement of case of a 61-year old woman who suffered around 2.5 cm in diameter in the skull. After Neurology and Neuro- the surgeon’s fingers are directly transferred to repeatedly from vertigo. Most recently her the surgery, the woman was able to lead a nor- logical Intensive Medi- the instruments and possible tremors are avoided. problems had become even more severe. She mal life. cine in Arnsdorf, Ger- had sudden attacks of vertigo several times a It is above all the 3-D optics that allow ideal ori- Rate of complications: roughly 5–8% many. Being the initia- entation in the operative field, a significant day, which were of strikingly short duration. tor of the first large- advantage over traditional laparoscopy, which The unpleasant event lasted from just 30 sec- The decision for such an intervention howev- scale European case-control study on requires orientation in a two-dimensional space – onds to a maximum of five minutes, usually er should be carefully considered on account abdominal fat mass and stroke risk he a fact which poses problems for many, particular- accompanied by a whistling sound in the right of possible complications, emphasized Prof- presented the study results at the an- ly inexperienced, surgeons. In short, the da Vinci ear. Another particularity was the fact that the essor Friedrich Albert, head of the neu- nual congress of the European technology combines the advantages of laparo- attacks ceased when the patient lay down on rosurgery unit of Paracelsus Hospital, Neurological Society, held in June in scopic access (minimally invasive) with those of her right side, as was reported in the journal Osnabrück, after carrying out the surgery on Nice, France. open procedures (3-D view, intuitive movements, HNO [ENT] by Dr Wolfgang Reuter and team the vertigo patient. ‘The operation is only rec- Dr Back and his research team were dexterity). from Lippstadt, Germany. ommended if the patient’s everyday life is able to demonstrate that in overweight Robot-assisted surgery, however, requires sub- These typical symptoms indicated vestibu- considerably restricted because of the attacks patients it is not the body mass index stantial initial investments and the operating lar paroxysmia (disabling positional vertigo) and the diagnosis of disabling positional verti- (BMI) that counts when assessing costs are comparatively steep. A system comes which is well-known for its extremely short go is unequivocal.’ He pointed out that this stroke risk but solely abdominal girth. with a price tag of around €1.3 to 1.5 million. The attacks lasting from seconds to minutes and surgery carries a roughly 5–8% risk of serious ‘There had only been insufficient stud- annual maintenance costs will amount to approx. which can be triggered or ended by certain complications, e.g. loss of hearing, facial ies that analysed the fat distribution pat- €50,000 plus approx. €1,000 to 1,500 per proce- positions of the head. Tinnitus, sounds in the paresis, or vascular damage that could lead to tern of stroke patients. The few avail- dure for the instruments. Costs are thus one rea- ears, is also characteristic accompanying corresponding ischaemia of the brain stem. able preliminary data were collected in son why da Vinci robots are not yet being used symptoms for this diagnosis. The cause of dis- The chances of success of such an opera- the US. Now we are proud to say that widely. abling positional vertigo is an artery of the tion cannot be precisely quantified owing to we were the first Europeans to present From October 2007 to December 2007 we per- cerebellum being compressed by the VIII cra- lack of data, but according to Prof Albert meaningful data that show that abdomi- formed radical prostatectomies in 40 patients nial nerve from, which not only consists of they are thought to be good. Complete free- nal adipositas is the sole independent using the da Vinci system. The average patient age fibres transmitting the sense of balance but dom from symptoms, or at least a marked risk factor associated with cerebrovas- was 66 years, the average PSA was 11.6 ng/ml. also contains the auditory nerve. improvement, can be anticipated in about cular stroke,’ he explained. Average OR time, including docking times, was 75–80% of cases, much the same rate as for Funded by the German Ministry for Test treatment with carbamazepine trigeminal neuralgia – likewise caused by too 188 minutes, no transfusions were required. No clarifies the situation Education and Research, the research patient required a conversion (open surgical pro- close contact between a vessel and a cranial project was conducted in Mannheim cedure), no major complications, such as injuries The diagnosis of disabling positional vertigo nerve. and Heidelberg, Germany, between *Compression through contact with blood vessel, of the rectum, were recorded. Histological analy- was confirmed in the 61-year old woman by February 2005 and January 2006. ‘We treating with carbamazepine, a low dose of VIIIth n. Vestibulocochlear nerve, +Branch of the ses had found a pT2 tumour in 31 patients the anterior inferior cerebellar a., #Pons (Source: took great pains to assemble a suitable (77.5%) and a pT3 tumour in 9 patients (22.5%). which is recommended as first line therapy Reuter W., Fetter M., Albert F.K., HNO 2008; 56: regional cohort of regular people. In the Positive margins were detected in 6.5% (2/31) of for vestibular paroxysmia in various guide- 421-424, pic 3, © Springer Medizin Verlag 2007). end we had 379 stroke patients and a the pT2 tumours and 33.3% (3/9) of the pT3 control group twice that size in order to tumours. Catheters were placed on average for Conclusion for general practice optimise the statistical relevance of our 6.1 days. results. Average patient age was 65.’ After three months 77.5% of the patients were ● For some forms of dizziness neurosurgery the head (for example by lying down on one’s The researchers measured the waist- fully continent, after six months the rate had may be a great help. side). to-hip ratio (WHR) by taking the abdom- increased to 90%. Short-term oncological and ● This applies, for example, to disabling ● The first line therapy for disabling positional inal girth at the navel and dividing the functional results are thus highly promising and positional vertigo, which is among the ten vertigo is not considered to be surgery but result by the circumference of the hip at comparable to the results achieved with endoscop- most frequent causes of symptoms of vertigo carbamazepine, which is also indicated for the hip bone. Abdominal adipositas is a ic, extraperitoneal radical prostatectomy (EERPE) and results from too close contact between trigeminal neuralgia. The dose given is 200 to 600 value defined by the World Health which we perform routinely in our hospital. an artery and the eighth cranial nerve (in the mg per day. Organisation (WHO): in men a value It remains to be seen whether the da Vinci same way as an artery compresses the fifth ● Oxcarbazepine can also be administered in which above 1.00 is considered pathological, prostatectomy will yield better long-term results. cranial nerve in trigeminal neuralgia). case the dose suggested is 300 to 900 mg per day. in women a value of 0.85. The WHR is So far, the international literature does not indi- ● Typical symptoms of disabling positional If there is intolerance to these drugs, gabapentin more precise than the body mass index cate the advantages of robot-assisted surgery to vertigo are short attacks which in severe or phenytoin can be used as alternatives. (BMI): ‘The BMI does not differentiate have long-term impacts on the ‘quality indicators’ cases may occur up to 30 times a day. There ● The surgical treatment of disabling positional fat mass and muscle mass. That means a of radical prostatectomy such as complications, are often also sounds in the ears on the side vertigo consists of widening the gap between the person’s individual physical state is not tumour control, continence or potency. affected. The attacks are moreover frequently artery causing the problem and the eighth cranial taken into account. The waist-to-hip triggered or ended by certain positions of nerve. ratio on the other hand is more predic- 20 ’ EUROPEAN HOSPITAL Vol 17 Issue 4/08 NEUROLOGY Coma: Functional MRI to predict first signs of awareness to modern emergency medicine and haemodynamics, indirectly to obtain and space. According to time, tools Presently we have no direct treat- intensive care, an increasing number information about the activity of neu- to measure electrical activity from ments to help the brain recover of patients survive injuries, toxica- rons in special parts of the brain. But the scalp are even more precise – from traumatic or anoxic cases, tions or hypoxia. fMRI can do more: The technique these would be EEG and Magneto- because first we would have to ‘Unfortunately they are often con- enables us to communicate with the encephalography (MEG). That’s why know what gives rise to recovery of sidered as a homogenous group of patient. We can ask him questions by the gold standard is to record simul- consciousness. We know that the hopeless cases, but this is not true. telling him to think of playing tennis taneously both: EEG during fMRI. vegetative state can be permanent Studies have proved that around three if he wants to say “yes”, or imaging to The present challenge is that MRI or transitory and that the longer or four in 10 patients diagnosed as walk through his home if he wants to needs a very high magnetic field – at someone stays unconscious the unconscious in fact show signs of say “no”. We then directly see the the moment 3-Tesla, but we can smaller their chance of recovery. awareness. There are at least four dif- reaction of brain activity in specific move up to 7T, or even higher. Retrospective studies indicate that Professor Steven Laureys ferent states of severe brain damage areas on the monitor. It permit us to Unfortunately the signals of both patients taking specific drugs appar- we observe: coma, vegetative state, give back autonomy to the person to fMRI replaces PET scanning, which tools distort each other. So the EEG ently recover more often. In the minimally conscious state (clearly dis- decide for himself if, for example, he requires radiotracers injection. With electrodes must be shielded to avoid future, fMRI could help to measure cernible evidence of consciousness of wants life-prolonging measures.’ fMRI you can possibly acquire more image interference and burning at the effects of drugs testing directly self or environment) and locked-in- ‘In functional neurological imaging scans and a better resolution in time the patient. to the central nervous system. syndrome (fully conscious but paral- ysed). Especially the demilitation of vegetative and minimally conscious states is very difficult to differentiate. fMRI is helping us to understand the brain function and cognitive process- es. ‘Functional magnetic resonance imaging (fMRI) shows the function of the brain in contrast to MRI which dis- plays structural images. The haemo- globin in the red blood cells transport oxygen to the brain and can be used to make scans with the help of a magnet field. So actually, we measure the blood oxygen level, also called generally a risk Abdominal girth is decisive tive since this adipositas marker identifies visceral (abdominal) fat mass independent of body height and physique. Even more: our study clear- ly shows that the BMI is not an inde- pendent stroke risk factor,’ Dr Back emphasised. ‘The analysis of our data demon- strated that, after adjustment for fac- tors such as hypertension, smoking, physical inactivity, or diabetes, patho- logical abdominal girth was the sole indicator for increased risk of stroke, with the risk being four to seven times higher and women being in gen- eral slightly more at risk than men.’ But why is abdominal fat so dan- gerous? Is it a certain type of fat that builds up around the abdomen, the so-called visceral fatty tissue that determines abdominal girth? ‘Intra- abdominal fat mass has crucial impli- cations for a body’s fat and carbohy- drate metabolism since it is particu- larly that kind of fat mass that causes free fatty acids, cytokines and hor- mones to enter the portal circulation and thus increases the risk of meta- bolic syndrome or diabetes.’ Consequently, with regard to stroke the Mannheim-Heidelberg Stroke Study arrives at very similar conclusions in a large-scale interna- tional study, which in 2005 showed the risk of myocardial infarction to be associated with abdominal adiposi- tas. ‘Adipositas – both in children and in adults – will become one of the major health issues,’ Dr Back prophe- sised. ‘The number of people in industrialised countries that develop a metabolic syndrome is increasing steadily. We should therefore expect the number of patients with a highly unfavourable vascular risk profile to skyrocket over the coming decades. We urgently require additional stud- ies that not only explore the associa- tion between abdominal girth and increased stroke risk but that also look at how the treatment of adiposi- tas, particularly abdominal weight loss, decreases the risk of stroke and myocardial infarction.’

EUROPEAN HOSPITAL Vol 17 Issue 4/08 21 Больничный Менеджмент Поликлиники в Автор статьи Марк Николлс

реформа дестабилизирует Великобритании? работу как в больницах, так и во врачебных практиках. внедрить эту систему в рамках будут вытеснены и лишатся При существующем положении службы здравоохранения практики. вещей больницы получают Лондона. Теперь, однако, он Представитель Департамента оплату за лечение каждого хочет организовать отдельную здравоохранения заявила, пациента. Если поликлиники систему из 150 медицинских однако: «Мы не навязываем будут лечить более простые центров под руководством поликлиники в качестве какой-то случаи, это оттянет часть врачей общей практики по всей сверхструктуры, призванной доходов больничного треста, что Англии. Поликлиники, по его заменить существующие вызывает озабоченность. замыслу, – это своего рода службы. 150 медицинских Доктор Чаанд Нагпол, врач Лорд Дарзи врачебные практики, но высшего центров будут дополнять общей практики из Лондона, Д-р Чаанд Нагпол уровня, предлагающие существующие врачебные уполномоченный по ведению планами продлить часы приема обширный спектр медицинских практики, предоставят переговоров от Комитета врачей во врачебных практиках в В Англии взаимоотношения услуг. В состав лечебного пациентам дополнительные общей практики Британской вечернее время, а также между врачами общей практики персонала должен входить возможности для того, чтобы медицинской ассоциации, принимать пациентов в и больницами в настоящее большой коллектив врачей попасть к врачу. отметил, что проблема выходные дни. время претерпевают период широкого профиля, а также Службы анализа и разработки имеющихся планов по созданию В докладе Дарзи содержатся некоторой нестабильности. Это стоматологи, медсестры, концепций Медицинского фонда поликлиник, а также также, в числе других, положение связано с акушерки, терапевты и короля высказали опасение, что медицинских центров под следующие предложения: пересмотром состояния дел в больничные врачи. Такие центры реформа может повлечь за руководством врачей общего
чтобы больницы публиковали здравоохранении по стране в могут осуществлять собой отрицательные профиля заключается в статистику летальных исходов целом, при том, что одной из диагностические и рентгеновские последствия, если врачи общей отсутствии определенности по по результатам лечения поставленных задач является обследования, анализы крови. практики, а также другой количественным данным. Неясно различных заболеваний; укрепление контактов и тесное Министры в правительстве медицинский персонал также в деталях, как центры
чтобы пациенты преклонного взаимодействие именно между утверждают, что подобные сконцентрируются, в итоге, все в будут функционировать. Он возраста и пациенты в этими двумя медицинскими центры улучшат медицинское одном здании. Пациентам, в прибавил : «Неясно и то, как терминальной стадии сферами. обслуживание, так как предложат особенности в сельской врачи общей практики и заболевания в случае Данная проблема более широкий спектр услуг и местности, станет трудно больничные врачи будут предполагаемого смертельного рассматривалась в отчете о будут открыты с 8 утра до 8 попасть на прием к своему взаимодействовать в их рамках исхода имели возможность состоянии дел в вечера. По их словам, в семейному врачу. и как это партнерство будет выбора и могли выписаться из здравоохранении Англии, поликлиниках можно будет Консультанты Национальной оформлено с финансовой точки больницы.; представленном Министром быстро попасть на прием; службы здравоохранения также зрения. Нам нужна более
чтобы было расширено поле здравоохранения, лордом Дарзи. сократится также время на сомневаются в достоинствах подробная информация, только деятельности для частных Предложенные в его докладе ожидание диагностических поликлиник. В результате тогда мы сможем сформировать медицинских фирм, меры затрагивают широкий круг обследований, которые сейчас опросов, проведенных свое мнение.» предоставляющих первичные вопросов, вместе с тем возможно провести лишь в Британской медицинской Вышеизложенное услуги. наибольшее внимание больницах. ассоциацией, получено 1587 предложение является одним из Он заявил, что обновленный привлекло предложение о Представители врачей, а также ответов. При этом 60% последних по времени устав Национальной службы создании медицинских центров пациенты высказывают опрошенных не согласны, или появления в целом ряду здравоохранения под руководством врачей общей опасения, что поликлиники крайне не согласны с тем, что вопросов, приведших к Великобритании будет практики, или «поликлиник» – уничтожат человеческие реформа приведет к улучшению конфликтной ситуации между предусматривать тщательное под этим названием они стали отношения, которые ныне медицинского обслуживания; врачами общей практики и соблюдение известны. существуют между пациентами и 42% не уверены в том, что она правительственными службами. конфиденциальности, контроль Лорд Дарзи, являющийся их семейным врачом, а также, облегчит доступ пациентов на Не так давно Британская медицинских карт пациентов, практикующим хирургом, что определенное количество прием и лечение; более 70% медицинская ассоциация обеспечение альтернативного первоначально предложил ныне практикующих врачей опрошенных считают, что выразила несогласие в связи с мнения. Кризисный менеджмент в

больницах. больницы имеют устаревшие планы действий в критических Двери отделения неотложной Норман Хекер, руководитель ситуациях, не отвечающие помощи больницы широко проекта неотложной современным условиям и распахиваются. Вокруг медицинской помощи в требованиям. Очаги опасности, воцаряется хаос. Куда ни Немецком институте медицины также как и структура в разных кинешь взгляд – всюду мечутся катастроф, хорошо больницах различны, поэтому врачи и больничный персонал, разбирается в катастрофах, необходимо провести и очень много пострадавших. пандемиях, массовых индивидуальный анализ На атомной электростанции несчастных случаях. Он рисков, с тем,чтобы произошел взрыв. Рабочие консультирует и обучает разработать эффективную тяжело ранены, многие кричат больничный персонал систему кризисного от боли, многие потеряли поведению в «сценарии менеджмента». сознание. Спасатели cуетливо худшего варианта»; ведь на «Нам достаточно хорошо толкают тележки по длинным ошибках, подобных описанным известно, что больницы как в коридорам. Доставлено уже 50 выше, тоже можно учиться. Германии, так и в других жертв несчастного случая, Хекер знает «Планировать, или странах испытывают которым нужно оказать не планировать, обучаться, или финансовый прессинг. Одно медицинскую помощь. Но кому не обучаться – разница может это уже подтверждает в первую очередь и где? «Я здесь быть такой же, как необходимость думаю, что и реактор на разница между жизнью и индивидуального подхода для необходимо организовать штаб Руководители лечебного атомной станции тоже смертью. Важно регулярно каждого лечебного учреждения по преодолению кризисной учреждения могут и будут, в поврежден!» – это кто-то из тренироваться, отрабатывая с тем, чтобы не поставить под ситуации, который возьмет на случае необеспечения ими санитаров старается различные сценарии, тогда при угрозу его эффективную работу себя координацию работы предварительного перекричать общий шум. «Вы реальной чрезвычайной и гарантировать первоклассное отдельных служб. Необходимо планирования, нести что, с ума сошли?! – кричит ситуации каждое действие уже обслуживание больных также и также разработать надежную уголовную, или персональную другой. – Ведь рабочие могли будет отточено». Часто хорошо в нормальных условиях. В схему передачи информации. материальную ответственность. сильно облучиться, мы не обученный персонал, а также каждом лечебном учреждении Особенно важно заранее Лечебные учреждения, как с можем их просто так оптимированные планы необходимо по меньшей мере распределить, кто за что точки зрения медицинской перемещать по больнице!». Но действий в чрезвычайных ежегодно проводить должен отвечать, объясняет этики, так и с точки зрения уже поздно. Внезапно, так же ситуациях предотвращают их тренировочное обучение по Норман Хокер: «Необходимо закона обязаны обеспечивать, быстро, как некоторое время эскалацию. Для этого больницы действиям в чрезвычайных определить, кто и как должен вне зависимости от назад начался хаос, должны регулярно критически ситауциях». руководить клиникой в ограниченности их ресурсов, воцаряется тишина, и все пересматривать свою Эффективный кризисный кризисной ситуации. Штаб наилучшее медицинское думают одно и то же: «Как концепцию безопасности на менеджмент – это три «К» – берет на себя стратегическое обеспечение для пациентов хорошо, что это только учебная соответствие реальным командование, коммуникация, руководство и координирует даже в случае чрезвычайной тревога!» требованиям. «Многие координация. Это означает, что ситуацию на месте. ситуации».

22 EUROPEAN HOSPITAL Vol 17 Issue 4/08 Менеджмент / Лаборатория & фармакология / Ультразвук / Кардиология

Ультразвук Кардиология

Эмбриональная Цель ‘euHeart ’– О лечении гипертонии в мире хирургия – персонализация диагностики ультразвуковая и лечения диагностика и кардиоваскулярных операции в заболеваний. микроформате Компания Royal Philips Electronics возглавит проект «Евро - Очень немногие врачи решаютсся сердце» (‘euHeart’). Это новый исследовательский проект, проводить операции на финансируемый Евросоюзом. Его целью является совершенствование диагностики, терапевтического эмбриональном уровне. В Д-р Томаш Здроевски, Д-р Фиона Тернбул, Д-р Якуб Кассим Сейдат, Германии расположен один из планирования и лечения сердечно-сосудистых заболеваний. Гданьский медицинский Сиднейский Университет Квазулу- центров, занимающий ведущие Проект «Евро-сердце» выделяет в качестве основной цели университет, Польша университет, Наталь, Дурбан, позиции в этой области: исследований диагностику и лечение сердечных Австралия Южноафриканская Республика Немецкий центр эмбриональной заболеваний, таких как: сердечная недостаточность, В различных странах хирургии и малоинвазивной ишемическая болезнь сердца, аритмии, врожденные пороки возможности организации лечения повышенного кровяного хирургии (DZFT) при сердца. Он дополняет тем самым заявленный недавно давления тоже очень различны, но, в целом, можно сказать, Университетской клинике в Бонне. Операции, проводимые в проект «Сердечный Цикл» (HeartCycle), также что большинство больных с этим диагнозом не получают этом Центре, сопровождаются возглавляемый данной фирмой. Проект «Сердечный Цикл» адекватного медицинского контроля. В отсутствии лечения эти значительно меньшим концентрирует усилия на организации долговременного болезни могут стать причиной возникновения сердечно- количеством осложнений, по лечения пациентов с хроническими заболеваниями сердца. сосудистых заболеваний, инфаркта миокарда, инсульта. По сравнению с операциями, Созданный недавно консорциум ‘euHeart’ставит целью данным Всемирной организации здравоохранения, гипертония осуществляемыми улучшить диагностику, терапевтическое планирование и составляет 4,5% от всех болезней, отягчающих человечество, традиционными методами, а, лечение сердечно-сосудистых заболеваний путем создания причем она распространена как во многих странах третьего кроме того, уменьшается нагрузка компьютерных моделей нормального, а также мира, так и в развитых странах. на плод и на беременную обусловленного болезнью функционирования сердца и В нашем специальном выпуске ESC (стр.2) три эксперта, женщину. В центре проведено аорты индивидуально для каждого пациента. представляющие три континента, рассказывают о гипертонии более 200 эмбриональных Более подробную информацию об этом научном проекте Вы как факторе риска, а также об организации лечения этого операций на неродившемся плоде с применением новых можете прочитать на 1 стр. нашего издания (ESC-Special). заболевания в своих странах. малоинвазивных методик, при этом удалось предотвратить смерть, или инвалидность у Обмороки - диагностика и Лаборатория & фармакология младенцев. терапия лаборатории на чипе. Прогресс в достижениях OptoLabCard В результате вышеуказанных эмбриональной хирургии во При определении этиологии синкопальных состояний Испанские исследователи разработок через три года многом зависит от развития имеет место проблема, какой объём диагностических мер разрабатывают новую ожидается появление и систем получения графического необходим в действительности, и от каких методов лабораторию на чипе, которая коммерческого образца. изображения, а также от обследования можно отказаться. В целях большей позволит осуществлять тесты за Приборы, умещающиеся в руке, разработки необходимых оперативности необходимо, по мнению экспертов, 20-30 минут. Исследователи, при смогут определять наличие операционных инструментов. Как концентрироваться на выяснении вопроса – носит ли финансировании Европейского бактерий в продуктах, а также оказалось, одной из важнейших Союза, разработали оптическую диагностировать самые методик в руках специалистов причина возникновения данных синкопальных состояний кардиогенный характер. Ответ на этот вопрос можно диагностическую лабораторную различные заболевания – рак, является ультразвуковая гепатит, СПИД, грипп за 20-30 получить относительно легко. карточку. Их система позволяет диагностика. подготавливать образцы и минут. С их помощью можно (См. страницы: 16) Более подробную информацию о диагностике и терапии производить ДНК-тесты на будет воспроизводить синкопе Вы можете прочитать на 10 стр. нашего издания бактериях при помощи лабораторные реакции в любом Менеджмент (ESC-Special). портативной, простой в месте и в любое время. применении, экономичной (См. страницы: 9) Внебольничный и больничный MRSA Метициллин-резистентный Staphylococcus aureus (золоти- стый стафилококк) стал предста- Мартини-Клиник влять большую проблему в области осуществления Центр рака простаты в Гамбурге, Германия инфекционного контроля, так как наблюдается распространение С созданием Мартини-Клиник на территории Клиники Помимо выдающихся медицинских результатов на данного штамма во многих Университета Гамбур-Еппендорф (УКЕ), Германия, скорейшее выздоровление оказывает влияние особая странах. В результате того, что появилась современная частная клиника рака простаты. атмосфера Мартини-Клиника. Поэтому мы предлагаем сроки пребывания в больницах Только в 2007 году в Мартини-Клинике и клинике УКЕ комфорт, отвечающий самым высоким требованиям сокращаются, и лечение произ- врачами было проведено 1350 операций по удалению рака пациентов из различных стран мира. Наши пациенты из водится в специализированных простаты. Тем самым Мартини-Клиник относится к трем Германии и из других стран мира ценят вид отеля клиникa, амбулаториях, заражение большим центрам по вопросам диагностики, лечения и который сделает восстановительный период максимально стафилококком происходит в исследования рака предстательной железы в мире. приятным. лечебных учреждениях, но затем Martini-Klinik am UKE GmbH С помощью команды врачей и санитарных работников во инфекция распространяется во Martinistraße 52 | D - 20246 Hamburg | Germany главе с профессором Хартвигом Гуландом международно внебольничных условиях, Тел.: +49 (0) 40 42 803 1690 (сотрудница, владеющая русским языком) (внебольничный стафилококк). признанные в области лечения рака предстательной Эл. почта: [email protected] | www.martini-klinik.de Хотя внебольничный железы эксперты индивидуально заботятся о каждом стафилококк в Европе пока не пациенте. www.uke-io.de подлежит обязательной регист- рации, рекомендуется проводить бактериологическую пробу при лечении бессимптомных инфекционных заболеваний кожи и мягких тканей в пунктах неотложной помощи и в амбулаторных врачебных практиках. (См. страницы: 2)

EUROPEAN HOSPITAL Vol 17 Issue 4/08 23 Урология Метод будущего – соноэластография Проведение щадящих нервы операций простатэктомии является специализацией частной клиники Мартини, расположенной на территории Университетской клиники Эппендорф (UKE) в Гамбурге. Эта клиника по праву занимает одно из первых мест в мире по количеству проведенных операций. В области диагностики специалисты на Эльбе также занимают лидирующие позиции; они, одни из немногих в Европе, используют в настоящее время соноэластографию в качестве дополнительного инструмента для более точной и надёжной идентификации карциномы простаты. Конечно, это делается для того, чтобы повысить шансы пациента на выздоровление. В беседе с EUROPEAN HOSPITAL (EH) главный врач и руководитель отделения диагностики клиники Мартини д-р Георг Саломон (ГС) рассказывает о накопленном опыте в применении данного метода. EH: Д-р Саломон, Вы для того, чтобы удержать позитивном показателе 87% и соответствующие учебные Во-первых, тем, что данный используете метод уровень «золотого стандарта». В при предварительном пособия. Сначала необходимо метод долгое время не находил соноэластографии в заключение мы сравниваем негативном показателе 59%. Это научиться распознавать интереса со стороны диагностике более полугода, полученные результаты, а также говорит о том, что указанный графическое изображение производителей медицинской что Вы можете рассказать, сопоставляем их с информацией метод значительно лучше по уплотнённого ареала ткани. Это техники. Много лет назад были исходя из опыта Вашей из нашего банка данных, сравнению с обычным означает, что врач, проводящий сделаны многообещающие работы? накопленных в результате ультразвуковым обследованием. обследование, должен разработки, которые затем, ГС: Мы используем в проведённых методом Диагностическую эффективность осуществлять очень точные однако, не были реализованы. В настоящее време метод соноэластографии данного метода мы сможем движения ультразвуковой настоящее время, насколько мне соноэластографии у пациентов, обследований. адекватно оценить после того, головкой, чтобы получить известно, единственную систему имеющих сочетание признаков EH: Можно ли уже говорить как у нас будет накоплено растянутое графическое на рынке, дающую необходимый высокого риска по возможному на основании полученных больше данных, которые мы изображение. Следующим шагом диагностический эффект на наличию карциномы простаты. Вами данных о надёжности сможем соответствующим является оценка графического практике, производит фирма Это означает, что у данных этого метода ? образом проанализировать. изображения на основании его Хитачи. Мы констатируем, тем пациентов проведен ГС: Группа наших пациентов с Чтобы метод повторяемости. В заключение не менее, что сейчас в данном первоначальный анализ негативным анализом биопсии соноэластографии утвердился в проводится сравнение сегменте рынка началось биопсии, который показал составляет примерно сто качестве диагностического полученной эластограммы с движение и другие фирмы стали отсутствие опухоли, но выявил человек, поэтому мы должны инструмента по выявлению результатами обычного проявлять усиленный интерес к высокие показатели PSA. У провести оценку полученных карциномы простаты, он должен ультразвукового обследования. соноэластографии. Это, в пациентов этой группы мы данных, чтобы сделать иметь такую же надёжность, как Если эластограмма показывает общем, однозначно говорит в её используем метод обоснованный вывод о уже существующие лучшие уплотнение ткани, то обычное пользу. Параллельно с этим соноэластографии в дополнение надежности этого метода. Мы методики. На сегодняшний день обследование ультразвуком проявляется тенденция со к обычному обследованию можем, тем не менее, уже я рассматриваю измерение может дать ответ о характере стороны медиков по ультразвуком, чтобы на основе сейчас заключить на основании плотности ткани как чисто этого уплотнения, например, не использованию произведённых измерений проведенных обследований, что сопутствующую методику, является ли это уплотнение соноэластографии в качестве эластичности тканей выявить применение метода предоставляющую в наше известковым отложением. В дополнительного обследования, возможные выделяющиеся соноэластографии имеет распоряжение дополнительную настоящее время критерии а это, в свою очередь, приводит ареалы, которые не были положительный диагностический информацию. оценки эластограммы ещё не к тому, что мы получим больший определены при проведении эффект. Мы сравнили данные EH: Эта информация стандартизированы, но уже объём данных, который позволит биопсии. Исходя из нашей соноэластографического должна быть ещё имеются предложения о том, что нам развивать и улучшать практики, это даёт хорошие обследования пациентов с соответственно такое стандартизирование может данный метод. результаты. После определения карциномой простаты перед интерпретирована. А какие из себя представлять. В общем и целом, я полагаю, границ такого ареала мы можем проведением операции с требования метод EH: Несмотря на что в будущем провести дополнительный данными обследований после соноэластографии позитивные результаты соноэластография будет целевой анализ биопсии в целях операции. Соотношение предъявляет к врачу ? этого метода, он хорошей дополнительной повышения точности диагноза. В позитивных и негативных ГС: Как и в других областях, относительно мало возможностью для улучшения подтверждение этого метода мы результатов составило около для освоения метода распространён в Европе. Чем диагностики карциномы проводим 10-кратную биопсию, 76%, при предварительном соноэластографии имеются это объясняется ? простаты. Как мы используем ультразвуковую диагностику – недостаточно, или слишком часто? Автор – Др. Сонке Х. Бартлинг Визуализация с помощью ультразвуковой диагностики является очень эффективным методом, но, как правило, слишком мало используется. Данный метод имеет много привлекательных сторон. Он относится к числу преклинической медицине. окончательной диагностики сканирования, которые потом неинвазивных, и притом в Новейшие разработки датчиков методом исключения. читают врачи-радиологи. действительности соответствует уменьшеных в размерах дают В целях компенсации снижения Вне зависимости от различного этому определению. Подобно возможность получать окупаемости ультразвуковых применения ультразвука на магнитно-резонансной трехмерные, или даже исследований врачи стали местах, в целом можно сделать визуализации, ультразвуковая четырехмерные реконструкции. увеличивать их применение, и, вывод, что потенциал визуализация безвредна для Широкую известность получила зачастую, сверх меры. Это само по ультразвуковой визуализации не пациента. В последнее время эта реконструкция «лица плода», при себе также привело к снижению используется в полной мере. Лица, технология претерпела значи- этом будущие матери имеют окупаемости. Следует учитывать, определяющие политику в сфере тельные усовершенствования. возможность увидеть лицо что качественное ультразвуковое здравоохранения, а также Улучшилась разрешающая младенца в 3-х измерениях. Ультразвуковое обследование обследование требует времени. производители медицинской способность, появились новые По мнению многих, однако, нормальной почки – анализ Таким образом, можно техники обладают достаточными функциональные возможности, ультразвуковая визуализация интраваскулярного кровотока констатировать, что хорошее возможностями для того, чтобы методом допплеровского цветного изобретены новые концепции используется недостаточно, или, картирования – ультразвук может ультразвуковое обследование уже изменить это положение дел. использования контрастов. наоборот, слишком часто. Это давать комбинированную не очень хорошо окупается. Первые – принимая на себя Ультразвуковая диагностика очевидное противоречие можно информацию о структуре и Во многих странах ультразвук решение вопросов окупаемости, а неизменно находится на вооруже- объяснить тем, что данная функциях. используют врачи различного также обеспечивая хорошую нии у врачей на протяжении вот методика визуализации в очень профиля – радиологи, врачи узкой квалификацию персонала, уже нескольких десятилетий. Часто значительной степени зависит от зарегистрировать то, что не было специализации и врачи общей осуществляющего ультразвуковые она может быть применима взамен квалификации специалиста, увидено. Следовательно, нельзя практики. В США проблема обследования. более дорогостоящих, или в который осуществляет обследова- сделать ретроспекцию обследова- окупаемости ультразвуковых Производители, в свою очередь, большей степени инвазивных, т.е. ние. Датчики дают возможность ния, если доктор во время обследований была решены по- – делая новые разработки менее «травмирующих» методик. К заглянуть внутрь тела человека, но обследования что-то не увидит, его другому: система сканирования зависимыми в использовании от настоящему времени разработаны только туда, куда смотрит прибор, трудно в этом обвинить. высоко стандартизирована, уровня квалификации небольшие и гибкие в применении поэтому ультразвуковое Вследствие вышеизложенного, сканирование осуществляют обслуживающих их людей, приборы для ультразвуковой обследование не дает возможно- ультразвуковое обследование техники – радиологи, они разрабатывая новые виды визуализации, их можно сти обстоятельно задокументиров- используется, в основном, для подготавливают стандартизи- датчиков и обеспечивая хорошую использовать в амбулаториях, в ать результаты, то есть нельзя скрининга, но не для рованные протоколы сопроводительную документацию.

24 EUROPEAN HOSPITAL Vol 17 Issue 4/08 стволовые клетки ПЭТ/КТ: Предельно точная диагностика рака ЕН: Почему этот метод настолько важен изображении ПЭТ как светящиеся точки. для диагностики опухолевых заболеваний? Таким образом, клетки опухоли четко Ришке: ПЭТ/КТ - один из самых отграничиваются от здоровых клеток высокоинформативных методов в онкологии: органа. Даже миллиметровые обследование дает предельно точные данные о опухолевые узлы отчетливо видны при величине опухолевых образований и помогает обследовании. Однако локализировать распознать возможный рецидив намного раньше опухолевые образования с помощью ПЭТ обычных методов диагностики. Особым часто оказывается сложно, так как преимуществом является точная локализация отображенные им структуры и ткани нужного фрагмента органа перед операцией или порой не совсем четки. На для биопсии. Метод становится все более важным комбинированном снимке ПЭТ и при планировании облучения опухоли, а также показывает опухолевые структуры с для наблюдения за изменениями опухоли после повышенной биологической активностью, лучевой или химиотерапии, позволяя сделать а КТ локализирует их на своего рода крайне важные выводы в отношении успеха трехмерной анатомической карте стратегии лечения. человеческого тела. Более подробную информацию Вы ЕН: Как проводится обследование с сможете найти на сайте ПЭТ/КТ центра ПЭТ/КТ? www.sanafontis.com Ришке: ПЭТ отображает процессы обмена веществ в клетках организма: пациенты получают молекулу фруктозы низкой степени радиоактивности (FDG), которая накапливается в клетках организма как обычная фруктоза. Ра- Доктор Кристиан Ришке, преимуществах позитронно- ковые клетки делятся интенсивнее и чаще, чем заведующaя центром эмиссионной томографии (ПЭТ) здоровые, т.е. нуждаются в существенно большем диагностической радиологии и в комбинации с компьютерной количестве энергии. Их усиленный обмен веществ нуклеарной медицины города томографией (КТ) для ведет к более высокому накоплению FDG - группы Фрайбурга, рассказывает о онкологических пациентов. высокоактивных раковых клеток появляются на Yслуги в аутсорсинг - что на очереди? В системе предоставления медицинских услуг клиническими лабораториями наблюдается тихая революция. Согласно теории бизнеса, услуги лабораторий являются затратными местами, а затратные места можно перемещать, передавать другим исполнителям, объединять, переводить на контракт. В глобальном масштабе виде. Теперь же мы имеем рамках этой глобальной сети, только один аутсорсинг лабораторных дело с индустрией с годовым процент от указанного количества на принципах анализов и диагностики оборотом в 50 миллиардов аутсорсинга, здесь имеется тенденция к росту. происходит по модели, уже долларов, 50% которого Аутсорсинг клинических исследований идет испытанной в области приходится на 5 основных активнее; привлекают более низкие затраты, информатики. лабораторных сетей. Данная легче доступ к субъектам исследований. Только Две категории медицинских организационная модель в Индии насчитывается 30 глобальных услуг перемещаются за репродуцируется по всему компаний по клиническим исследованиям, границу: миру, сети объединенных действующих на основе аутсорсинга. Др.
диагностика и пробы на крупных лабораторий, Умаканта Сахоо, исполнительный директор патологию; предоставляющих услуги на одной из таких компаний, «Чилтерн
клинические испытания и контрактной основе, Интернэшенэл», предполагает, что объем рынка клинические исследования. организованы в Европе и имеют к 2010 году достигнет в этой области 1-1,5 Аутсорсинг собственно хорошие позиции. Очередная милллиардов долларов. Основное число биоматериала может тенденция в этой области – заказов поступает из Европы (70-80%), осуществляться по трем транснациональный аутсорсинг. остальные заказы идут из США – почти 20%. направлениям. Во-первых Национальные службы Новые проблемы являются следствием новых биоматериалы можно посылать здравоохранения, так же как и тенденций в практике оказания лабораторных прямо на анализ. отдельные больницы начали услуг, в том числе: соблюдение права пациента Во-вторых, их можно осваивать его преимущества, на конфиденциальность, барьеры в виде отсылать специалистам их привлекают расценки, всвякого рода регламентаций. фотомикрографии анализов которые зачастую значительно Не прекращаются также дебаты о качестве для рассмотрения и получения ниже, чем у местных анализов, о минимизации ошибок при передаче результата. Разница между лабораторий. Использование результатов. Эти проблемы в лабораторном часовыми поясами является услуг телепатологии медицинском обслуживании на протяжении при этом преимуществом: значительно расширяется не многих лет вызывали озабоченность. Теперь результаты можно подготовить только в Европе и США, но и и же, когда данная сфера стала в течение ночи, и утром, в в странах западной Азии, транснациональным бизнесом, дебаты по начале рабочего дня, они уже Бангладеш, Шри-Ланке, существующим в ней проблемам вышли за будут у заказчика. Непале, а также в странах рамки одельных медицинских учреждений и В-третьих, аутсорсинг Африки. Лидером рынка по организаций и форсировали национальные испытания на людях, предоставлению границы. Можно предвидеть, что только лишь (аналогично клиническим диагностических услуг является низкие цены не смогут служить решающим испытаниям); услуги Индия, но и страны Ближнего фактором в данном сегменте индустрии лабораторий, соответственно, Востока, а также юго-восточной медицинского сервиса, первостепенное будут осуществляются на такой Азии, в т.ч., Таиланд, значение будет иметь качество. же основе. Индонезия и Вьетнам Общественность еще мало информирована о Это, действительно, очень оказывают такие услуги в своих практикующемся аутсорсинге лабораторных крупный бизнес. Двадцать лет клинических лабораториях. медицинских услуг. По мере дальнейшего назад в США вышеупомянутая Более 10 миллионов развития вышеуказанной тенденции пациенты сфера медицинских услуг медицинских анализов и другие заинтересованные группы тоже существовала в разобщенном осуществляется ежегодно в выскажут свою точку зрения.

EUROPEAN HOSPITAL Vol 17 Issue 4/08 25 WEIGHING MACHINES NEW chair scale into place from behind from 200 kilograms with a gradua- a patient.’ Each footrest can also tion of 100 grams. The operating A scales to have faith in be adjusted separately, allowing and display element has easy-to- The seca 959, a chair scale, has been designed by seca gmbh one foot at a time to be placed on read 20 mm high LCD figures. The & co. kg, Hamburg, Germany, with input from experts, to the supports after the patient is ‘hold’ function keeps the mea- accommodate patients with mobility or other problems. seated. sured weight on display after the It is not only easy for patients and nurses to use, but, In addition, the swivel armrests patient has left the scale. The as the firm explains, ‘… practically eliminates can be moved aside when a patient caregiver can attend to the body contact, which patients of Islamic faith in is being transferred from a bed or patient first and then note the particular find unpleasant and try to avoid.’ wheelchair on to the chair scale. weight. The adjustable footrests are unique: Nurses who tend patients with The model also provides a body they can be turned to the side or tucked hemiplegia (paralysis on one side mass index (BMI) function. The completely under the chair seat, giving a of the body) and hemiparesis (par- patient’s height is entered, weight patient plenty of foot room and a sure tial paralysis of one side of the determined and, at the touch of a foothold when taking a seat. ‘The body) appreciate this labour-saving button, the BMI is calculated. adjustable footrests also eliminate function, seca explains. Though small and lightweight, the danger of the caregiver’s The seca 959 (Class III calibrat- the battery operated scale is banging a patient’s Achilles ten- ed) weighs patients up to 150 kilo- robust and also highly manoeu- don or ankle when wheeling the grams in 50-gram increments and vrable even in tight spaces. ProDoc incorporates digital height rods Detecto’s new ProDoc Professional Doctor Scale series incorporates time-saving digital weight, height, and body mass index (BMI) measurements. The ProDoc series are heavy- duty scales that can weigh up to 220 kg while providing the accuracy needed with 0.1 kg increments. The LCD display provides easy-to-view 25 mm readouts. All ProDoc scales feature adjustable locking feet and a bubble level for weighing on any surface. They also include selectable Sleep Mode (up to 9 minutes) and selectable Auto Shutoff (up to nine minutes) plus Memory Function which stores and recalls up to four patient/family member weights, Detecto reports. The firm’s comfort-height 122-cm-high model PD300DHR features digital weight and height measurement for accurate calculation of BMI. Detecto also adds that the time- saving digital height rod displays patient height quickly on the weight display. ‘Simply step on the scale and touch one key to see your weight and another key to automatically calculate BMI.’ The scales also have integral wheels for easy transportation. Detecto points out that it offers a complete line of ProDoc scales, so multiple configurations are available. ‘The ProDoc’s feature medical-grade accuracy and are versatile enough to be used in exam rooms or physician offices for medical use, or in homes or fitness centres for healthcare measurements.’ The Cardinal Detecto range will be on show at MEDICA 2009 in Dusseldorf, Germany, this November. Hall 12 – B34

26 EUROPEAN HOSPITAL Vol 17 Issue 4/08 E VENTS EUROPEAN HOSPITAL

EUROPEAN HOSPITAL Publisher, For half a century, day after day, Theodor-Althoff-Str. 39, 45133 Essen, Germany Phone: +49 (0)201 87 126 850 Dräger’s Vapor has saved lives. Yet Fax: +49 (0)201 87 126 864 no patient knows this. Only the e-mail: [email protected] anaesthetist and surgical team can be fully aware of its value in keeping www.european-hospital.com their patients unconscious and pain free during surgery, Dräger reports proudly, in the 50th year of Vapor’s Editor-in-Chief Brenda Marsh service. Art Director Mary Pargeter Delivering anaesthetics could never be exact until the mid-20th Executive Directors Daniela Zimmermann, Reiner Hoffmann

International Media/ Editor Gabriela Eriksen/ Denise Hennig

Dräger celebrates half a century of Vapor care Managing Editor Meike Lerner century, when new technologies and ways, according to clinical remains in Vapor, the vaporizer’s 300 Medical Writer Edda Grabar alternative liquid anaesthetics indication, but each needs its own ml tank accommodates standard 250 arrived, stimulating demand for a Vapor. This means that the ml refills, thus virtually eliminating Editorial Assistant Karoline Laarmann

new and precise dosing technique. vaporizer must be moved, in a wastage,’ explains Dräger. Production & In 1958 Dräger produced Vapor, a sealed state, between hospital Special Applications Distribution: Janka Hoppe calibrated dosing device that could departments. To make this easier, When a patient needs to be sedated Russian Supplement Sergey Bezrukov, be attached to the anaesthesia Dräger integrated a patented for an MRI scan, Vapor can be used Fibrotex GmbH, equipment that supplies fresh gas. transport setting, a hand wheel, in conjunction with a Fabius Fischerstr. 1 40477 Düsseldorf Vapor adds the anaesthesia dose magnetic resonance tomography Tel: +49 211 550 49 70, and concentration as defined and temperature compensation, the (MRT) anaesthesia unit. Vapor is e-mail: [email protected] set by the anaesthetist to the fresh manufacturer points out. Other interoperable with 1.5 tesla and 3-T gas. Although the dosing (bypass) features include a bypass MRT systems. Founded by Heinz-Jürgen Witzke mechanism used by the Vapor has mechanism that is adjusted down to The Vapor output remains stable Correspondents changed very little, the device’s micrometer level, and the dosage within physician-defined anaesthesia Austria: Christian Pruszinsky. Baltic: Andrius Vagoras. technology is continuously area is free of aluminium, which dosage at temperatures ranging from Czech Republic: Rostislav Kuklik. France: Jane McDougall, Keith Halson. Germany: Anja Behringer, optimised, the firm points out. may react with the anaesthetic. 10 to 40°C. This is particularly Annette Bus, Karl Eberius, Guido Gebhardt, Heidi Materials Transportable and standard bottle important for bone surgery, where Heinhold. Great Britain: Brenda Marsh, Ian Mason. Impressively, Vapor never needs refills the operating theatre temperature of Poland: Pjotr Szoblik. Russia: Olga Ostrovskaya. Spain: Eduardo de la Sota. Switzerland: Dr André Weissen. recalibration. Special stainless steel Today’s five main types of liquid and this hermetically seals the 15°C is maintained, or for surgery on USA: Karen M Dente, Kerry Heacox, i.t. Communications, and brass alloys in the device anaesthetics – sevoflurane, vaporizer (prior to this, the device burn victims, for which theatre Ivan Oransky, Craig Webb. ensure a long service life, resistance desflurane, enflurane, halothane and had to be emptied each time). temperature must be raised, Dräger UK editorial address to alteration, and pressure and isoflurane – are used in various ‘Even if only a minute of aesthetic points out. 55 Wey Meadows,Weybridge, Surrey KT13 8XY

Subscriptions 7th National Congress on Janka Hoppe, European Hospital, 20–22 Theodor-Althoff-Str. 39, 45133 Essen, Germany Laboratory Medicine Subscription rate October French to the 6 issues: 42 Euro, single copy: 7 Euro. Send order and 3rd National Symposium on 2008 cheque to: European Hospital Subscription Dept Immunopathology Finishing media technique jöhri, fore in HIV tests Weilerswist, Germany Mexico – During the XVII pand the availability of this simple Bucharest, Printed by VVA GmbH, 3rd National Congress of International AIDS Conference held test ‘…to bring viral load monitoring Düsseldorf, Germany Clinical Laboratory Assistants Romania in Mexico City this August, keynote to patients in remote areas’. speakers from Europe, Latin bioMérieux began its work on HIV Publication frequency bi-monthly testing at the very beginning of the The 7th Romanian Society of Laboratory Medicine Congress 2008, America and Africa addressed European Hospital ISSN 0942-9085 held under the auspices IFCC, EFCC, BCLF, WASPaLM and the issues including the importance of AIDS epidemic 25 years ago, patronage of the Romanian Academy of Medical Sciences, will early detection of HIV infection, the developing one of the first screening relevance of rapid testing for tests in 1985. The firm has since Representatives highlight the most relevant issues in the diagnostic strategies, total Germany, South Europe, AUS, BR management of quality and other advances in the clinical laboratory. epidemiology studies, the use of produced a stream of innovative Andreas Conze, Dried Blood Spots for routine viral- tests and technologies to respond to Head Office, Tel: +49 201 87 126 950, The scientific programme will include a focus on the relevance of testing load testing in remote areas, and the new and changing needs in HIV e-mail: [email protected] clinical outcomes as well as standardisation. ‘Romanian standardisation experience of South Africa in routine testing, and reports that it now China & Hongkong efforts have begun for the pre-analytical aspects of clinical laboratory,’ say high-volume viral-load testing. provides the widest product ranges Gavin Hua, Professor Gheorghe Benga, RSLM President, and Dr Manole Cojocaru, ‘One of the latest advances in available to laboratories (with the Sun China Media Co., Ltd, Room 802, 15th Building, BinJiang Residential Quarter, Congress President, who expect about 500 delegates ‘from every corner of viral-load monitoring and our most exception of the US market) for Dongyuan Road, Futian District, Shenzhen, the world’ will attend this year’s event. recent developments is the Dry diagnosing and monitoring HIV Guangdong, China, Code: 518031 infection. This range covers third Tel: +86-0755-81 324 036 The 3rd Symposium on Immunopathology, held in conjunction with Blood Spot,’ explained the French e-mail: [email protected] Congress, will address teaching – particularly clinical aspects. firm bioMérieux, which organised and fourth generation screening The RSLM Congress will include the 3rd Congress of Clinical Laboratory the integrated symposium ‘Viral tests in various formats (automated GB, Scandinavia, BeNeLux, France Diagnosis is key in the fight against immuno-analysers, microplates for Simon Kramer, Assistants, which aims to share knowledge of advanced technology, standard Willem Alexander Plantsoen 25, 2991 NA Barendrecht operating procedures and educational material. Aids’ at the conference. high volumes, and rapid manual Tel:/Fax +31 180 6200 20 Currently used for research tests), as well as molecular tests for e-mail: [email protected] Details: www.srmlcongres.ro E-mail contact: [email protected] purposes, the company plans to ex- real-time viral-load monitoring. Israel Hannah Wizer, Company Page Products International Media, 28 Dep. of El-Ron Adv. & PR Co., Ltd., 7, Leteris street, The 20th WorldLab Aloka ESC 4 Ultrasound systems Tel-Aviv 64166, Israel September – Bayer Diabetes Care 11 Diabetes Tel: +972-3-6 955 367 email: [email protected] IFCC International Congress 2 October Biotronik ESC 11 Cardiology equipment Cardinal Detecto 5 Medical scales Japan Tetsuzo Asoshina, Echo Japan Corporation, of Clinical Chemistry and CMEF 21 Medical fair Grande Maison Room 303 Cordis ESC 9 Vascular disease management 2-2 Kudan Kita, 1 Chome Chiyoda-Ku Laboratory Medicine Fortaleza, Brazil Tokyo 102, Japan Dräger 13 Medical equipment Tel: + 81 3 3263 5065 ‘In the next 10–20 years, great changes will occur in the field of lab- ECR Cover Flap European Congress of Radiology e-mail: [email protected] oratory medicine. We will go from personalised tests, to predictive GE 9 Diagnostic imaging South Korea tests, to a personal (individualised) sensitive database, to great use of Hitachi 17 Diagnostic imaging CH Park, computer systems, to virtual laboratories, and to the need to focus Landwind 8 Diagnostic imaging Far East Marketing Inc, Room 103-1011, Brown Stone, 1330, Baekseok-dong, Ilsan-ku, ethical attention on respecting the integrity and greatness of the Mara 15 Management & radiology congress Goyang-si, Gyunggi-do, Korea 410-360 human being, just to mention some of the issues,’ said Paolo MCC Hospital World 1 Hospital fair and congress Tel: +82 2 730 1234 e-mail: [email protected] Mocarelli, Chairman of the IFCC International Scientific Committee. MEDICA 28 Medical trade fair We have worked while bearing most of these problems in mind, and Medtronic ESC 5 Medical technology Taiwan we hope that this congress will help in the long walk expected of Ben Chen, youth as well as the less youthful. Sanafontis 25 Cancer hospital Jurassic Communications Corp., Schiller ESC 3 Cardiology equipment 10th Floor-4, No 235, Chang Chuen Road, Taipei 10479, Taiwan R.O.C., Taking place at the same time will be the SBAC Shenzhen Well.d Medical Congress, for which Prof Ulisses Tuma and the Tel: +886 2 2503 8028 Electronics 1 Ultrasound systems e-mail: [email protected] Brazilian societies members have prepared an ‘inter- Siemens 3 & ESC 7 Diagnostic imaging national-level congress’, Paolo Mocarelli pointed out, St. Jude Medical ESC 12 Cardiology equipment USA & Canada adding that the to acknowledge the efforts of young Hanna Politis, UK Specialist Hospitals 26 Specialist hospital Media International, 8508 Plum scientists ‘to whom the future belongs’, every session University Medical Centre Creek Drive, Gaitherburg, MD 20882, USA has ‘two selected speakers’ (born after 1/1/1973). Tel: +1 301 8696 610 Hamburg-Eppendorf 23 University clinic email: [email protected] Congress languages: English, Portuguese and Spanish. INDEX ADVERTISERS

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