P06 IGRT FREQUENCY P07 TRANSATLANTIC WORK P07 NANOPARTICLES IN MRI Its effect on geometric Collaboration on new UK Paramagnetic nanoparticles accuracy and set-up margins proton therapy installation may enhance MRI contrast SCOPE INSTITUTE OF PHYSICS AND ENGINEERING IN MEDICINE | www.ipem.ac.uk | Volume 20 Issue 4 | DECEMBER 2011

Open-loop lung simulator For ventilation of preterm infants Radium storage during WWII The recovery of radium after bomb explosions

EMPEC 2011 Meeting reports from Dublin  **%()

DOSIMETRY SOLUTIONS   *( & $*%#

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"## $%& '   )")'%).%.+!  ---.'%).%.+! PRESIDENT’S LETTER | SCOPE

IN THE SPOTLIGHT

he New Year is a time costs is only too real for many. For when we traditionally others the perception is that we are look back on the past poorly engaged with the need to take and resolve to do services closer to the patient. The things differently in demand for our skills will expand in the future. At the primary and social care settings with Toutset of my term of office as the planned NHS reforms President, I must record my thanks to but are we fully engaged in those that have completed their terms Peter Jarritt this commissioning agenda? of office and hand on an organisation President The economic spotlight which is well placed to face the will shine brightly for the spotlight being shone upon us. next 2–3 years, demanding It is also an opportune time to that we seek to deliver an welcome the first cohort of the overall reduction in our Modernising Scientific Careers’ costs to the health service. scientist trainees in medical physics We also stand firmly in the and engineering. As you celebrate spotlight of the NHS reform your success in securing a place on agenda. The Department of these training programmes and the Health initiative to change the training opportunity this will bring to apply and education structures across the your scientific skills in the delivery of whole of healthcare science was almost quality healthcare, those who will immediately challenged by other assume that the new healthcare science teach, train and mentor you through political decisions such as the increase educational programmes will develop the programme have the in university tuition fees which has the practitioner grades as required in the responsibility and privilege to nurture potential to completely destabilise the workplace. The IPEM must take your talents and endeavour to ensure training and education of our ownership of this issue on behalf of the that you surpass the achievements of practitioner workforce. profession. I strongly believe we have your predecessors. a continuing role in the training and I am acutely aware that healthcare SHINING BRIGHTLY education of our workforce. science has never before been so What can IPEM reflect in this Thirdly, we must continue to centrally placed in the spotlight. In spotlight? There are a number of key support and develop our publication the broader arena the life sciences and priorities for the Institute to address activities through our journals and the associated pathology services are over the next few years. Primarily we scientific report series. Publications in the midst of a radical must grow as a community of people must be timely and evidence based. transformation programme driven by with common interests, engaging with These activities have a worldwide the successes of scientific and colleagues from many professions and audience and we should not lose sight engineering advances to automate forming a voice which speaks with of this aspect of our activities as a complex diagnostic biochemical tests. authority on the effective delivery and professional body and a charity. The transformation is further fuelled optimisation of healthcare services. We Lastly, we have a unique by the ability of technology to deliver must innovate and fully engage with opportunity over the next 2 years to much more ‘point of care’ testing and our academic and industrial colleagues truly promote the impact of physics modify the configuration of the to bring new technologies and and engineering in medicine through delivery of healthcare. The applications to enhance service the delivery of the International physiological sciences are being delivery. We must understand the new Conference on Medical Physics from challenged to enhance their role in the NHS structures and how to effectively 1st–4th September 2013 in Brighton. delivery of patient-facing services and engage with national and local This will be a celebration of the 50th to explore moving the focus from the healthcare commissioning groups to anniversary of the foundation of the acute sector to primary care. This ensure that innovations are evaluated International Organization for Medical element of the spotlight is challenging and, where proven effective, adopted. Physics. This backdrop will allow us to the artificial boundaries between We must be able to share our keep our profession positively and physics and engineering and knowledge and understanding rapidly constructively in the spotlight. physiological measurement to ensure we can all benefit from our I hope this is an agenda we can all potentially impacting upon members corporate understanding. embrace. It will only be through our in their current and future roles. The Secondly, we must re-organise our own actions and determination that physical sciences are perhaps training and education infrastructure these opportunities can be grasped. perceived as vital to the delivery of and expertise. We must recognise our With a spirit of ‘ringing out the old safe patient services, yet expensive. need to engage with experts to help us and ringing in the new’ I wish you all The pressure from Trust management develop and deliver the highest quality a happy Christmas season and a to re-profile our workforce and lower training programmes. We must not rewarding and fulfilling New Year.

SCOPE | DECEMBER 2011 | 03 SCOPE | CONTENTS

THIS ISSUE

28 COVER FEATURE EMPEC 2011 Two meeting reports from the European Medical Physics and Engineering Conference in Dublin

08 A STUDY IN PROCRASTINATION Continuing the CEng theme, the story of how accreditation was finally achieved, after 18 years!

11 MUSINGS OF A CEng REGISTRANT WORKING OUTSIDE THE NHS A second story of how CEng accreditation was gained, from an author not working within the NHS

13 LUNG SIMULATOR: OPEN-LOOP CONTROLLED ACTIVE LUNG SIMULATOR A piston-based neonatal lung simulator is described, along with an open- 08 loop control system, designed for use in preterm infants

21 SAFE STORAGE: RADIUM CLINICAL NEEDLES AND TUBES DURING WWII We uncover the story of the loss and subsequent discovery of radium in storage following a bomb explosion during World War II

24 CLINICAL SCIENTIST STEERING GROUP SET UP FOR ADVICE TO NPL A steering group of nine clinical scientists has been established to give advice and guidance to the Radiation Dosimetry group at NPL TRAVEL AWARD 13 25 IPEM USA TRAVEL AWARD: A TRAINEE’S PERSPECTIVE Naomi Crossland MEETING REPORTS 32 ITERATIVE RECONSTRUCTION IN NUCLEAR MEDICINE Helen Blundell 34 STEREOTACTIC RADIOTHERAPY: NEW EQUIPMENT, NOVEL TECHNIQUES Imran Patel 36 PARTNER COURSE: CLINICAL TRIALS ON SPECIFIC INDICATION Stacey McGowan 40 LIVERPOOL SHORT COURSE ON MEDICAL STATISTICS Hamid Reza Zolfagharinia 21 HISTORICAL FEATURE 50 A HISTORY OF MEDICAL PHYSICS Francis Duck REGULARS 03 PRESIDENT’S LETTER In the spotlight 05 EDITORIAL The Keith Boddy prize 06 NEWS Headlines in global research 42 MEMBERS’ NEWS New members admitted to IPEM 44 BOOK REVIEWS Nine books are reviewed! 25

04 | DECEMBER 2011 | SCOPE COMMENT | SCOPE Scope is the quarterly INTERNATIONAL EDITOR magazine of the Institute of (North America) Physics and Engineering in Richard A. Amos Medicine Department of Radiation IPEM Fairmount House, Physics, The University of 230 Tadcaster Road, Texas M.D. Anderson Cancer York, YO24 1ES Center, 1840 Old Spanish T 01904 610821 Trail,Houston, F 01904 612279 Texas 77054, U.S.A. THE KEITH BODDY PRIZE E [email protected] T + 1 713 563 6894 W www.ipem.ac.uk F + 1 713 563 1521 cope has a new prize, named in W www.scopeonline.co.uk E richamos@mdanderson. org honour of the late Keith Boddy, EDITOR-IN-CHIEF Marc E. Miquel INTERNATIONAL EDITOR former HPA President. The prize Clinical Physics, Ryan D. Lewis will be awarded every year to the 4th Floor Dominion House, Department of Medical St Bartholomew’s Hospital, Physics and Clinical best educational article (review, London EC1A 7BE Engineering, Abertawe Bro T +44 (0)203 4655 785 Morgannwg University, tutorial, feature) and presented at F +44 (0)207 377 7100 NHS Trust, Singleton E [email protected] Hospital, Swansea, the dinner of the annual Medical Wales, SA2 8QA Physics and Engineering Conference. Well, apart ASSISTANT EDITOR T +44(0)179 220 5666 S Gemma Whitelaw extension 6438 from this year as it took us a bit longer than Radiotherapy Physics, E ryan.lewis@swansea- Basement, New KGV tr.wales.nhs.uk expected to finalise all the details. Despite this Building, St Bartholomew's Hospital, West Smithfield, ONLINE EDITOR hiccup, it is a pleasure to announce that our first London, EC1A 7BE Dr Damian JJ Farnell E gemma.whitelaw@barts Division of Mathematics and worthy winner is Dr Jenny Freeman. Over the andthelondon.nhs.uk Statistics, Faculty of years, Jenny has provided us with an excellent and Advanced Technology, MEETING REPORTS University of Glamorgan, extremely well received series of statistics tutorials, EDITOR Pontypridd CF37 1DL If you want to Angela Cotton T +44 (0)1443 484510 a subject that often scares a lot of readers away. If Head of Non-Ionising E [email protected] emulate Jenny and Radiation Support, Medical you want to emulate Jenny and become the next Physics & Bioengineering, Published on behalf of become the next winner just get typing and send us your articles. Southampton General the Institute of Physics Hospital, Southampton, and Engineering in “winner just get This year MPEC was held in Dublin, as part of SO16 3DR Medicine by E angela.cotton@suht. CENTURY ONE typing and send us the European Medical Physics and Engineering swest.nhs.uk PUBLISHING LTD. Alban Row, 27–31 Verulam your articles Conference, and we have some extended reports in NEWS EDITORS Road, St Albans, Usman I. Lula Herts, AL3 4DG the meeting sections. Department of T 01727 893 894 Along with the MPEC articles you will find a Radiotherapy, Poole F 01727 893 895 Hospital, Longfleet Road, E enquiries@centuryone selection of meeting and course reports. Poole, BH15 2JB publishing.ltd.uk E [email protected] W www.centuryone In the features, you will find two articles of the Richard A. Amos publishing.ltd.uk ” CEng series where Bruce Carey-Smith and Department of Radiation Physics, The University of CHIEF EXECUTIVE Nicholas Abraham recount their tribulations to Texas M.D. Anderson Nick Simpson Cancer Center, 1840 Old T 01727 893 894 reach the coveted professional qualification. The Spanish Trail,Houston, E nick@centuryone Texas 77054, U.S.A. publishing.ltd.uk issue also includes a detailed feature on a lung T + 1 713 563 6894 F + 1 713 563 1521 ADVERTISING SALES simulator for preterm infants and an introduction E richamos@mdanderson. David Murray to the NPL Radiation Dosimetry steering group. org T 01727 739 182 E d.murray@centuryone Finally, David Murnaghan dug in our archives and BOOK REVIEW EDITORS publishing.ltd.uk Marium Naeem introduces an article that originally featured in the Department of Radiotherapy SUB EDITOR Physics, St Thomas' Karen Mclaren HPA Bulletin 40th anniversary issue. Hospital, London, SE1 7EH E karen@centuryone Elsewhere you will find your regular news items E marium.naeem@ publishing.ltd.uk gstt.nhs.uk and a bonanza of book reviews. This is Marium’s Usman I. Lula DESIGN & PRODUCTION Department of Heena Gudka last issue as Book Review Editor – thanks for all Radiotherapy, Poole E studio@centuryone Hospital, Longfleet Road, publishing.ltd.uk the hard work – and Usman will now man the Poole, BH15 2JB E [email protected] PRINTED BY Ubidesk book review fort on his own. Century One Publishing Ltd As it is becoming customary, we are closing the ENGINEERING & ACADEMIC EDITOR Scope is published quarterly magazine with the new instalment of Francis Dr Constantinos Zervides by the Institute of Physics Intercollege Larnaca and Engineering in Medicine Duck’s medical physics history saga. In part IV, we 6019 Larnaca, Cyprus but the views expressed are E c.zervides@intercollege- not necessarily the official are crossing the Channel and looking at the lives larnaca.com views of the Institute. and works of Thomas Young and the Arnott T 00357-24-747500/559 Authors instructions and F 00357-24-652213 copyright agreement can be brothers, Neil and James. found on the IPEM website. MEMBERS’ NEWS EDITOR Articles should be sent to the Hope you enjoy this issue. Matt Gwilliam appropriate member of the Cancer Research UK editorial team. By submitting Clinical MR Research to Scope, you agree to Group, Institute of Cancer transfer copyright to IPEM. P.s. If you would like us to write about an Research and Royal We reserve the right to edit interesting paper published recently in your area Marsden NHS Foundation your article. Proofs are not Trust, Sutton, SM2 5PT sent to contributors. The of medical physics and engineering – that is E [email protected] integrity of advertising material cannot be practical, is easy to implement in the clinic (or INTERNATIONAL EDITOR guaranteed. (Developing countries) elsewhere) and has clinical significance - then we Andrew Gammie Copyright would really like to hear from you! Readers are Clinical Engineer, Reproduction in whole or Bristol Urological Institute, part by any means without requested to contact the News Editors. BS10 5NB written permission of the T +44(0)117 950 5050 publisher is strictly extension 2448 or 5184 forbidden. © IPEM 2011 E [email protected] ISSN 0964-9565 MARC E. MIQUEL EDITOR-IN-CHIEF

SCOPE | DECEMBER 2011 | 05 SCOPE | NEWS BY USMAN I. LULA AND RICHARD AMOS

The effect of IGRT frequency on geometric accuracy and set-up margins

(when rotations did not exceed ±5°), TABLE 1 with a further verification scan. Residual set-up errors of three Mean (M), systematic (∑) and anatomical axes and four random (σ) residual set-up error ‘simulated’ (less than daily) IG M-L (mm) C-C (mm) A-P (mm) protocols were compared to an ‘assumed’ gold standard, the daily M ∑ σ M ∑ σ M ∑ σ IG (table 1). Set-up errors were then No IG –0.20 1.5 2.9 0.10 2.2 3.7 0.34 1.6 2.5 used to calculate population-based First 5-days IG –0.21 2.0 2.9 1.29 2.6 3.7 0.16 1.8 2.5 set-up margins (using the Van Herk Weekly IG –0.20 1.3 2.7 0.07 1.7 3.5 0.24 1.4 2.4 margin recipe, table 2). Bland- Alternate IG –0.23 1.0 2.4 0.09 1.3 3.1 0.23 1.2 2.1 Altman plots and t-tests were Daily IG –0.29 0.9 1.7 0.03 0.7 2.0 0.09 1.0 1.7 employed in the study. This study showed that four ‘less TABLE 1. Mean (M), systematic (∑) and random (σ) residual set-up errors for five imaging protocols. than daily’ hypothetical IG protocols incurred residual setup errors of TABLE 2 ≥5mm in 20–43 per cent of fractions compared to only 6 per cent of Population-based set-up margins fractions in the daily IG protocol. M-L (mm) C-C (mm) A-P (mm) Generally, with increasing No IG 6 mm 8 mm 6 mm frequency, reductions in systematic First 5-days IG 7 mm 9 mm 6 mm error (∑) were noted, with only daily Weekly IG 5 mm 7 mm 5 mm IG showing reduction in random Alternate IG 4 mm 5 mm 5 mm errors (σ). Moreover, the derived Daily IG 3 mm 3 mm 4 mm margins were 5–9 mm for ‘less than daily’ IG and 3–4 mm for daily IG. It TABLE 2. Population-based set-up margins using the Van Herk margin recipe (2.5∑ + 0.7σ). was also found that the use of the Abbreviations: M-L = medio-lateral; C-C = cranial-caudal; A-P = anterior-posterior; IG = image-guidance. first 5-day IG was suboptimal for Both tables kindly supplied by Jane Higgins, Radiation Medicine Program, Princess Margaret Hospital, lung patients (clearly shown on the Toronto, Canada, M5G 2M9. Tables © Elsevier, Int J Radiat Oncol 2011; 80(5): 1330–37. Bland-Altman plots with the mean Globally, lung cancer continues to misalignment (on-set, online) and total, 100 consecutive ‘radical’ lung set-up error being statistically be the leading cause of cancer- thus ensure accurate and precise cancer patients (4,237 daily kV- significant), due to the inability to related deaths. Chemoradiotherapy RT delivery to the intended clinical CBCT scans analysed) were planned reduce the random error and the is the standard of care for patients at target. kV-CBCT provides excellent using either conformal or intensity potential increase in the systematic an advanced stage of the disease. bone and good soft tissue contrast modulated RT. Patients were error from fraction 6 and onwards. With a 5-year survival rate of around and the associated software is immobilised on a chest board (both In conclusion, daily IG as 30 per cent, further improvements capable of providing rapid arms above the head) and employed in this study was highly in high dose radiotherapy (RT) registration of images (reference underwent a free breathing 4D CT effective at reducing geometric set- treatment are necessary. 3D/4D CT scan and the kV-CBCT scan. The PTV was drawn around up error, allowing potential margin Large planning target volume scan). One crucial parameter to the tumour volumes as per ICRU reduction and, consequently, a (PTV) margins are used during the consider during imaging is the Report 62 and local protocol. The reduction in normal tissue toxicity RT planning stage for advanced lung imaging frequency. Researchers in exhale CT data sets were exported for patients undergoing cancer patients to minimise the risk the Lung Radiation Medicine Team and used as reference scans to conventionally fractionated lung RT. of underdosage in the clinical target at the Princess Margaret Hospital compare against CBCT scans. Centres should consider several volume – this may occur during (Toronto, Canada) have highlighted Patients were set up using lateral aspects prior adjusting margins treatment due to frequent that very limited publications exist and anterior tattoos and CBCT including (but not limited to): alignment inaccuracies. The on the optimal kV-CBCT imaging scanned. A two-step registration dosimetric and *geometric downside of using large margins is frequency in relation to locally process was used in software: outcome (*calculation of site that it limits the dose ceiling and advanced lung cancer. automatic spine matching (using specific margins related to their dose sparing of critical structures, The aim of this study was to the bone match algorithm) and then own IGRT patient images).” i.e. limiting gains in the therapeutic assess ‘the relative effectiveness of visual inspection of the visible ratio. Image guidance RT (IGRT) five IG frequencies on reducing tumour and carina. Corrections MORE INFORMATION This work was recently published in the using kV-CBCT is one solution to patient position inaccuracies and were applied using either assisted Red Journal: Int J Radiat Oncol 2011; this dilemma – it can be used to set-up margins for locally or remote couch shifts, with a 80(5): 1330–37. http://www.redjournal.org/article/S03 identify and correct patient advanced lung cancer patients’. In correction threshold of ≥3 mm 60-3016(10)00510-9/abstract

06 | DECEMBER 2011 | SCOPE NEWS BY USMAN I. LULA AND RICHARD AMOS | SCOPE

Transatlantic work on UK IN BRIEF proton therapy installation WHITE PAPER ON SAFE IMRT The American Society for Texas-based ProTom International, Radiation Oncology Inc. has entered into an (ASTRO) has developed a arrangement with UK-based white paper on the safe Advanced Proton Solutions use of intensity- Holdings Ltd (APS) to provide its modulated radiation Radiance 330™ proton therapy therapy and its integration into the radiation oncology system for a new APS facility to be clinic. It is the first in a built in London. series for ASTRO's Target The City of London has granted Safely initiative. planning permission for the new purpose-built facility to be BRAIN IMPLANT developed in Moorgate. The SEIZURE TEST development will be on four levels Researchers have below ground, together with developed a method for ground and seven upper-level modulating individual floors. The four basement levels neurons in rats. They coated multielectrode will house ProTom’s proton therapy arrays with a drug-loaded beam equipment, and the upper polymer which was floors will include ancillary uses Compact ring of the ProTom synchrotron. electrically stimulated, such as treatment and examination causing neurochemicals rooms, offices and a waiting area compared to conventional kV x-ray populated urban areas such as to dissociate and diffuse for patients. based computed tomography (CT), London. The first Radiance 330™ to the necessary locations. ProTom’s Radiance 330™ and the accuracy of proton range system has recently been installed Results showed that the drugs retained their consists of a synchrotron which can calculations in treatment plans at the McLaren Proton Therapy activity and function with accelerate protons up to 250 MeV, generated on pCT datasets is Center (MPTC) on the campus of spatial and temporal as is typical for therapy improved compared to those the McLaren Regional Medical precision. applications, and beyond up to 330 generated on CT datasets as Center and the Great Lakes Cancer MeV for proton computed proton radiography is a direct Institute in Michigan, and 'SWINE FLU' tomography (pCT) techniques. The measure of stopping power. commissioning is underway. BREATH TEST potential for performing pCT is The design of the synchrotron, ProTom has also entered into an A breath test to measure exciting, and unique to the gantry and delivery nozzle are all exclusive arrangement with New the immune response to Radiance 330™ system. Soft tissue compact, making the system ideal Jersey-based company Atlantic the H1N1 flu virus could delineation is superior with pCT for installation in densely Health System. help ease future vaccine shortages by identifying people who have already been infected with the virus. The test measures Nanoparticles enhance MRI contrast biomolecules that accumulate in response to Ultra-small gadolinium oxide (US- performance of nanoparticles in relaxivity decreased slightly at 0.47 the H1N1 strain. Gd O ) nanoparticles are being MRI cell tracking studies. They and 1.41 T, good for clinical MRI, but 2 3 FUNCTIONAL developed and tested as positive measured the efficiency of Gd2O3 it was enhanced at higher fields (7 contrast agents for molecular and suspensions for MRI applications and 11.7 T) upon agglomeration, ULTRASOUND cellular MRI. These particles can (longitudinal and transverse thereby affecting the positive Functional imaging label and track cells in vivo. relaxivities). Data acquired at contrast enhancement effect. modalities identify brain activity by measuring Positive contrast agents enhance magnetic field strengths typical of Given that agglomeration can changes in blood flow. the signal, resulting in a local hospital scanners (0.5–3 T) were occur once particles are ingested, Researchers have a better ‘brightening’ in MRI scans. These compared with those from higher this is significant to clearly establish alternative: functional agents could represent an attractive field strengths (7–11.7 T), as found in the magnetic field strengths at ultrasound, an tool for examining cell diffusion MRI systems mainly used in pre- which US-Gd2O3 particles might be ultrasensitive imaging processes. However, once clinical research. preferentially used as positive technique that can internalised into cells, nanoparticles At every magnetic field, the contrast agents for MRI. visualise whole-brain microvasculature tend to agglomerate in cell longitudinal relaxivity decreased MORE INFORMATION dynamics with high endosomes. Researchers have upon agglomeration, whilst This story was reported on NanoTech spatiotemporal resolution. determined how much aggregation remaining high enough to provide Web on 29th September: http://nanotechweb.org/cws/article/ takes place, and how this affects the positive contrast. The transverse lab/47359

SCOPE | DECEMBER 2011 | 07 A STUDY IN PROCRASTINATION (DON’T TRY THIS AT HOME)

Nicholas Abraham y name is Nicholas much of a good time’. At that age, that , IEng, CEng* and I have no first was a win-win for me, and I did have a (Imperial College Healthcare Trust, degree. very good time indeed. Shame about London) is proud of being That’s Nicholas, the degree though. But I simply wasn’t CEng to you. mature enough at that age to hack it. addressed this way, but it took a Nicholas, IEng So I started work, doing metals MCEng actually. research. Fabulous. I was operating long time to get there And my story? serious machinery that would keep In 1970, as a boy of 18, I scraped Jeremy Clarkson quiet. A foundry in a into London University to do a residential road right close to Euston physics degree. The following Station. Can you imagine it? It’s not summer I scraped right out again. I there any more. I also started an HNC remember the course tutor saying at in Applied Physics, which was less the time that the only people who abstract and had lots of electronics and failed were the people who had ‘too technology in it.

08 | DECEMBER 2011 | SCOPE FEATURE | SCOPE

lines of: ‘Geeky new machines need I set up and ran the first ambulatory drivers’, and after a few refusals, I ECG clinical service at Charing Cross managed to get a job at Charing Cross Hospital. I worked out how we could Hospital. double the storage capacity of the C- On my first day at work, my new 120 audio cassette tapes that we were boss, Dr Green (it was nearly 15 years using at the time. I tried ‘turning the before I was allowed to call him Harry tape over’, and came to realise that – those were the days!), enrolled me in only side two was recording. another HNC, one that was even Eventually I worked out that the better than the first. Physiological boffins at the CRC had configured the Measurements. I was a Physiological channels to record on the edge tracks Measurements Technician. How cool (1 and 4). So naturally, reversing the was that! tape simply over-recorded the data in a different direction. FURTHERING MY CAREER The simple expedient of using Another 2 years of bliss, as a tracks 1 and 3, as in conventional supernumerary, rotating through cassette recorders, meant that all four outpatient clinics, operating theatres, tracks on the tape could be used, and intensive care units, dialysis units and did not overwrite each other when the cardiology departments, to name a cassette was turned over. This also few, working alongside doctors and meant fewer cassettes for the patient to nurses, sharing their experience of worry about, although it must be said everyday clinical practice. It was a that this knowledge was gained at the life-changing learning experience for expense of several patients having to me, and gave me a deep-seated return to the lab to have their knowledge of what medical life is like, recordings repeated. as well as how fundamentally the So, June 1975 sees me with two everyday practice of so much of HNCs, running a three-person clinical medicine depends on engineering. measurements service. By that time, I Dismantling kit for running repairs had had major exams every summer in the middle of open heart surgery for the previous 7 years. So I had 2 was all in a day’s work. How that years off from studying. honed my faultfinding skills! The toolbox was almost as big as the GOING BACK TO STUDYING monitoring system. You had to know But I wanted a degree. A lot of my everything from what chamber of the colleagues had one. My wife had one heart you were in, through to the (in metallurgy) and an MSc in voltage output levels needed to Biomedical Engineering (my marriage display traces on monitor screens. rows (sic) prevent me from Sublime, even if not terribly well paid, commenting further). Doing a BSc on the job was scary and thrilling in the back of an HNC is a long 4-year equal measure. part-time haul. I’d been studying and I began to learn what worked on taking exams since I was 16, I had 2 the wards and in the theatre. The HNCs, and I just couldn’t face 4 more conventional engineering approach years to get not a lot further forward. was often not intuitive for nurses, and It was then that I spotted a part- I soon developed insight and expertise time MSc in Instrumentation Applied in understanding the ‘whole chain’ to Medicine & Biology. Would they concept of clinical engineering. If what take me? Er, no they wouldn’t, thank you supplied for surgeons or nurses to you very much for your interest all the

The metals research company was ▼ Waiting for use had instructions that were even same and we wish you well in the moving out of London, and I wanted the grass to slightly ambiguous or unclear, you future. What bit of ‘graduate entry’ did to stay. So, knowing what I liked, I grow. could be sure of a poor uptake of you not understand? said goodbye to metallurgy and went whatever technology you were trying I persisted anyhow and got an looking for another career working to introduce. interview. They graciously allowed me with machinery, but within a more Harry Green worked half time for to take a ‘postgraduate’ 1-year part- evenly gender-balanced workforce. Professor Heinz Wolff, in the time Diploma in Electronics and (That bit worked out for me!) Bioengineering Division of the Computer Technology. If I passed that, At that time, 1973, science and Clinical Research Centre, which was so their logic went, then I must de facto technology were at their entry level in then at Northwick Park Hospital in be of graduate level. Although I’d many areas of medicine. NHS Harrow. He would regularly bring probably fail. Well, I didn’t. Even after hospitals enjoyed Crown Immunity, bench prototypes of new devices from passing though, the college still made regulation was light and litigation was the CRC to Charing Cross, and I me beg some testimonials from doctors rare. There were also adverts for would adapt them to be usable on the I’d worked with, to further legitimise

technical staff most weeks, along the ward, or even by patients at home. my ‘graduate’ aspiration. ▼

SCOPE | DECEMBER 2011 | 09 SCOPE | FEATURE

▼ Then the real work started; 2 years Instead, I shelved it for a while, and through with it. I will always be part-time doing the MSc. It was hard, I am we know how ‘a while’ can easily grateful for their support. but pleasingly evocative of the become 6 years. But by then, things The end of the story is a bit messy. Physiological Measurements HNC, in proud. It’s move on, the rules change a bit and The professional review interview was the number of hours we spent in amazing the trail slowly went stone cold. no cakewalk for me. A couple of small groups, being tutored by top “what you procedural mishaps wrong-footed me clinicians and scientists. We did a can GETTING THERE IN THE END at the start, and my fear was not so great deal of radiation physics and So, 6 years later in 1998, I thought I’d much that of failing, but of having to nuclear medicine, none of which I achieve in better have another go. Being smart, or endure the utter ignominy of letting ever used in anger, but every bit of it 18 years if more like smart ***ed, I thought that a down those colleagues who had still stands me in good stead when I you put turn on IPEM’s Engineering Group encouraged me over the years. have to interact with specialists in Board would be just the thing to bring Being an IPEM Engineering those subjects. your mind myself back up to speed, see how the Advisory Group insider, I expected a So, MSc in 1980. I applied for and to it other CEng applicants do it, slip in my phone call from a chum to follow quite got IEng in 1982 via the Institute of own application and job’s done. soon after the interview. Thanks to the Electrical and Electronics Technician The EGB needed a registrar to consummate professionalism (more, I Engineers, which I had joined back in update the procedures for IEng suspect, the bloody-mindedness!) of 1976 as a Technician Associate. registration. As I was the only IEng on my chums, it never came though, and I Nowadays you’d describe this as ” the board, and easily flattered, I was had an uncomfortable couple of weeks ‘entry level.’ Er, entry? put to work. It was a lot of work, but I wondering if something had gone By then, I was a Chief did enjoy it. I had the perverse wrong. Physiological Measurements pleasure of coaching IEng registrants, But it all came right in the end. A Technician! How much higher could a interviewing them, recommending nice letter from IPEM and my day of person go? them for registration and seeing their fame in the Daily Telegraph on a page Well here comes the plug, or names in the Daily Telegraph. All of headed ‘The Engineering Elite’. I am product placement as the BBC is now which occupied my time on the EGB proud. It’s amazing what you can obliged to warn us. In 1992, I applied admirably well, but what about me? achieve in 18 years if you put your to join the Biological Engineering My cunning plan had flopped. mind to it. Society (later to become IPEM) and How many times did I set aside a So, to conclude, remember that your was accepted as a Corporate Member. Friday afternoon, get all the papers society, your IPEM colleagues and the In the same year, I applied to register out, only to realise that it took the best EC all want you to get on. Don’t rule as a CEng via the BES. Unfortunately, part of an afternoon to even get back yourself out just because you haven’t compu-ah said ‘no’. I was very to where I had left off. As the years followed the standard academic route. disappointed. So much so that I didn’t went by, I began to wonder if I would And finally – don’t put it off! really read the Engineering Council’s ever actually get the application out of My name is Nicholas and I still have letter that had kindly been leaked to the door. no first degree. me. I should have. It was over 15 Ultimately it was the sustained and Please be inspired to aspire. n years later that I read the letter non-judgemental support of my carefully. They were actually being professional colleagues in IPEM that *When the now-treasured certificate very helpful, and encouraging me to created embarrassment in me, which finally arrived, that was exactly how it was addressed to me by the Engineering resubmit. My loss. Make it your soon grew into a feeling that I’d be Council. Well they should know, lesson. letting them down if I didn’t go shouldn’t they?

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10 | DECEMBER 2011 | SCOPE FEATURE | SCOPE

Musings of a CEng registrant working outside the NHS Bruce Carey-Smith (Bath Institute of Mechanical Engineering) ▼ The author their work would comfortably fit with examples of within this description. However, for the SomnIA engineers working within healthcare, prototypes. although pure scientific research can be a component, our fundamental role is applying scientific knowledge to engineering problems. Our professional contribution is to creatively apply that knowledge with proper regard for ‘intended function, economics of operation and safety to life and property’.

MY APPLICATION I submitted my application for CEng to IPEM after working for 3 years with the Bath Institute of Medical Engineering (BIME). The application was a culmination of 5 years on the IPEM Clinical Scientist training scheme. My Part I training was in clinical engineering with modalities in medical equipment management, assistive technology and physiological measurement. With 7 years in the communications electronics industry and a PhD in electronics engineering, I was interested in a position which would allow me to continue in electronics design and development and a post at BIME was ideal. I continued my Part II training and was registered with the HPC in mid-2010. BIME is a small charity whose aim is to use engineering expertise to develop solutions for people with healthcare and assistive technology needs. A couple of examples of projects in which I have been involved give a flavour for the type of work BIME undertakes. The Cooker Minder y recent application clinical needs. The bottom line is that is a safety device aimed at supporting to become a the way we approach and carry out the independence of people with Chartered Engineer our work is the same. Both medical dementia. It was developed after a (CEng) through physicists and clinical engineers are need was identified amongst IPEM has given me involved in the application and community occupational therapists cause to mull over development of scientific principles and carers. By sensing potentially Mwhat distinguishes an engineer to the diagnosis, treatment and hazardous situations it isolates the working within healthcare from other prevention of disease. cooker and guides the user through types of clinical scientist. After all, the In the Engineering Council’s the process of making the kitchen safe same core competencies apply across standard for professional and reconnecting the cooker. A the board: we all strive to deal competence, engineering is described number of different prototypes have professionally and communicate as ‘using judgement and experience been successfully trialled in people’s effectively with patients, the general to solve problems when the limits of homes and a market-ready device is public and other clinical staff; we all scientific knowledge or mathematics currently being developed. work to develop safe and effective are evident’. I suspect that for many SomnIA is a Research Council-

processes and solutions to meet members of IPEM, at least some of funded, multidisciplinary ▼

SCOPE | DECEMBER 2011 | 11 SCOPE | FEATURE

▼ collaborative project investigating the working directly with patients and there are significant benefits in potential of non-pharmacological clinical staff throughout the becoming chartered. Personally, the interventions to help improve sleep development process, and this leads main benefit for me is that it formalises quality amongst older people. to huge overlap with the kind of the many aspects of good engineering Working with older people and their work carried out by clinical scientists practice that I have learnt over the carers in residential homes, a number within the NHS. For this reason, both years, drawing them together within of factors were identified that affect membership of IPEM and HPC the competencies and holding me to sleep and which could be addressed registration give tremendous benefits account for their maintenance under through simple technological by providing a link in to a wealth of continuing professional development. intervention. Several of these experience in medical physics and These aspects include: keeping interventions were developed and clinical engineering and by ensuring informed in areas of technical trialled with older people, including high standards of professional knowledge in order to contribute automatic lighting designed to conduct are maintained. effectively; taking a broad view of minimise night-time disturbance and solutions to ensure that benefits an easy-to-control source of soporific BENEFITS OF REGISTRATION outweigh cost and risk; taking a music. Projects like these not only lead The requirements for and benefits leadership role in project management to useful products but contribute to a from clinical scientist registration and staff development, and better understanding of user-led within BIME have parallels with communicating effectively with both design amongst people with assistive holding chartered engineer status. professionals and the general public. technology and healthcare needs. This CEng is not a career requirement But another benefit is that the process is a key aim for BIME. within the organisation. Although of becoming a chartered engineer has Being outside the NHS, registration HPC registration is often specified for led to me taking greater pride in the as a clinical scientist is not a career many clinical scientist roles, I have contribution professional engineering requirement within BIME. However, not seen many advertised where makes to healthcare. These are the organisation prides itself in CEng was a requirement. However, captured within the competencies of the profession and its code of conduct. ▼ Cooker Minder This set of competencies and the prototype. commitment to work within this code has been developed and is shared by many others who have become chartered engineers. For those working within engineering in healthcare, professional engineering status is a worthwhile step… and what’s more is relatively straightforward. I’m not the first to point it out, but one of the benefits of becoming a chartered engineer through IPEM is a natural progression from clinical scientist registration. Most of the competencies are demonstrated in the process of meeting the Health Professions Council (HPC) criteria for registration, and with the addition of appropriate management experience the CEng application is straightforward. The application requires only a short report describing the additional competencies along with references to the appropriate sections of the Part II portfolio. The professional review interview is very similar to the Part II viva voce and is relatively painless. Engineering has a significant role to play in the effective delivery of healthcare. It is not divorced from pure scientific enquiry, but rather brings together scientific understanding and patient need in the delivery of effective solutions. Professional engineering registration supports this, complementing the clinical focus of HPC registration. I’d encourage other engineers to go for it. n

12 | DECEMBER 2011 | SCOPE FEATURE | SCOPE

LUNG SIMULATOR OPEN-LOOP CONTROLLED ACTIVE LUNG SIMULATOR

Stefano Cecchini, Emiliano Schena and Sergio Silvestri (University Campus Bio-Medico, Rome Italy) describe a simulator developed for preterm infants

any preterm infants ▼ This article low birth weight of premature infants, In consideration of the require mechanical describes a since the artificial respiratory support aforementioned observations, the ventilation for piston-based may injure the lungs or exacerbate the measurement of some critical respiratory support neonatal lung pre-existing conditions. Studies ventilatory parameters provided by simulator along because of demonstrate that protracted neonatal ventilators, especially if with the open- immaturity of the loop control mechanical ventilation is significantly dedicated to preterm infants’ Mrespiratory system or pathological associated with a poor neurological ventilation, plays a major role in the system. pulmonary conditions. However, outcome1 and that pulmonary injury performance evaluation of these some risk factors are associated with may be caused by the delivery of high devices. Thus, research has been 2

mechanical ventilation because of the tidal volume. carried out for a decade, in the ▼

SCOPE | DECEMBER 2011 | 13 SCOPE | FEATURE ▼ ▼ TABLE 1. medical and biomedical engineering Typical ranges of fields, in order to analyse the design TABLE 1 tidal volume (VT) and development of devices that and functional could reliably and accurately assess residual capacity the neonatal ventilator performances, Preterm infant RDS BPD (FRC) for preterm the stability of the delivered tidal infants. volume and reproduce the breathing pattern of preterm infants. Some research prototypes, VT [ml] 6–9 3–7 4–8 described in the literature, and commercially available simulators use compliant bellows, often equipped with springs or rigid containers, to simulate the mechanical behaviour of the FRC [ml] 50–90 25–40 30–40 respiratory system, in a limited range of variation. The main shortcomings in using bellows are the limited control possibilities and, therefore, difficulty in varying the respiratory parameters with accuracy and ▼ FIGURE 1. repeatability. Currently, better (α) Cross-section alternatives to bellows-based lung of the pulmonary simulators appear to be piston-driven simulator actively controlled mechanical electromechanical analogues, or pneumatically system: (A) controlled simulators. Here the stepper motors, problem is that piston dimensions (B) and inertia may not allow fast potentiometers for position movements at low volume sensing, (C) slits ventilations, which are typical in for FRC premature infants. variations, (D) Moreover, in order to accurately spherical central reproduce the ventilated tidal chamber, (E) volume with a mechanical analogue, cylinders-pistons, gas compression and thermal effects (F) differential during ventilation must be taken into pressure account: in most cases infant transducers, (G) mechanical analogues will behave orifice flow sensor. (β) Detail somewhere between the isothermal 3 of the orifice and the adiabatic conditions. As a flowmeter. (χ) consequence, there will be an Detail of the uncertain thermal behaviour of gas, actuation module. which may lead to underestimation or overestimation of the tidal volume delivered depending on how fast the

▼ pistons are actuated. FIGURE 2. We decided to further analyse this Pistons hypothesis by means of the design displacement, s, as a function of and realisation of a novel mechanical time for five analogue for preterm respiratory different set tidal simulation whose actuation is only volumes (VT) based on the application of perfect covering the gas law and adiabatic equations. The whole simulation main idea consists of dividing every range (3–8 ml). respiratory act into short time intervals, shorter than 1 ms, in which the gas thermal transformation could reasonably be assumed to be adiabatic. All of the gas variables are then calculated by applying perfect gas law to gas conditions at the end of every time interval. Following, we describe the piston- based neonatal lung simulator along

14 | DECEMBER 2011 | SCOPE FEATURE | SCOPE

with the open-loop control system. VT), even if the maximum VT The input signals are: direction (the The electromechanical system has The achievable at the highest breathing level of this signal establishes the been designed and realised in order frequency (120 bpm) is limited to 8 direction of axis translation); clock to obtain pressure, volume and flow software ml. In fact, the motor’s highest linear signal (each pulse produces one step, waveforms similar to those of controls speed (about 18 mm/s with 7 N so that the signal frequency [Hz] preterm infants in pathological “the force) allows moving the pistons in corresponds to the piston speed conditions. order to obtain a VT of 8 ml at 120 [step/s]) and step size (half step or actuators bpm of frequency. full step of the rotor). The clock DESIGN OF THE SIMULATOR so as to Each relative position of the signal has a variable frequency, and Mechanical parameters for system obtain a pistons is measured by a this leads to different velocities to design potentiometer (LCP8P-10-5K Eti simulate different respiratory At the current state-of-the-art, volume Systems, figure 1(B)) with accuracy patterns. In order to emulate respiratory distress syndrome (RDS) waveform equal to 2 per cent of the measured inspiration and expiration phases, and bronchopulmonary dysplasia value allowing an accuracy of 8 per pistons are moved away from and (BPD) continue to remain the major cent on ventilated VT, where the towards the spherical chamber, morbidity causes in very low birth piston’s cross-section dimensional respectively, and also the I:E ratio can weight infants.4 Therefore, a variability has been supposed be modified. thorough analysis of the specific negligible. All the components are The software controls the medical literature on preterm ” disposed on a 580 × 580 cm flat plan. actuators so as to obtain a volume neonates allowed us to identify the The central chamber has a tap to waveform, which allows pressure typical ranges of respiratory allocate a pressure sensor variations in the spherical chamber parameters for these small subjects (DC020NDR5 Honeywell, accuracy and flow-rate variations across the affected by the aforementioned 0.15 per cent and range ± 5 kPa, orifice, thus simulating respiratory pathologies. By considering a figure 1(F)), which measures patterns. preterm newborn of mean birth mass pulmonary pressure, and a threaded equal to 1 kg, respiratory parameters outlet where the flow resistance is Motion equation of the pistons ranges are reported in table 1. allocated. Two nominally identical A fourth order polynomial has been As far as it concerns the breathing pressure sensors have been used to considered to perform actuator frequency, it varies in a wide range, measure the gas pressure inside the movement in order to realise piston from 50 bpm up to 100 bpm spherical chamber and the pressure displacements and speed patterns; according the severity of the lung drop across the orifice meter. this way the volume waveform disease, for unhealthy newborns5 and We have chosen to simulate the shows continuous derivatives and its the time since the birth in healthy airflow resistance by an orifice with shape is similar to physiological tidal term and preterm newborns: the internal diameter of 1.2 mm and volume pattern. The equations of respiratory rate can reach values of conical edges (45˚), see figure 1(G) motion have been implemented in 115 bpm immediately after birth and and the detail in figure 1(β). The discrete time by dividing each decrease progressively. orifice has been designed not only to respiratory act into 1,500 time simulate the airflow resistance but intervals, each one corresponding to Electromechanical system also to allow flow-rate bidirectional Δt = tn − tn−1. Figure 2 shows the description measurements. In order to find a displacement profiles for different With reference to figure 1, we breakthrough between sensitivity VT values, with a breathing designed an electromechanical and symmetry, the pressure taps frequency equal to 60 bpm and I:E system composed of four cylinders- have been placed in proximity of the ratio = 1:2. pistons (2KS444P Airport vena contracta in both flow rate Corporation, 15.5 cm2 cross-section directions. The orifice is Flow rate calculation each, figure 1(E)) perpendicularly characterised by a quadratic relation By considering the generic instant tn, connected to a central spherical between pressure drop and flow rate the control volume V(tn), contained chamber of internal volume equal to and allows simulating fluid-dynamic between the orifice and the piston 25 ml (figure 1(D)), which represents resistances comprised in the range plates, can be expressed as a function the lowest FRC value the simulator 6–13 kPa/l/s (about 60–130 of the volume at previous iteration can reproduce (table 1, column for cmH2O/l/s), for flow rates in the V(tn−1) and piston displacement in RDS-affected infants). Higher FRC range ± 4 l/min, which are in the the time interval Δt: values, up to 90 ml, are obtained by same order of magnitude as those manually translating the pistons’ measured by Hjalmarson et al. in starting positions thanks to four slits healthy and BPD-affected preterm (1) 6 (figure 1(C)). infants. The orifice, after calibration, with v(tn), Δs(tn) and S being the A stepper motor (26DBM20D2U-K has also been used as a flow sensor, piston velocity, displacement at McLennan) with a maximum travel allowing bidirectional flow instant tn, and piston section, of 13.2 mm and a step length of 0.05 measurements through differential respectively. The volume variation, mm/step actuates each piston pressure measurements across the caused by the piston movements, (figures 1(A) and 1(χ)). This allows orifice (figure 1(F)). produces a pressure variation of the regulating VT from 3 ml up to 8 ml A LabView®-based application air contained within the control with a volume resolution equal to has been developed in order to volume through an adiabatic 0.08 ml (0.4 per cent of the lowest generate the input signals for stepper transformation. This approximation

FRC and 3 per cent of the minimum motor drivers (MSE 162 McLennan). can be hypothesised if the time of ▼

SCOPE | DECEMBER 2011 | 15 SCOPE | FEATURE ▼ ▼ FIGURE 3. expansion (compression during Control interface expiration) is very short, in the order and calculated of 1 ms. Thus, the absolute gas waveforms. pressure P(tn) within the control volume can be calculated as:

(2)

where γ is the heat capacity ratio γ ≅ ( air 1.4) and P(tn−1) is the absolute gas pressure at time tn−1. Pressure differences between the external environment and the control volume generate an air flow-rate across the orifice: in particular, an inward or outward airflow will be present if the internal pressure is lower or higher than external barometric pressure, respectively. Based on incompressible flow theory, the volumetric air flow rate at time tn, Q(tn), can then be calculated by the equation:7

(3)

where Patm is the external barometric ρ pressure, the air density, A1 and A2 the pipe and the orifice cross- sections, respectively, and Cd the discharge coefficient of the orifice. We measured barometric pressure using a Fortin barometer, with a resolution of 0.1 mmHg, and external temperature using a liquid thermometer with accuracy equal to 0.5˚C. The values of these parameters must be provided to the software every time a simulation is performed. The software also calculates actual air density value. The Cd value in equation 3 has been obtained from an experimental characterisation of the orifice resistance, since it represents the ratio between the theoretical flow rate, calculated in equation 3 with Cd = 1, and the actual flow rate. The C value ▼ d FIGURE 4. obtained has been introduced into the Measured and software. simulated The amount of air mass, m , pressure n moved by the system during time waveforms interval Δt, and the whole air mass during a closed- orifice test. amount, m(tn), present in the system (between the orifice and the pistons) at time tn, are calculated by the equations: (4)

(5)

16 | DECEMBER 2011 | SCOPE FEATURE | SCOPE

Temperature calculation The simulation calculates the Since we considered the gas The patterns of piston displacement and (9) performing an adiabatic speed, the chamber pressure and A least-square parabolic transformation during the time sampling volume, and the gas temperature regression has been applied to interval Δt, the gas temperature in time of the and air flow for every time interval determine the best estimate for the the control volume at instant tn can “speed (Δt) building the waveforms for calibration curve (R = 0.988). The be calculated as: each respiratory act (figure 3). orifice, used as a bidirectional waveform flow-meter, has shown a is variable Actuation software repeatability value of better than 2 (6) depending The actuation software is structured per cent across the whole on the in order to digitally generate the calibration range. where T(tn−1) is the air temperature speed waveform calculated, as First tests have been performed in the control volume at time tn−1. imposed explained above, through the by manually closing the orifice The air mass mn, at external breathing model; it also establishes the sense (infinite air flow resistance) and temperature (T), mixes with the air and clock signals as inputs to the measuring the pressure in the mass present in the pulmonary frequency drivers of the stepper motors. In chamber during a whole push–pull simulator at the previous time step and VT particular, the software generates movement of the pistons. In figure m(tn−1) at temperature T(tn), two square wave digital signals: the 4, the acquired pressure waveform calculated according to equation 6. first one establishes the direction of corresponding to one measurement As a simplifying hypothesis, we actuation and is obtained from the set is reported as an example, consider an instantaneous mixing, sign of the speed waveform; the along with the pressure waveform and so, the gas temperature in the ” other one is the clock signal, whose obtained by the mathematical control volume, Te(tn), is calculated: frequency [Hz] is equal to the model described above. piston speed [step/s]. The sampling As can be seen from figure 4, the time of the speed waveform is adiabatic model allows making variable depending on the imposed very realistic simulations: by using (7) breathing frequency and VT. The the above-described mathematical motor driver, by receiving actuation model, a pressure waveform Pressure calculation signals, selectively activates the almost equal to the measured From previously reported motor phases. waveform can be obtained. MSE = equations, the air equilibrium 0.004 kPa2 has been calculated, as pressure Pe(tn) inside the control RESULTS AND DISCUSSION an index that quantifies the volume at time tn can be calculated Experimental tests have been similarity between the simulated by applying the perfect gas carried out in order to validate the (Psim) pressure waveform and the equation and equation 7: mathematical model and to test its measured (Pmeas) pressure ability in reproducing neonatal waveform. This preliminary breathing waveforms and main evidence also indicates that the mechanical respiratory parameters leaks, which could lead to pressure (8) without the need for a closed-loop loss, and thus to a questionable with Rg being the gas molar mass, control. reliability of the respiratory 8 Rg(air) = 286.5 J/(kg·K). Preliminary tests have been simulator, are negligible in the All the calculations (equations executed in order to experimentally realised simulator. 1–8) are performed every time assess the flow rate–pressure drop Experimental tests have also interval by using, as initial relationship of the orifice, which been carried out, at different conditions in the instant tn, the final also represents the respiratory breathing frequencies, VT and FRC states of the variable in the instant resistance. An air flow controller values: pneumatic parameter tn−1 (Pe(tn−1) and Te(tn−1)). (Bronkhorst El-Flow, range of waveforms (pressure, volume and The software allows the setting 0.01–10.00 l/min, accuracy ±0.8 per flow rate) have then been of the following parameters: cent of the set-point value) has been compared with the outputs of the respiratory frequency, I:E ratio, Vt, used to generate a constant air flow mathematical model presented in FRC and temperature. The first two rate ranging from 0.01 l/min to the previous section. For further parameters give information about 10.00 l/min, in steps of 1.00 l/min, reference, a commercial flowmeter the duration of the entire in both directions. The pressure (model 4121 TSI: accuracy 2 per respiratory act and of its two phases sensor output has been sampled at cent of measured value and range (inspiratory period, ti, and 100 samples/s by an analogue to 0–20 l/min) has been used to verify expiratory period, te): in particular, digital board and processed by a the orifice flowmeter performances they determine the time interval Labview®-based software designed also in transient conditions (see duration (Δt) and the number of specifically. Five measurement sets figure 5). time intervals for inspiration and have been acquired for static The sensor analogue outputs expiration phases. The set Vt is calibration in the 20–25˚C gas have been acquired through a used for piston displacement temperature range. DAQ device and processed by a control signal. FRC, barometric The best fit function, LabView®-based software that also pressure and ambient temperature corresponding to the mathematical calculates the pressure, volume represent the initial conditions of model described by equation 3, has and flow rate patterns by

gas in the control volume. been obtained: averaging 10 subsequent acts. Flow ▼

SCOPE | DECEMBER 2011 | 17 SCOPE | FEATURE ▼ ▼ FIGURE 5. pneumotacograph adaptor, nearest The simulator in the endotracheal tube: values in operation and the the order of 10 ± 3 cmH2O are control panel, reported. As far as it concerns the developed in gas flow rate, the average peak LabView 7.1 flow rate during inspiration has environment. been assessed on 15 resting newborns:10 the value of 44 ml/s (2.6 l/min) agrees with the values obtained by the proposed system. The mean airway resistance value, obtained as the ratio between the maximum pressure drop and the maximum flow rate across the orifice, is about 8.04 kPa/l/s (about 82 cmH2O/l/s). This value

▼ results close to the average value FIGURE 6. identified by Hjalmarson et al. on Measured and infants with mild BPD (80 simulated cmH O/l/s).6 Moreover, our pressure, flow 2 rate and volume simulated airway resistance fits in 8 waveforms at the range identified by Frey et al. breathing (0.5–10 kPa/l/s in the flow rate frequency = 60 range 0.0–0.3 l/s). bpm, Vt = 6 ml The described simulator and FRC = 70 ml, maintains a difference lower than I:E ratio = 1:2. 10 per cent on peak values in all the conditions in which it has been tested. There have been some research efforts, over the years, to hypothesise which kind of gas transformation was more adequate to reproduce gas compression and expansion during the mechanical ventilation. A very slow transformation optimises the heat exchange between the gas and the container wall, whilst maintaining the gas temperature mostly constant; on the other hand, a very fast transformation minimises the heat exchange making the transformation adiabatic. Taking into account the physics and the speed of the mechanical ventilation, it is unlikely to model it as a pure isothermal transformation and, at the same time, it is limitative to think it could be adiabatic. Frey et al. and Torzala built simulators of copper rate, pressure and volume Moreover, the respiratory elements filled with copper wool in waveforms have been sampled at parameter values appear to agree order to maximise and homogenise 1,500 samples/s. with the values obtained from in vivo the heat dissipation and so, based

Figure 6 shows, as an example, measurements found in the ▼ FIGURE 7. the reproducibility of the model on the simulated and measured literature. In fact, mean values of Pressure, flow isothermal gas transformation.8,11 pressure, flow rate and volume respiratory rate of 60 ± 15 bpm were rate and volume On the contrary, we do not adopt percentage waveforms obtained with a set measured on 11 healthy newborns,9 any particular hardware expedient, differences breathing frequency equal to 60 whereas rates of 50–80 bpm were but propose an approach that can between 6 bpm, Vt = 6 ml and FRC = 70 ml. measured on RDS-affected infants. measured and be generalised to different The similarity between the Neonatal peak inspiratory pressure simulated geometries and materials. The core waveforms is remarkable, and it values have also been measured in patterns with of the theoretical model proposed confirms the validity of the vivo for low birth weight infants by FRC = 70 ml and is the reduction of the simulation mathematical model. using the port, in the FRC = 50 ml. interval (step shorter than 1 ms)

18 | DECEMBER 2011 | SCOPE that allows considering a whole delivered pressures, flows and respiratory act as composed by a volumes, and the ability of the large number of almost ventilator to adapt to patient instantaneous adiabatic requests and to deliver ventilation transformations. support tailored to the current In order to assess the status of the patient. It also allows reproducibility of the pneumatic testing trigger sensitivity and time parameters obtained by the response by simulating breathing proposed system and the attempts of different levels in flow limitations of its practical or pressure. realisation, extensive experimental This would make the described tests have been carried out. system an important tool during The percentage deviations the acceptance procedure of a new between measured and simulated neonatal ventilator into the waveforms have been calculated hospital or during the periodical and reported into the histograms function assessment of the device. (figure 7) as a function of set breathing frequency and VT, for CONCLUSIONS AND FRC values equal to 70 ml and 50 FURTHER WORK ml. The percentage deviations on An open-loop controlled flow rate are generally smaller than electromechanical system able to the deviations on pressure, reproduce the main pulmonary although both mostly show the parameters and breathing patterns same trend. The theoretical model of preterm healthy and pathologic of the system is well reproduced by infants has been described. It the simulator’s behaviour (with allows to reproduce spontaneous global deviations lower than 20 per breathing with physiological cent) at frequencies between 80 and volume, pressure and flow rate 100 bpm, and at 60 bpm for VT waveforms from a theoretical greater than 5 ml. The histograms model, based on the gas adiabatic also show the same trend of the transformation. deviation parameters for the The proposed system does not different FRC values. show the drawbacks of closed 8 Like Frey et al., the actual VT in loop-controlled simulators such as our simulator is not perfectly equal time-consuming calibrations and to the simulated one. Percentage tuning of the controller, but its errors on VT values vary from 7 per small size makes it able to perform cent at VT = 3ml (i.e., mostly 0.2 ml) simulations specifically directed to down to 2.2 per cent, up to 3.5 per preterm infant respiration analysis cent for VT in the range 4–7ml (i.e., and neonatal ventilator testing. We always less than 0.2 ml) and 1.3 per propose that the quite high cent for VT = 8 ml (i.e., mostly 0.1 differences with theoretical ml). As concerns the percentage behaviour are mostly attributable errors calculated for the whole to the choice of stepper motors, waveforms of a respiratory act, we rather than to the method. obtained average volume Therefore, a further deviations equal to 17 per cent for implementation of the present FRC = 70 ml, and 14 per cent for system will be the use of DC FRC = 50 ml. motors, which show a more In perspective, the presented reproducible behaviour also at simulator, connected to the lower speeds. These technological ventilator at the ‘Y’ of the breathing limitations must be solved in order circuit, would allow reproduction to extend the simulation of the passive and the active parameters to lower frequencies mechanical behaviours and to with comparable accuracy. verify the actual ventilator Results reported in the present performances in controlled and work also appear to confirm that in assisted ventilation modalities (e.g., order to realise devices for infant the correspondence between set pulmonary testing, gas parameters and delivered ones and compressibility must necessarily be the stability of the ventilator taken into account and, in order to performances). The simulator increase the accuracy of the allows checking the stability of the simulated parameters, the ventilator performances, the thermodynamic gas reference

correspondence between set and could be an adiabatic model. ▼

SCOPE | DECEMBER 2011 | 19 SCOPE | FEATURE ▼ REFERENCES

1 Iijima S, Arai H, Ozawa Y, Kawase Y, Uga N. Clinical 6 Hjalmarson O, Sandberg KL. Lung functions at term patterns in extremely preterm (22 to 24 weeks of reflects severity of bronchopulmonary dysplasia. J gestation) infants in relation to survival time and Pediatr 2005; 146: 86–90. prognosis. Am J Perinatol 2009; 26: 399–406. 7 Miller RW. Flow Measurement Engineering Handbook, 2 Jobe AH, Hillman N, Polglase G, Kramer BW, Kallapur 3rd edition. McGraw-Hill Companies, 1996: 9.83. S, Pillow J. Injury and inflammation from resuscitation of the preterm infant. Neonatology 2008; 94: 190–96. 8 Frey U, Reinman B, Stocks J. The infant lung function model: a mechanical analogue to test infant lung 3 Silvestri S. The influence of flow rate on breathing function equipment. Eur Respir J 2001; 17: 755–64. circuit compliance and tidal volume delivered to patient in mechanical ventilation. Physiol Meas 2006; 27: 9 Gupta SK, Wagener JS, Erenberg A. Pulmonary 23–33. mechanics in healthy term neonates: variability in measurements obtained with a computerized system. J 4 Ramanathan R, Sardesai S. Lung protective ventilatory Pediatr 1990; 117: 603–6. strategies in very low birth weight infants. J Perinatol 2008; 28: S41–6. 10 Cunningham MD, Desai NS. Methods of assessment and findings regarding pulmonary function in infant less 5 Schmalish G, Wauer R, Böhme B. Changes in than 1000 grams. Clin Perinatol 1956; 13: 299–313. pulmonary function in preterm infants recovering from RDS following early treatment with Ambroxol: results of 11 Torzala T. Ventilator performance testing. Med a randomized trial. Pediatr Pulm 1999; 27: 104–12. Electron 1987; 8: 70–79.

20 | DECEMBER 2011 | SCOPE Safe storage Radium clinical needles and tubes during World War II

David J. Murnaghan (Royal Dublin Society) has uncovered the story of the recovery

of radium following bomb explosions at the Marie Curie Hospital in 1944 uring the ‘Blitz’ there ▼ Painstakingly suspended and replaced by low containers were lost in the debris. was serious concern searching energy superficial x-rays. An The recovery of the containers and, about what would through the alternative was the use of shielded more importantly, the radium is an happen if radium rubble. containers into which the radium interesting story. This story was told sources were sources were placed at night. The by E.E. Smith of the National damaged as a result containers were lowered into a Physical Laboratory in the Dof bombing. Lost sources would be a borehole to position them well September 1983 issue of the Hospital potential risk to the public as below the level that could be Physicists’ Association Bulletin. A war gamma radiation emitters. Even damaged by bomb explosions. artist was commissioned to record more dangerous, if damaged, the Where no borehole was available a the event and the painting is in the sources would release their radium secure location was an alternative Imperial War Museum. salt and be a major cause of location for the shielded containers. Rather than my retelling this contamination. Precautions were Alas, these precautions did not story, it is preferable to reprint E.E. put in place. In some hospitals, always work. In February 1944, the Smith’s own account of the recovery where possible, treatment using Marie Curie Hospital received a of the radium in which he played a

radium needles and tubes was direct hit and two shielded major role. ▼

SCOPE | DECEMBER 2011 | 21 SCOPE | FEATURE

▼ recover the radium while ensuring the building near to where the The recovery of that those involved were not exposed cylinders had previously been. radium from the to undue radiological hazard. Progress was slow, not only because of Two items of equipment were the nature of the debris but also bombed Marie available for conducting the search. because it was necessary to avoid any Curie Hospital, One was a compact, tripod-mounted further collapse of the structure. I took gold-leaf electroscope which we readings at frequent intervals with February–March referred to as the Mayneord negative results. As the clearance 1944 electroscope. The unusual feature of proceeded, the working front widened this was an aluminium disc, about 15 thus diminishing the rate of By E.E. Smith. Originally published cm diameter, which could be attached penetration and by the morning of in the HPA Bulletin Special HPA 40th externally to the gold-leaf terminal. In 23rd there were still no signs of the Anniversary Issue, September 1983, this form the electroscope was not radium. However, someone had pp. 16–17. only very sensitive to gamma informed the Daily Mail and we were radiation but also to alpha radiation visited by one of their reporters, Guy n mid-February 1944 the Marie as, for example, from atmospheric Ramsey. I had to be reticent, not only Curie Hospital, Hampstead, radon. It was, of course, of little use because this was a bombing incident suffered a direct hit from a outdoors in inclement weather. The but also because, as a member of the bomb which demolished the other item was referred to as the NPL staff, I was forbidden to give rear of the premises and ‘clucking hen’. It had been described press interviews without prior consent severely damaged the rest. The by Dr T. A. Chalmers, then of St and strict supervision. I therefore Ihospital’s entire stock of radium, Bartholomew’s Hospital, London, in contacted the authorities who, after about 400 mg in needles and tubes, the mid-thirties and had a due consideration of the propaganda was stored in two steel cylinders of conventional neon lamp as its aspects, gave me permission to be the type approved in 1941 for such a sensitive element. This was enclosed interviewed and photographed. purpose. These cylinders were about in a light-tight container attached to 25 cm long and 20 cm diameter and the end of a tube of suitable length for PRESS INTEREST had a central cavity about 5 cm surveying the ground and for poking The next morning, the Mail carried the diameter closed by a threaded steel into crevices. The lamp was connected scoop which, as it involved a bombed plug. The mass was about 60 kg and via a resistor and a pair of hospital and lost radium, was the wall thickness of 7.5 cm gave not headphones to a radio high-tension extremely newsworthy. This resulted only physical protection but also battery, the voltage of which was in a flood of rival reporters descending afforded some radiological adjusted so that, in the absence of upon the site. For a few days I was a protection, the gamma rays from any extraneous radiation, it was at the celebrity. However, news soon gets contents being attenuated to about 10 minimum for the lamp to strike. A stale and, as nothing exciting per cent. Tests had demonstrated that capacitor was in parallel with the appeared to be happening, interest the cylinders were virtually bomb- lamp and was discharged when it abated almost as rapidly as it had proof and could, therefore, be kept in struck, thus reducing the voltage and arisen. By the end of the week none reasonably accessible places. In the quenching the lamp. The discharge but the faithful Mr Ramsey was case of the Marie Curie Hospital, could be heard in the headphones as a paying any visits. He was about to get they had been in a semi-basement ‘cluck’, hence the name. In the a reward for his perseverance. room at the rear of the building, in presence of radiation, the threshold of It so happened that I had observed the region of maximum damage. striking was reduced so that the rate the first feeble indications on the The National Physical Laboratory of cluck increased, becoming more evening of his initial visit but I kept was responsible, during the war, for and more rapid the nearer a source this to myself because I did not want dealing with incidents involving was approached. Not all lamps were to have an audience of reporters from radium and, in consequence, Walter equally useful for this purpose but, then on. These indications were Binks and I visited the scene on the with a good one, an initial rate of encouraging and enabled a little morning of Sunday 20th February about 5/min would be approximately direction to be given. Site problems where we met Dr Gilmour, Medical doubled by l mg radium at a metre and safety aspects continued to limit Director of the Hospital and Lord distance. ▼ The original the rate of progress and nothing had Amulree of the Ministry of Health. The work of clearance commenced photograph of been found by the weekend. Walter Neither cylinder could be seen on Monday 21st, starting at the rear of the recovery. Binks and I devoted the Sunday to a among the debris and a preliminary careful, detailed examination of the survey with our instruments site uninterrupted by either workers revealed neither gamma rays nor or newsmen. As a result I was able to radon. It was accordingly decided give precise instructions on the that the debris would have to be following day and, despite having to systematically removed under the proceed literally brick by brick, shortly supervision of NPL staff and that the after midday one of the missing work would be carried out by the cylinders became visible. It had been local Civil Defence Heavy Rescue driven about 15 ft from its original Squad when it could be spared from position and had been brought to rest its primary duty of rescuing human by the retaining wall of an area casualties. Our concern was to passage. It was removed to the

22 | DECEMBER 2011 | SCOPE FEATURE | SCOPE

roadway in the chance presence of also devoted to the hospital. clearance continued but with more Guy Ramsey and his photographer It had The recovery, intact, of three- and more direction and at last, on 30th and appeared to be undamaged apart quarters of the radium was a matter March, the second cylinder was from some superficial indentations. travelled for satisfaction but it meant that the recovered. Like the first, it and its The plug unscrewed readily and the some 50 ft search for the second cylinder would contents were found to be intact. It contents appeared to have been “through be all the more difficult. A survey of had travelled some 50 ft through what unaffected. A test revealed no radon the site, as soon as the first cylinder had been the basement of the so the cylinder and its contents were what had had been removed, was completely building, having passed through made over to Professor Sidney Russ been the blank. With a strong feeling of anti- positions that had been occupied by a of the Middlesex Hospital, honorary basement climax, the laborious task of systematic number of walls. The direction of physicist to the Marie Curie. He took clearance was resumed. The working travel was at a considerable angle them away in order to examine the of the front was now more than 50 ft wide from that of the other cylinder, which radium and he reported that it building and, as it was obvious that until some supported the conclusion that the amounted to about 300 mg and had indications had been received there bomb had exploded in close proximity suffered no damage. would be no imminent discovery or to their original position. The This partial success revived the hazard, I reduced my visits to the site adequacy of the cylinder as a means interest of the press and this time the to every second or third day. of storing radium in wartime had BBC also. I gave a road-side recorded been demonstrated in a most interview to Margaret Bucknall on ” THE SECOND DISCOVERY convincing manner! 29th February which was broadcast in When more than another week had The interest which had attended a news programme that day and I elapsed without any indications, l the search at the outset had vanished took part in ‘The World Goes By’ on began to wonder if the cylinder had by its conclusion and all the notice it the following Saturday. Dr Gilmour been lifted out of the site altogether received was a brief footnote in some also took part and, together, we and was residing in one of the large, of the papers. Nevertheless, a war helped to boost the appeal fund deserted gardens in the vicinity. artist was commissioned to record the which had been launched on behalf Fortunately, before this became a event and a painting featuring Walter of the hospital. By a fortunate serious consideration, faint indications Binks and myself among the wreckage coincidence, the London premier of of the second cylinder were received of the Marie Curie Hospital is now an the film Marie Curie was imminent and from that moment it became item in the collection of the Imperial and it is my recollection that this was merely a matter of time. The careful War Museum. n ▼

SCOPE | DECEMBER 2011 | 23 SCOPE | FEATURE

Clinical scientist steering group set up for advice to NPL group Catharine Clark and Hayley James (National Physical Laboratory, London)

ational Physical ▼ FIGURE 1. Laboratory (NPL) is The current the UK’s National members of the Measurement Institute, National Physical based in Teddington Laboratory on the outskirts of Radiation NLondon. It is a world-leading centre Dosimetry of excellence in developing and steering group applying the most accurate and NPL staff measurement standards, science and (left to right: technology. The Radiation Dosimetry Vere Smyth, group develop, maintain and Catharine Clark, disseminate the UK national Carole Meehan, dosimetric standards for x-rays, γ- Steve Bolton, Hayley James, rays and charged particles such as Ran Mackay, electrons and protons. They engage in Tom Jordan, research on the interaction of ionising Peter Sharpe, radiation with matter to address the Rebecca needs of industry, healthcare and Nutbrown, government and provide traceability Russell Thomas, in quality assurance, international Graham and national specification standards Chalmers, and measurement protocols. Simon Duane. areas of reference dosimetry. every 6 months and the next one is on Not pictured are A further conclusion of this review 12th January 2012. The meeting Alison Scott, REVIEW OF SERVICES was that it would be useful to have a agenda consists of presentations from David Thwaites In October 2008 the NPL installed an clinical scientist’s input at NPL. This NPL on current projects and possible and Viv Elekta Synergy linac and the Cosgrove). was addressed by employing a clinical future projects and presentations from Radiation Dosimetry group scientist part time at NPL, with the steering group members covering undertook a review of its services other part of the job being in clinical topics where collaboration with the with a view to better addressing the physics. Catharine Clark has taken on Radiation Dosimetry group would be needs of hospital physicists in this role working at both NPL and at beneficial. Recent topics for discussion radiotherapy departments. This Royal Surrey County Hospital. In have included: included a tour of 22 UK centres to conjunction with this, Russell Thomas n proton dosimetry development and determine which areas of research from NPL undertook IPEM Part II a traceable dosimetry chain; and services could be most useful to training in radiotherapy physics and n EPID dosimetry; expand or develop. Discussions successfully achieved state n dosimetry for molecular focussed on three main areas: registration as a clinical scientist. radiotherapy; n What were the main problem areas n small-field dosimetry, and and issues in radiotherapy THE STEERING GROUP n rotational radiotherapy audit. treatment implementation or A steering group consisting of nine A further remit of the steering delivery that could be addressed clinical scientists working as hospital group is to act as a conduit for the by the NPL? physicists has also been established to radiotherapy physics community to n What types of service from the give advice and guidance to the communicate with NPL regarding any NPL would the hospital Radiation Dosimetry group at NPL areas or projects where they feel input potentially wish to take advantage (figure 1). The current membership of from the Radiation Dosimetry group of? this group is: Steve Bolton would be helpful. If anyone would n What opportunities were there for (Manchester and Chair of IPEM like to submit ideas for collaborative collaborative research and interdepartmental audit group), work or issues that may be addressed development between the NPL Graham Chalmers (Birmingham and by the Radiation Dosimetry group and hospitals? Chair of IPEM RTSIG), Hayley James please contact either the NPL or any A summary of these discussions (Ipswich), Tom Jordan (Guildford), member of the steering group. n led to four key themes: audit, Ranald Mackay (Manchester), Carole calibration, teaching and research, as Meehan (Royal Marsden, London), Contacts Catharine Clark well as an intention to develop Alison Scott (Liverpool), David ([email protected]) beyond traditional reference Thwaites (Sydney, Australia, and Hayley James ([email protected]) dosimetry into areas of relevant Leeds) and Viv Cosgrove (Leeds). NPL Radiation Dosimetry Group clinical application as well as new Steering group meetings are held ([email protected])

24 | DECEMBER 2011 | SCOPE TRAVEL AWARD | SCOPE

IPEM USA TRAVEL AWARD: A TRAINEE’S PERSPECTIVE NAOMI CROSSLAND Bristol General Hospital

shore of Lake Union and the fantastic Agua Verde Mexican restaurant/canoe club! There may be few finer ways to unwind after work than a paddle around the lake against a backdrop of houseboats and shiny skyscrapers under the evening sun. A kayak trip around the perimeter of the lake took me past not only the ‘Sleepless in Seattle’ houseboat, but also two of the other major cancer treatment facilities in the city: the Seattle Cancer Care Alliance and the Fred Hutchinson Cancer Research Centre. The radiation therapy programme in Seattle is shared between multiple affiliate oncology facilities under the UW umbrella. Consequently, the UWMC does not see patients undergoing gamma knife treatments, or female patients for breast cancer or gynaecological brachytherapy; it specialises in head and neck treatments, CNS, lungs, liver treatments, TBI, IORT, TSEI and, of course, neutron therapy.

ABOUT NEUTRON THERAPY pproaching the placement abroad. I had the freedom ▼ FIGURE 1. The Radiation Oncology department end of my 2-year to arrange and organise my UWMC standing at the UWMC is one of the leaders journey to placement in any area of medical tall in the in the field of neutron therapy. Fast complete Part I physics and any hospital of my background, the neutrons are used to treat tumours clinical science choosing (provided the hospital was colourful in areas such as the salivary glands, training in willing to accommodate me!). I was kayaks of Agua the lumbar spine and the femur. It Verde in the medical physics, I delighted to find the UWMC has been shown1 that neutron beam foreground. wasA very fortunate to be sponsored extremely accommodating. radiotherapy provides the best cure by IPEM to visit the University of for inoperable tumours in regions Washington Medical Center UWMC’S PLACE IN SEATTLE such as the salivary glands. Whilst (UWMC) in Seattle, USA. The The UWMC is, as its title suggests, the neutron depth dose curve purpose of my visit was broadly to situated on the campus of the resembles that of 4 MV photons, the enhance my training experience in University of Washington, in Seattle. biological effect of neutrons is radiotherapy by visiting a different It is a particularly beautiful location: significantly different to that of hospital and with a different the UW campus has some majestic photons. Neutrons, being healthcare system. I was particularly old buildings (particularly the uncharged, interact primarily interested to learn more about library), a botany greenhouse that is through nuclear scattering neutron therapy; the UWMC being home to the pungent corpse flower, interactions. The highest probability one of only a few places in the world which came into bloom whilst I was of interaction is with hydrogen currently using neutrons as a form of there, and with a fantastic view of nuclei, which have similar mass to external beam therapy. the nearest active volcano, Mount the neutron. Being one of only three One of the main attractions of the Rainier, which finally emerged from clinical neutron facilities in the US, training scheme at UHBristol, where its blanket of cloud on my very last patients come from all over the US I am completing my Part I, was the day! The Medical Center itself is a and abroad to have this type of

option to take a 2-week elective very short stroll away from the north treatment. ▼

SCOPE | DECEMBER 2011 | 25 SCOPE | TRAVEL AWARD

▼ Neutron therapy did not take off in the UK, after extensive pioneering research and clinical trials in the 1970s. However, the UK legacy lives on: the 1-metre thick MLCs currently in use in the head of the neutron treatment unit at the UWMC come from one of the neutron facilities in the UK. Neutrons have been in clinical use at the UWMC since the 1980s. For someone brand new to the medical physics profession, who has been brought up on touch-screen and integrated control interfaces such as Mosaic, I very much enjoyed the ‘80s feel of the neutron machine controls, with its analogue dials for kV exposure settings (the head of the neutron machine also contains an x-ray generator), and large panels full of buttons, switches and dials in the engineers’ control area, reminding me of scenes from the lair of an evil genius in a James Bond movie. The computer systems are in the process of being upgraded, although I can’t help hoping the appearance doesn’t change much! In the treatment room, which is accessed through a 9-foot thick mechanical door, my attention was first drawn by the size of the machine. The neutron head is several metres tall, containing, amongst other things, the beryllium target, the 1-metre thick MLCs and a great deal of shielding material, mostly hydrogen-rich plastics. In order to deliver gantry angles greater than 90º, the floor opens up to accommodate the neutron head, revealing a substantial drop – enough to make me thankful for the use of physical immobilisation straps, if I were a patient! Around the back of the gantry is no less exciting. As a visitor from England, I was treated to the ‘royal tour’ of the cyclotron facility, which involved weaving amongst the beam-channelling pipes to explore every aspect of the cyclotron’s function. This cyclotron uses a ‘D’- ring which accelerates protons up to 50.5 MeV. These protons may be magnetically steered into one of three paths: 1. to a radioisotope production channel, where radioactive tin is produced by layering strips of Cd in the path of the protons; 2. to a channel which may be used for various research purposes, or 3. four days a week, the protons are

26 | DECEMBER 2011 | SCOPE TRAVEL AWARD | SCOPE

directed through to the beryllium DIFFERENCES BETWEEN ▼ FIGURE 2. reflective ball attachments to target in the head of the neutron SEATTLE AND UHBRISTOL Me on Queen monitor the patient’s intrafraction treatment unit. Fast neutrons are Aside from touring the neutron Anne Hill, with the movement. The initial isocentre emitted on collision of the proton facility, my time was divided SpaceNeedle and positioning is confirmed by the linac beam with the neutron-rich between visits to the range of clinical downtown onboard cone beam CT imaging beryllium nuclei. departments in the Radiation skyscrapers in system. At each treatment fraction, Radiation protection is slightly Oncology centre. This was a valuable the background. the position of the bite block panel more complicated with neutrons, opportunity to learn about the of reflectors is read by an infrared because radiation dose arises not methods and practices of the UWMC, camera, thus any rotation or only from scatter during beam and make comparisons with my own translation of the head which may delivery but also from delayed workplace. I was very interested to have occurred inside the mask is emissions due to neutron activation discover the subtle differences in measured and checked against a of the various nuclei with which they localisation and shielding techniques. user-defined tolerance level based interact. Therefore a minute’s delay is By far the majority of new ideas on the initial positioning. The observed between cessation of that I encountered were on the Hexapod treatment table is robotic treatment and the radiographers (or subject of tumour localisation. and has an additional tilt degree of therapists, as they are known in the Calypso ‘GPS for the body’: Some freedom, to enable accurate patient US) entering the room. A minute is external beam prostate treatments re-alignment if the positioning is long enough for the majority of use real-time tracking of the tumour confirmed to be out of tolerance. activated nuclei to have decayed. volume, developed by Calypso On the subject of shielding, I was Medical Inc., a company interested to learn that the UWMC THE RADIATION ONCOLOGY headquartered in Seattle. The manufactured lead-alloy lung blocks PHYSICISTS position of the prostate is tracked by for their TBI patients, to provide Dr George Sandison, who was a surgically implanting in the prostate shielding for the lungs. At the ▼ wonderful host throughout my visit, three small radiofrequency FIGURE 3. UWMC, TBI patients are treated currently leads a team of 13 other transponders that are stimulated to View of Mount standing up (whenever possible), physicists (three of whom are provide their signal location, and Rainier from the using ant and post beams only, ‘residents’) and one university hence position, by triangulation. This UW campus. whereas at UHBristol the patients student. The work of the physicist at means that for each treatment lay on the couch and the treatment UWMC is largely very similar to my fraction the patient is set up alternates between ant/post and experience at UHBristol, with routine according to the actual location of the lateral beams. Many of these QA, plan checking and treatment isocentre, rather than the particular differences I expect I troubleshooting, particularly for the original tattoos. Calypso has the could have encountered had I ‘physicist of the day’, being the additional advantage of tracking the visited a different hospital in the UK. norm. However, one aspect I found prostate position in real time, so that However, I had never come across particularly appealing at UWMC was if the prostate moves significantly, Calypso tracking before. the great emphasis on research: e.g. due to coughing or motion of In my opinion, the opportunity to almost all medical physicists hold bowel gas, the treatment beam can be spend some time in another hospital, PhDs, and their working calendar paused. especially one overseas, is an contains frequent research days, 4D-CT: I had not seen this excellent addition to the clinical devoted solely to progressing with technique in action before. For lung science training programme. Despite whatever projects they are currently patients, 4D-CT was used to depict it being 5 months since my training working on. the motion of the tumour volume placement in the radiotherapy during the patient’s breathing cycle, department at UHBristol, I was RESIDENTS AND TRAINING

so that the PTV could be tailored to ▼ pleasantly surprised to realise, SCHEMES closely encompass the maximum FIGURE 4. through chatting to the physicists at The residency programme in the US displacement of the tumour volume. Seattle from the the UWMC, how much confidence I water. appears to be equivalent to the Part II Active breathing control: This had in my understanding of the training that I will be following next technique is in the process of work in my hospital and in the year in the UK. In the US, the commissioning at UHBristol. For subject of radiotherapy in general. I REFERENCE Resident gains 2 years of clinical liver tumours, active breathing think that stepping outside the 1 experience before becoming eligible control was used to eliminate the Lennox AJ. training environment and using High-energy to take part in the next stage of need to expand the target volume to one’s knowledge, even if just in Neutron examination to achieve the status of account for breathing-induced conversations with colleagues from Therapy for qualified medical physicist. In the US motion of tumours. The patient’s air other areas, as I did, is a valuable Radioresistant this ‘next stage’ is Parts 2 and 3 of the intake is artificially controlled so that Cancers. way to consolidate what has been American Board of Radiology exams. their breath is held at a fixed lung Northern learned. I am extremely grateful to To qualify for the residency volume for a fixed time period (e.g. Illinois George Sandison and all staff in programme, applicants must possess 20 seconds), during which the University Radiation Oncology at the UWMC appropriate postgraduate treatment beam is delivered to the Institute for for allowing me to have such an qualifications: in the US a minimum stationary target. Neutron enjoyable and interesting of a 2-year master’s course in Hexapod head localisation: Brain Therapy at experience. I am also very grateful to medical physics is expected, although treatments performed at the UWMC Fermilab, the IPEM for funding my visit as in reality the majority of successful make use of a thermoplastic mask www.neutron part of the travel bursary applicants already have a PhD. combined with a bite block with therapy.com programme.

SCOPE | DECEMBER 2011 | 27 SCOPE | MEETING REPORTS

EUROPEAN MEDICAL PHYSICS AND ENGINEERING CONFERENCE 2011 STEPHEN EVANS Director, Science Board, IPEM; Northampton General Hospital

TRINITY COLLEGE, DUBLIN, IRELAND 1st–3rd September 2011

AROUND 500 DELEGATES GATHERED at Trinity This marked the changeover of the IPEM President to College Dublin (figure 1) for the European Medical Peter Jarritt. Chris Gibson, the outgoing President, was Physics and Engineering Conference (EMPEC 2011). The acknowledged for having done a remarkable job for the conference combined the European Federation of Institute in these challenging times showing true Organisations for Medical Physics (EFOMP) 5th leadership qualities (figure 4). European Conference on Medical Physics, the Irish Association of Physicists in Medicine (IAPM) annual SOCIAL ACTIVITIES Scientific Meeting and IPEM’s annual Medical Physics After the day of talks, delegates were able to take part in and Engineering Conference. an ‘Irish night’ at the famous Old Jameson Distillery, go to a formal reception at Dublin’s historic Trinity College MATERIAL COVERED Dining Hall or simply have a good ‘craic’ in the Attendees and speakers from all over Europe and far effervescent city centre. The gala dinner was held nearby beyond took part in sessions covering the full range of in The Alexander Hotel where delegates were medical physics and clinical engineering specialties entertained by presidential speeches. Various tours to including diagnostic x-ray and nuclear medicine interesting sights in and around Dublin were also held imaging, radiotherapy, ultrasound, rehabilitation during the conference for accompanying persons. engineering, MRI, physiological measurement, Delegates who were not on too strong a mission may dosimetry, nuclear medicine, radiation protection and also have been able to take some time out between talks medical devices (figure 2). There were also sessions on to visit Trinity College’s famous Book of Kells or even innovation relevant to healthcare, updates on training, buy a Kell tie or scarf (figure 5)! modelling and simulation and seminars for junior scientists. The sessions ran in five parallel streams LESSONS LEARNED FROM PLANNING THE allowing delegates to attend relevant sessions MEETINGS throughout the conference. A pre-conference workshop Looking back at the meetings held to discuss the holding in association with AAPM was held on ‘Justification and of a joint conference in Dublin we can now answer a few optimisation’ with leading speakers from Europe and questions that arose at that time: America. The standard of the presentations was n Would IPEM members identify this as their MPEC and exceptionally high and demonstrated the wealth of attend a conference outside the UK? Yes. talent and expertise we have within our fields. n Would there be enough delegates to make the conference a success? Yes. KEYNOTE SPEAKERS n Would the quantity and quality of submitted abstracts Keynote speakers included the IPEM Woolmer lecture be high? Yes. by Willi Kalender (Friedrich-Alexander University, n Would we attract enough sponsors and have a vibrant Erlangen-Nuremberg, Germany; figure 3), who had technical exhibition and atmospheric venue? Yes. encouraging and optimistic views about the future of n Would we organise a similar joint meeting again? Most CT, Thomas Mackie (University of Wisconsin-Madison, definitely, yes. WI, USA) gave the AAPM’s O’Connor lecture on The conference ended on Saturday in style and gusto radiotherapy advancements and Sue Hill (Department with the EFOMP Honorary Membership Award going to of Health, London) gave a talk on the UK’s plans to Inger-Lena Lamm (Lund University Hospital, Sweden) Modernise Scientific Careers, identifying mapping with who presented a talk entitled ‘…Hats and all that’. It was the European Commission’s work on the Medical a funny and moving account of I-L Lamm’s career to Physics Expert. Insights were obtained in the date. rehabilitation engineering session from Heinz Wolff in his keynote speech entitled ‘Crunch and care’ and the ACKNOWLEDGEMENTS AND NEXT YEAR’S CON- Hospital Physicists’ Association plenary lecture was FERENCE given by Justin McCarthy (Cardiff University) on how As Director of Science Board, I would like to issue a big vital clinical engineering is for the health of the nation. thank you to all the IAPM, EFOMP and IPEM members With around 30 sponsors at the technical exhibition on the organising and scientific committees who put in a and around 80 scientific posters, the conference had a tremendous amount of work to make the conference a tremendously vibrant and invigorating atmosphere. great success. Also thanks go to Conference Partners who made sure that the conference ran smoothly. IPEM’S ANNUAL GENERAL MEETING Next year it will be a collegiate occasion for MPEC12 As usual, the IPEM AGM was held during the which will be held in Oxford on 10th–12th September. conference and although voting on matters is now by This is sure to be an inspiring conference so pencil these post, attendance at the AGM was exceptionally high. dates in your diary now. n

28 | DECEMBER 2011 | SCOPE MEETING REPORTS | SCOPE

▼ FIGURE 1. Trinity College, Dublin (courtesy of Robert Neilson, General Secretary, IPEM).

▼ FIGURE 2. [LEFT] Left to right: Nick Stone, Steve Keevil and Finton Bradley in conference (courtesy of Robert Neilson).

▼ FIGURE 3. [RIGHT] Presentation to Professor Kalendar by Dr Chris Gibson, IPEM President (courtesy of Robert Neilson).

▼ FIGURE 4. [LEFT] The reward (courtesy of Giles Morrison).

▼ FIGURE 5. [RIGHT] A Kell tie.

SCOPE | DECEMBER 2011 | 29 SCOPE | MEETING REPORTS

EUROPEAN MEDICAL PHYSICS AND ENGINEERING CONFERENCE 2011 KARMENOS-KONSTANTINOS GALLIAS A.R.N.A.S. Civico, Palermo, Italy

TRINITY COLLEGE, DUBLIN, IRELAND 1st–3rd September 2011

THE FIRST DOCUMENTED HISTORY of Dublin begins This conference was programmed as a mix of learning with the Viking raids in the eigth and ninth centuries. and relaxing. The social programme was marvellous. We These led to the establishment of a settlement on the south had the chance to experience a traditional Irish night, with side of the mouth of the Liffey, after the lake where the famous Irish drinks. During the gala dinner, on Friday 2nd Danes first moored their boats. The city took the name September, we had the opportunity to meet each other in a Dublin, which comes from the Gaelic dubh linn or ‘black friendly place. The optional tours were also very exciting, pool’, where the Poddle stream met the River Liffey (figure including visits to St Patrick’s Cathedral (figure 7), 1) to form a deep pool at Dublin Castle. Christchurch Cathedral, the Guinness storehouse, old Early September in Dublin is a very beautiful period. Jameson Distillery, etc. The Dublin Bay and castle tour and The colours of green, dark yellow, blue, brown and white the Wicklow tour allowed a chance, in my opinion, to feel don’t look out of place in an Irish dance, which not only the real spirit of Ireland! makes a perfect companion to study but also for beautiful The main objectives for me, to compare the procedures weekend excursions (figures 2–4). used in the rest of Europe with those carried out in the The EMPEC 2011 conference (figure 5) was organised hospital I work in and to learn and study techniques in the by the Irish Association of Physicists in Medicine (IAPM) fields of radiotherapy and non-ionising radiation, were and was hosted this year by Trinity College Dublin, absolutely achieved. This conference helped me to improve founded in 1592 (figure 6). This year is also the my clinical knowledge and gave me the opportunity to tercentennial anniversary of Trinity College’s medical meet and exchange opinions with colleagues from all school, one of the oldest in Europe. around the world. More than 560 delegates attended this Topics from all the fields of medical physics were conference, from more than 40 countries. presented and discussed. There was also a special session During the conference I had the chance to meet on innovation and about how we can think more industrious and open-minded colleagues, characterised by innovatively. Morning tutorials were also given in various analytical and innovative thinking. I met positive and fields (rotational therapy, imaging, 1D systems and polite people with multilateral activities and interests. The FMEA). The QA aspect was also raised in a comprehensive EMPEC 2011 was definitely a fantastic experience! manner, due to the importance of this in the whole chain, I wish to thank IAPM and especially Dr Fintan Bradley that has as its last point the correct ‘dose delivery’ to the (IAPM President), because they gave me the unique patient in diagnostic and/or treatment procedures. opportunity to enjoy this experience, and in particular I Education and training in medical physics were also wish to thank the EMPEC 2011 committee for their bursary discussed. and their politeness. The topics were presented by lecturers that are working A great acknowledgment also goes to IPEM and in in the various fields of medical physics, lots of them have particular to the IPEM Prizes and Awards Advisory Group been for decades. During the conference, questions and for their bursary contribution to support my attendance at discussions were always encouraged by the lecturers. the EMPEC 2011 conference. A special thank you goes also Their clinical and educational experience and training to Marie Goodall and Dr Lorenzo Bianchi for their were very meaningful and helpful for me to gain kindness and collaboration in preparing all of the experience and knowledge regarding my clinical work. necessary paperwork. n

▼ FIGURE 1. Liffey River.

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▼ FIGURE 2. St Stephen’s Green.

▼ FIGURE 3. Dublin Castle.

▼ FIGURE 4. [LEFT] Dublin Castle.

▼ FIGURE 5. [RIGHT] EMPEC 2011.

▼ FIGURE 6. [LEFT] Trinity College.

▼ FIGURE 7. [RIGHT] St Patrick’s Cathedral.

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ITERATIVE RECONSTRUCTION IN NUCLEAR MEDICINE: TOWARDS A ‘CLEARER’ PICTURE HELEN BLUNDELL Cardiff and Vale University Health Board

QUEEN ELIZABETH POSTGRADUATE CENTRE, BIRMINGHAM 8th February 2011

THE USE OF ITERATIVE reconstruction in nuclear body planar scintigraphy for patients with metastatic bone medicine SPECT imaging and PET imaging is becoming disease. Results showed early noisy images and artefacts increasingly widespread, so this meeting served as both a due to low count densities in the patient scans. Adapted timely introduction to the physics behind the technique filters in the newer version of software have improved this and a review of current developments in reconstruction situation. techniques designed to optimise image quality. Mark Boyle (Grantham Hospital) returned to the The first two teaching lectures were given by Richard subject of myocardial perfusion imaging (MPI), Lawson (Central Manchester University Hospitals NHS concluding that iterative reconstruction was a valid Trust) and Brian Hutton (University College, London). alternative to FBP in cardiac imaging, providing that care These were an excellent introduction to the subject, was taken to establish optimum acquisition and outlining how an iterative process can be used in place of reconstruction parameters. filtered back projection (FBP) to reconstruct tomographic James Birchall (Derby Hospitals) spoke from the slices. The process begins by making an estimate of the clinician’s perspective, showing a wide range of clinical distribution of activity within the patient. The cases including gated myocardial perfusion imaging, I-123 corresponding estimated projections are then generated by MIBG tumour imaging, DaTscan dopamine receptor using a projection matrix to model the acquisition process imaging and octreotide tumour imaging. It was clear to and these are compared with the measured projections. see from the images that the use of iterative reconstruction The differences are used to update the estimated with attenuation, scatter and resolution corrections gave distribution. This process is repeated until a designated the best quality images visually and therefore best lesion end point is reached. The most commonly used algorithms detectability. One word of caution was that when relative are maximum likelihood expectation maximisation quantification (either T/N or in the case of PET SUV (MLEM) and the faster ordered subsets expectation [standardised uptake value] ratios) is being used the maximisation (OSEM). number of sets and subsets of iterations can affect these A major advantage of iterative reconstruction indices of uptake. algorithms over FBP is that the algorithms can incorporate The final three presentations of the day were on the use physical effects such as attenuation, scatter and loss of of iterative reconstruction techniques applied to PET resolution into the model of the acquisition process, imaging. thereby correcting the final images. David Dommett (GlaxoSmithKline, London) spoke In the second session, Johan Nuyts (Katholieke about phantom and clinical investigations used to Universiteit Leuven, Belgium) spoke on resolution compare the Siemens TrueX iterative reconstruction recovery and noise suppression in iterative techniques. algorithm with FBP. This algorithm uses measured point The technique of maximum a posteriori (MAP) was spread functions (PSF) across the field of view to model introduced as an alternative to MLEM which gives even the response of the imaging system. The results showed better lesion detection and noise characteristics. that TrueX contrast becomes better than FBP only at a high Louise Fraser (Administration of Radioactive number of subsets and iterations. For low numbers of Substances Advisory Committee, Didcot) then outlined the counts and where quantitative analysis is the principal results of the validation process for using resolution goal, FBP remains the preferred method. recovery software to recover image quality from David Towey (Charing Cross Hospital, London) also myocardial perfusion images acquired with only half the spoke about the TrueX algorithm comparing it with 3D- activity administered. At a time when Tc-99m supplies are OSEM. Phantom studies showed that optimised still not secure, this is particularly relevant. The pilot study reconstruction settings gave increased contrast for TrueX, was carried out by acquiring half-count data from gated which did not fall off when objects were displaced from studies and reconstructing this using iterative the centre of the field of view as is the case with 3D- reconstruction with resolution recovery. The full-count OSEM. Caution should however be taken when moving to data was reconstructed using standard protocols. The using PSF as SUVmax values will change. results of comparing the two sets of images were that there Ian Armstrong (Manchester Royal Infirmary) closed was very little clinical difference between the two sets of the day by discussing optimisation of reconstruction images and no statistically significant difference between parameters used for F-18 FDG PETCT in oncology, to calculated ejection fractions. A larger multi-centre trail is obtain the best possible image quality for a range of now needed, but if this gives the same outcome ARSAC patient sizes. would recommend the use of half-activity myocardial In conclusion, this was a meeting which was both perfusion studies reconstructed with resolution recovery. educational and enjoyable and I’m sure that all of the After lunch, Felicity Horton (Royal Surrey County delegates ended the day feeling a lot more confident in Hospital, Guildford) discussed the use of total body their understanding of iterative reconstruction techniques SPECT with Astonish resolution recovery versus whole and their applications. n

32 | DECEMBER 2011 | SCOPE Barts Water The original plastic water substitute material

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STEREOTACTIC RADIOTHERAPY: NEW EQUIPMENT, NOVEL TECHNIQUES IMRAN PATEL The Christie NHS Foundation Trust, Manchester

HAMILTON HOUSE, LONDON 9th March 2011

THIS WAS A ONE-DAY meeting organised by Helen Canada). David provided an excellent overview of liver Mayles (Clatterbridge Centre for Oncology, Wirral) on SBRT and his was the best talk of the day. He talked behalf of the IPEM Radiotherapy Special Interest Group. about how hepatocellular carcinoma was the third The meeting was attended by more than 60 delegates, leading cause of cancer death worldwide, though it is which included a mixture of physicists, radiographers not common in the UK or Canada, and provided clinical and clinicians. The aim of the meeting was to consider examples of patients from his centre who have benefited the potential improvements in patient therapy and the from SBRT. He pointed out that the key developments issues associated with frameless stereotactic facilitating SBRT to be considered as a treatment radiosurgery (SRS) and stereotactic radiotherapy (SRT). modality have been advances in motion The programme of the day consisted of 14 talks, three of management/image guidance. Maria Hawkins (Royal which were from invited speakers who covered the Marsden NHS Foundation Trust, Sutton) then presented basics of cooking liver (David Roberge, McGill her group’s work which compared volumetric University, Montreal, Canada), surface imaging for modulated arc therapy (VMAT) and respiratory gated cranial SRS/SRT (Todd Pawlicki, University of highly conformal SBRT for partial liver radiotherapy. California, San Diego, USA) and comparison of Monte Ten patients who had been treated at their centre with Carlo planning system against collapsed cone algorithm standard radiotherapy were retrospectively re-planned (Markus Stock, Medical University of Vienna, Austria). using the two techniques and they concluded that gating There were also four poster presentations. offers the lowest critical structure dose. Also, VMAT can increase therapeutic ratio in patients that cannot tolerate TALKS FROM ADDENBROOKE’S HOSPITAL, gating, which could make dose escalation possible. CAMBRIDGE However they noted that the mean liver dose was higher During the meeting there were a couple of interesting for VMAT plans compared with SBRT plans for a given talks from Addenbrooke’s Hospital (Cambridge) on the escalated dose. In the afternoon session, Irena Blasiak- use of tomotherapy for SRS/SRT. The first of these was Wal (Royal Marsden NHS Foundation Trust, Sutton) by Sophie Manktelow who discussed the use of a new introduced a concept of individualising liver SBRT for planning technique for stereotactic brain treatments large tumour volumes based on radiation-induced liver with helical tomotherapy and compared this with an disease risk calculated using Lyman-Kutcher-Burmer existing technique using a conventional linac. The model.1 The prescription dose for the patients was conventional technique involved the use of non- stratified into three dose bins depending on the effective coplanar arc therapy with circular applicators. She volume of uninvolved liver that was to be irradiated. concluded that helical tomotherapy provides a good She found that it was organ at risk (OAR) tolerance treatment technique for SRS of the brain with improved doses that limited dose escalation when OARs conformity of the target dose compared to the overlapped planning target volumes (PTVs) and that the conventional technique (figure 1), particularly for non- size of the tumour was the limiting factor when PTVs circular targets. However her initial results suggested a were far away from OARs. slightly higher average dose to brain tissue compared Other topics covered during the day included the use with the conventional technique. The second talk was of different imaging equipment during SRT treatments, given by Elizabeth Tait, who tried to answer the Cyberknife, commissioning Novalis, electronic portal question ‘Is tomotherapy a valid option for SBRT image dosimetry for cranial SRS/SRT and developments (stereotactic body radiation therapy) delivery of in SBRT for non-small cell lung cancer, which provided treatments for early stage non-small cell lung cancer?’. quite a wide focus on stereotactic radiotherapy, therefore She provided an excellent overview of tomotherapy- achieving the purpose of the meeting. Overall, this was a specific respiratory motion dose effects and discussed very interesting meeting and judging from the feedback the fact that large fraction sizes used in SRT and survey, it was enjoyed by many attendees. n randomness of breathing cancel out many of these effects based on some preliminary work. However, there was no conclusive evidence provided to answer the REFERENCE original question of whether tomotherapy was a valid treatment option.

TREATMENT OF LIVER CANCER WITH SBRT 1 Dawson LA, Normolle D, Balter JM, McGinn CJ, Over the course of the day there were a few Lawrence TS, Ten Haken RK. Analysis of presentations concentrating on the treatment of liver radiation-induced liver disease using the Lyman cancer with SBRT, one of which was given by invited NTCP model. Int J Radiat Oncol 2002; 53: 1422. speaker David Roberge (McGill University, Montreal,

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▼ FIGURE 1A. Treatment plan dose distribution for stereotactic radiosurgery of the brain using helical tomotherapy.

▼ FIGURE 1B. Treatment plan dose distribution for stereotactic radiosurgery of the brain using conventional linac (non- coplanar arcs with circular applicators).

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PARTNER COURSE: CLINICAL TRIALS ON SPECIFIC INDICATION FOR CARBON IONS THERAPY STACEY MCGOWAN Department of Oncology, University of Cambridge

PAVIA, ITALY 8th–10th April 2011

AS A PROTON RADIOTHERAPY PhD student I was the importance of randomised clinical trials (RCT). He lucky enough to be able to attend the PARTNER course demonstrated that without RCTs you can never be on clinical trials at the Italian National Centre of certain if some underlying bias in your sample is Oncological Hadron Therapy (CNAO) in Italy. affecting your results. The example given was that in the PARTNER is a PARticle Training Network for European past it was believed that women who took HRT had a Radiotherapy (www.cern.ch/PARTNER) and is a lesser chance of developing cardiovascular disease European Commission-funded Marie Curie Initial compared with women who chose not to take HRT. Training Network (MC-ITN) initiative. It was When an RCT was carried out the results actually established in response to the critical need for showed the opposite. This was due to the fact that the reinforcing research in ion therapy and the training of subjects who were more likely to choose HRT were professionals in the rapidly emerging field of hadron women who were more likely to take care of their health therapy. PARTNER brings together key academic and this reduced their chances of developing heart institutes, research centres of excellence and the leading disease, with HRT actually increasing incidences of heart European companies in particle therapy, IBA and disease. The second lecture was given by Professor Siemens, and offers training for future young Orecchia entitled ‘Plans for future clinical trials at researchers in the field of particle therapy. CNAO is one CNAO’, informing us that between 50 and 65 per cent of of the first dual particle therapy centres in Europe and is Italian patients have radiotherapy as part of their cancer scheduled to start patient treatment later this year. treatment and that there are 7,000 cases of radiosensitive The meeting was two-and-a-half days long and was tumours in Italy where 20 per cent of these would be chaired by Manjit Dosanjh (CERN, Geneva, treated with ions in the future. Professor Orecchia Switzerland, and PARTNER Co-ordinator) and Roberto discussed the three central aims currently being worked Orecchia (CNAO, Pavia, Italy). The opening lecture by on at CNAO: Pierro Fossati (CNAO), entitled ‘Clinical trials and 1. physical dose characteristics; EBM’, really set the scene for the weekend. The lecture 2. biological dose characteristics, and highlighted the concept of evidence-based medicine and 3. developing clinical protocols.

▼ FIGURE 1. The accelerator at CNAO which accelerates both protons and 12C ions for clinical use.

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We then had a tour of the facility, looking at the ▼ FIGURE 2. The treatment treatment planning system, the accelerator and the room and beam treatment room (figures 1 and 2). The accelerator was delivery system. amazing, and it was exciting to see such a complex piece of scientific equipment in a hospital setting. This really made us realise how important it is for there to be collaborations between different scientific backgrounds with expertise from a wide selection of fields for the success of this project. I was a little disappointed by the treatment room as it looked too much like an experimental setting rather than the friendlier look of a conventional linac, which am used to seeing; all the same it was still very impressive. After lunch we heard several interesting talks, including one from Jean-Louis Habrand (Orsay, France) on proton therapy in children. This talk focussed on the fact that despite paediatric tumours being very rare, they still count as the second highest cause of death for children aged between 5 and 14. Conventional radiotherapy in children can lead to complications such as growth disturbances in the bone, neuro-psychological impairments, sterility and secondary malignancies. Chemotherapy also comes with risks such as cardiac failure, renal problems and secondary malignancies. Dr Habrand used some patient examples to show how, due to the fact that proton therapy is more conformal, it results in less dose to nearby structures therefore reducing the risk of normal tissue complication. He discussed how further studies were required, but that proton therapy can be very beneficial and cost effective treatment for paediactric cancers. We also heard from Jun-etsu Mizoe (National Institute for Radiological Sciences, Japan) on the NIRS approach with carbon ions: long-term results of clinical trials for head and neck cancers, and Stephanie Combs (Heidelberg Ion beam-Therapy [HIT] Centre,

▼ FIGURE 3. The display cabinet showing the original first x-rays by Roentgen. ▼

SCOPE | DECEMBER 2011 | 37 SCOPE | MEETING REPORTS ▼ Germany) on HIT (and GSI)‘s clinical experience. (GSI is scientific instruments as well as some slightly more the Helmholtz Centre for Heavy Ion Research, Germany.) gruesome artefacts! One item that sparked excitement was That evening we all met in the old town of Pavia, which is an old guest book from the museum with the signatures of a beautiful pedestrian area with tall balconied buildings the Nobel Prize winners Fermi, Thompson, Pauli and and cobbled streets. The whole group got to know each Blackett. We all signed our names in the current book, other over some Italian pizza and homemade ice cream. joking about how it will become a museum artefact once The second day we heard again from Dr Fossati. This we are all famous. Later we were all taken out for an time he discussed ‘How to compare European and amazing five-course Italian meal. Japanese GyE’. In Japan there is a wealth of clinical On the final day we heard from Dr Combs on the plans experience with carbon treatments that has to be for future trials at HIT and Dr Orecchia on the roles of considered. The lecture discussed the problems to be imaging in hadrontherapy. Closing discussions included solved since the Japanese are/have been treating with a how to implement a grid system in particle therapy for passive technique and a different method for measuring sharing patient treatments and outcomes, and a debate on RBE (relative biological effect) compared to GSI and HIT. the strict quality assurance required in radiotherapy and At CNAO treatments will be made with an active its irrelevance in other methods of cancer treatment such scanning technique and using the same treatment as surgery and chemotherapy. We all then gave our thanks planning system as that used at HIT. To treat a tumour and goodbyes and headed off to our respective airports or uniformly at all depths a spread-out Bragg peak (SOBP) is train stations until we all meet up again on the next course required which can be achieved via passive scattering or in computational modelling in Surrey. active scanning. Passive scattering uses the application of Despite not being a PARTNER student, I was accepted ‘scatterers’ in the beam line to achieve adequate dose into the group and made to feel more than welcome conformation to the target volume. Active scanning uses (figure 4). The whole weekend was a great success and the charged nature of protons to deflect the paths of one of the highlights of my PhD experience so far. I would different beams using magnetic fields. We heard from Dr like to take this moment to say thank you to PARTNER Mizoe again on ‘H&N SCC experience with carbon and (funded by EC, Grant Number 215840), CNAO and all the future trials with mixed beams’ and ‘Brain tumours: students for this opportunity, their hospitality and clinical trials for hadrontherapy in glial tumour’. Marco friendship. I would also like to thank IPEM and Krengli (Novara, Italy) also spoke to us about ‘Proton PARTNER for the financial support I received to attend therapy in adults (where do indications come from?)‘. This courses like this. n talk included a comparison of results from retrospective phase II studies and which criteria are used to validate ▼ TABLE 1. protons in the clinical setting. It was discussed how with TABLE 1 The number of proton therapy there is the opportunity to use dose proton and carbon escalation to improve local control, but further prospective ion treatment studies are required. He also showed some statistics on Number of Number of sites worldwide in County/Continent the development of proton centres worldwide, which are proton sites carbon sites 2011. shown in table 1. Unfortunately the two scheduled China 1 1 Japanese speakers could not attend the course due to the effects of the earthquake, however this time was filled Europe 13 1 with presentations from all the students about their PhD research which proved very successful, insightful and Japan 5 3 sparked some interesting discussion. North America 10 0 On the Saturday night we were taken to the scientific museum at the University of Pavia (figure 3), which is one South Africa 1 0 of the oldest universities in Europe, founded in 1361. The South Korea 1 0 museum consisted of originals of Alessandro Volta’s

▼ FIGURE 4. All of the attendees and presenters at the PARTNER Pavia course 2011.

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SCOPE | MEETING REPORTS | INTERNATIONAL NEWS

LIVERPOOL SHORT COURSE ON MEDICAL STATISTICS HAMID REZA ZOLFAGHARINIA Queen Alexandra Hospital, Portsmouth

ROYAL LIVERPOOL UNIVERSITY HOSPITAL 3rd–4th May 2011

HAVING JUST GONE THROUGH the not very pleasant covered during the course included hypothesis testing, last couple of months before my Part I vivas (although I analysis of variance, ROC analysis, correlation and did come out in the end with flying colours), I had regression, survival analysis and clinical decision making. realised that perhaps statistics is not my strongest point, especially when it came to showing evidence in my LOOKED AFTER WELL physiological measurements portfolio that I had Despite being a fast-pace course due to the volume of successfully utilised statistical tests in the analysis of subjects covered in 2 days, it was very well planned and some data. In addition, I had ended up with a lot of very the audience could keep up with the flow of presentations confusing data at the end of my MSc project on the use of due to the coherence of the contents and the exercises at artificial neural networks for the analysis of EEG signals the end of each section. We were also very well looked (brain electrical activities) to detect patterns of after in terms of refreshments and the very delicious drowsiness. I did not have a clue as to what would be the meals served for lunch. It was my first time eating Scouse, right statistical approach to analysing those sets of data. a traditional dish from Liverpool, and I quite enjoyed it. This was when I came across the advertisement for the Medical Statistics course, hosted at the Royal Liverpool EXPERT KNOWLEDGE University Hospital in May 2011. The course was Antonio and Azzam were both very knowledgeable on organised by the Department of Medical Physics and their subjects and very helpful with the questions asked Clinical Engineering at the Royal Liverpool and by the attendees. We were even encouraged to forward to Broadgreen University Hospital Trust and the University them in advance any specific statistics problems to be of Liverpool. It did not take much effort to secure the discussed during the course. I sent them my MSc project funding for the course as my managers knew the course results and I got a very comprehensive and helpful met the IPEM and HPC CPD scheme standards and could response as to how I should analyse the results. I have be very useful for a trainee aspiring to gain the right written a paper on the results of my study that has been scientific skills required from a clinical scientist, not to submitted to the journal Medical Engineering and Physics. I mention that they were also quite happy with my latest enjoyed my stay in Liverpool and the course was very achievement of passing the Part I vivas with merit. useful and informative. I strongly encourage any Part I and II trainees to attend the course – it will provide them ORGANISATION AND TOPICS COVERED ON with a shortcut to broaden their understanding and THE COURSE knowledge on statistical methods and tools required for The course was run by Azzam Taktak and Antonio scientific approaches to problems. It is also a good way of Eleuteri (Royal Liverpool University Hospital). It was showing evidence for having acquired some of the arranged over two days: a refresher course on day 1 and competencies required for applicants to attain registration an intermediate course on day 2. The range of subjects as clinical scientists. n

MEETINGS 2013

CONFERENCES

Meeting Venue and dates More information

International Brighton International Centre This exciting conference is a joint venture between IOMP Conference on Medical 1st–4th September 2013 (International Organization for Medical Physics), EFOMP Physics (European Federation of Organisations for Medical Physics) and IPEM.

Keep an eye on the website for future announcements (www.icmp2013.org) or for further information Email [email protected] or telephone Candi Colbourn on +44 (0)1904 610821.

Organised by the IPEM Conference Team, Fairmount House, 230 Tadcaster Road, York YO24 1ES, England.

40 | DECEMBER 2011 | SCOPE CurrentCurrent Status and FuturFuturee DirDirectionsections of SPECT/CT Imaging 16 MarchMarch 2012 | British Institute of Radiology

This meeting will comprcomprehensivelyehilhensively cover topics such as basic sciences, commissioning SPECTSPECT/CTSPECT/CT,/ potential clinical indicationss (oncology(oncology,y,, carcardiology,diologyy,, endocrinology, and infection, benignnign and malignant mmusculoskeletalu conditions) and training.raining. A distinguishedistinguishedd faculty of clinicians and scientists who araree currcurrentlyentl using SPECT/CT systems will addraddressess these topics. Who should attend?nd? NucNuclearlear memedicinedicine cconsultants/ trainees, radionuclideclide raradiologists,diologists, pphysicists,hysic technologists, radiologistsdiologists anandd MSc nucnuclearl medicine students. For moremore information and to registerregister visitv www.bir.org.ukwww.birr..org.uk RegisteredRegistered Charity No: 215869

SCOPE | DECEMBER 2011 | 41 SCOPE | MEMBERS’ NEWS

NEW MEMBERS 2011

Full name Job title Organisation Town

Jonathan Whybrow Medical Physicist Royal Devon & Exeter NHS FT Exeter Mohammad Hussein Medical Physicist Royal Surrey County Hospital Guildford Helen Rachel Chapman Radiotherapy Physicist The Royal Marsden Hospital NHS FT London Nadia Nazir Nuclear Medicine Physicist Mount Vernon Hospital Northwood Mark Tucker Clinical Scientist West Midland Rehabilitation Centre Birmingham Thomas Lister Clinical Scientist Salisbury NHS FT Salisbury David Willis Clinical Scientist Norfolk & Norwich University Hospital NHS FT Norfolk Martin Smith Clinical Scientist Nuffield Orthopaedic Centre NHS Trust Oxford David Bernstein Senior Radiotherapy Physicist The Royal Marsden Hospital NHS FT London Narinder Lalli Clinical Scientist UCL Hospitals NHS FT London Cesar Ramirez Tinoco Clinical Scientist Maidstone Hospital Maidstone Andrew Robinson Clinical Scientist Imperial College Heathcare NHS Trust London Nicole Scrivener Medical Physicist Northampton General Hospital NHS Trust Northampton James Burnley Clinical Scientist Queen Elizabeth Hospital Birmingham Josephine Clorley Clinical Scientist Taunton & Somerset NHS FT Taunton Lisa George Clinical Scientist Queen Elizabeth Hospital Birmingham Eleni Kalogianni Nuclear Medicine Physicist King’s College Hospital NHS FT London Lorna Tasker Clinical Scientist Abertawe Bro Morgannwg University Health Board Swansea Nicola Murphy Medical Physicist University Hospitals of Leicester NHS Trust Leicester Anton Paramithas PET Physicist St George’s Healthcare NHS Trust London Thomas Butterfield Clinical Scientist Sheffield Teaching Hospitals NHS FT Sheffield Philip Orr Clinical Scientist Belfast Health & Social Care Trust Belfast Philip Wheeler Clinical Scientist Cardiff & Vale University Health Board Cardiff Mark Long Clinical Scientist Maidstone & Tunbridge Wells NHS Trust Canterbury Andrew Shah Medical Physicist Mount Vernon Hospital Northwood Aled Parry Radiotherapy Physicist Mount Vernon Hospital Northwood Dominic Nolan Clinical Engineer Salisbury NHS FT Salisbury Ian Honey Clinical Scientist Guy’s & St Thomas’ NHS FT London Roxanne Potts Radiotherapy Physicist Maidstone & Tunbridge Wells NHS Trust Canterbury Benjamin Westen Trainee Radiotherapy Physicist Portsmouth Hospitals NHS Trust Portsmouth

Alison Foulis Advanced Healthcare Scientist NHS Greater Glasgow and Clyde Glasgow

Leanne Berrigan Medical Physicist Mater Private Hospital Dublin Dublin Matthew Williams Trainee Clinical Scientist Sandwell & West Birmingham Hospitals NHS Trust Birmingham Mourougan Sinnatamby Specialist Radiotherapist Maidstone & Tunbridge Wells NHS Trust Canterbury Andrew Labeodan Dosimetrist Royal Berkshire NHS FT Reading Dimitris Visvikis Director of Research INSERM Brest, France Simon Cherry Professor, Biomedical Engineering University of California USA Oi-Ching Choi Medical Physicist Cancer Centre London London Laura Shell CT Manager/Trust Radiation Co-ordinator Medway Maritime Hospital Gillingham Consultant Clinical Scientist and Paul Alan White Cambridge University Hospitals NHS FT Cambridge Head of Clinical Engineering

Anthony Fisher Clinical Scientist & Head of Department Royal Liverpool University Hospital Liverpool

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New member Qualifications Category Date elected or transfer BSc Physics, London / MSc Medical & Radiation Physics, Birmingham / DPhil Physics, Exeter Transfer Corporate 23 June 11

BSc Physics with Medical Physics, Surrey Transfer Corporate 23 June 11

BSc (Hons) Mathematics & Physics, Warwick Transfer Corporate 23 June 11 Transfer Corporate 23 June 11

BEng (Hons) Medical Engineering, Bradford / MPhil Biomechanics, Bradford Transfer Corporate 23 June 11

BSc (Hons) Physics, Bath / MSc (Hons) Medical Physics, Surrey Transfer Corporate 23 June 11

BSc (Hons) Physics with Astrophysics, Birmingham / PhD Astrophysics & Astronomy, Southampton Transfer Corporate 23 June 11

BMedSci Biomedical Materials Science, Birmingham Transfer Corporate 23 June 11

MSci Maths & Physics, Bristol Transfer Corporate 23 June 11

BSc (Hons) Physics, London Transfer Corporate 23 June 11

BSc (Hons) Physics & Engineering, Mexico / MSc Medical & Radiation Physics, Birmingham Transfer Corporate 23 June 11

BSc (Hons) Physics, Surrey Transfer Corporate 23 June 11

MPhys Applied Physics, Hull Transfer Corporate 23 June 11

BSc (Hons) Physics with Finance, Surrey / MSc Medical Physics, Surrey Transfer Corporate 23 June 11

BSc Astrophysics, Cardiff Transfer Corporate 23 June 11

MSci Physics with Medical Physics, Nottingham Transfer Corporate 23 June 11

BSc Physics, Patras / MSc Medical Physics, Surrey Transfer Corporate 23 June 11

MEng (Hons) Medical Engineering, Cardiff Transfer Corporate 23 June 11

BSc (Hons) Physics with Medical Applications, Liverpool Transfer Corporate 23 June 11

BSc Physical Sciences, London Transfer Corporate 23 June 11

MEng Electronics, York Transfer Corporate 23 June 11

MSci Mathematics & Physics, Belfast / PhD Physics, Belfast Transfer Corporate 23 June 11

BSc Physics, Warwick Transfer Corporate 23 June 11

MSci Physics, London / MSc Medical Physics, Surrey Transfer Corporate 23 June 11

BSc Physics, London / MSc Radiation Physics, London Transfer Corporate 23 June 11

MPhys Astrophysics, Cardiff / MSc Medical Radiation Physics, Swansea Transfer Corporate 23 June 11

MEng Mechanical Engineering, Loughborough Transfer Corporate 23 June 11 Transfer Corporate 8 June 11

BSc Physics & Astrophysics Transfer Corporate 10 June 11

BSc (Hons) Physics, Bath / MSc Computer Science, Bath New member Associate 2 Aug 11 MEng Mechanical Engineering, Durham / MSc Clinical Physics & Bioengineering, London / New member Associate 2 Aug 11 PhD Clinical Physics, Glasgow BSc (Hons) Experimental Physics & Biology, Maynooth / MSc (Hons) Medical Physics, Galway New member Associate 2 Aug 11

BA Physical Sciences, Cambridge New member Associate 2 Aug 11

BSc Physics, New Delhi / MSc Physics, Annamalai New member Associate 2 Aug 11

BSc Physics with Medical Applications, Liverpool New member Associate 2 Aug 11

BSc Physics with Maths, Reading / MSc Radiation Physics, London / PhD Medical Physics, London Transfer Fellowship 3 Aug 11

BSc Physics with Astronomy, London / PhD Medical Physics, London New member Fellowship 17 Aug 11

BSc (Hons) Radiotherapy & Oncology, Hong Kong / MSci Radiation Physics (Medical Applications), London New member Associate 25 Aug 11

PgD CT, London / BSc (Hons) Medical Imaging, Canterbury New member Associate 25 Aug 11

MSc Biomedical Engieering, Guildford / PhD, London Transfer Fellowship 31 Aug 11

BSc Biophysics & Applied Biology, CNAA / MSc Biomedical Engineering, Guildford / Transfer Fellowship 31 Aug 11 PhD Medical Physics & Bioengineering, Liverpool

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elcome to As a result of the diverse scope, it does another packed not cover each area in great depth; however, issue of Scope! it serves as an excellent starting point and We have been contains many references for further pleasantly reading. I can therefore see this book being overwhelmed an extremely useful first reference for any with the manager wishing to review their current Wfantastic response from our readers quality management practices. It is up-to- wanting to review books. As a result, we date in terms of technology and the latest present you with NINE book reviews thinking on quality management starting with two from Keri Owen, who programmes, and contains several practical has reviewed Quality and Safety in case studies and worked examples. Radiotherapy and Adaptive Radiation Quality and Safety in Throughout, it maintains a patient-centred Therapy. These are followed by Radiotherapy approach, making sure we never forget why Michelle Footman’s review of this is important: there is even an essay Fundamentals of Digital Imaging in The honourable dedication on the first page entitled: ‘Quality as viewed and lived by the Medicine and Sarah Cade’s review of of this book reads: ‘We dedicate this patient’. Applied Medical Image Processing. textbook to radiotherapy patients UK physicists might be tempted to Another review for the radiotherapy worldwide. Our hope is that it will result in dismiss this as an American issue only; after community has been presented by Rob further advances in the quality and safety of all we have a solid history of quality Chaldecott and Usman I. Lula of IPEM radiotherapy’. A sentiment we can all share, management in radiotherapy. However, Report 103: Small Field MV Photon and made all the more timely coming in the when you consider the amount of time Dosimetry. Jennifer Lowe presents us wake of debates sparked by the New York spent ‘QA-ing’ light-fields in comparison to with a review of Charged Particle and Times article ‘Radiation Offers New Cures, PTV volumes, and the relative effect they Photon Interactions with Matter. In the and New Ways to Do Harm’ (Walt have on our treatment quality, perhaps it is Popular Science section, we have The Bogdanich, January 2010). time for all of us to re-think our quality Big Questions: Physics from Angela The book forms part of a series programmes, and this book would certainly Newing followed by Physics and commissioned by the American Association be a valuable starting point. Technology for Future Presidents by of Physicists in Medicine (AAPM) in 2007 to Stephen Battershill. The review section address the challenge of keeping physicists Keri Owen, Principal Clinical Scientist at the would not be complete without a piece informed about rapidly advancing Queen Alexandra Hospital, Portsmouth, UK from our very own Editor-in-Chief, techniques, and at 600 pages aims to cover in Marc Miquel, who has reviewed its entirety the subject of quality and safety – QUALITY AND SAFETY IN RADIOTHERAPY Quantum Man: Richard Feynman’s Life so does the book deliver? (IMAGING IN MEDICAL DIAGNOSIS AND THERAPY SERIES) in Science. The first thing that struck me is the sheer TODD PAWLICKI, PETER DUNSCOMBE, ARNO J. The ‘Just Published!’ and ‘New scope of material covered. This is NOT a MUNDT AND PIERRE SCALLIET Reports’ sections list recently or soon-to- Publisher: Taylor & Francis book on quality assurance tests – it goes well ISBN: 978-1-4398043-6-0 be-released publications. For any beyond this and tackles quality at the Pages: 643, hardback readers interested in reviewing books, highest levels of management and strategy. please contact the editors and we will Virtually every aspect of quality and safety send you details on how to join our in radiotherapy is dissected in a series of online workspace on UbiDesk. Here essays. you will find a list of all available books The book opens with a chapter on quality and details of how to request them. management covering aspects of the history Sadly, Marium Naeem will be and practicality of setting up quality stepping down after 2 years of voluntary management programs. Risk management service as a Joint Book Reviews Editor and error analysis are covered in the next for Scope. She has done a marvellous chapter, including a welcome overview of job of maintaining a smooth flow of the failure modes and effects analysis book reviews, recruiting new members technique proposed by AAPM TG 100 with for reviewing texts (especially from her an excellent full example given for own department) and writing the brachytherapy. Chapter 3 discusses the Adaptive Radiation ‘Editors’ part’ of the book review section importance of monitoring quality, both for alternate submissions. It has been a clinically and through audits. Chapter 4 is Therapy real pleasure to work with Marium. I about the role of leadership and different In days gone by, radiotherapy was a fairly would like to thank her for all her staff groups in managing quality, and the straightforward treatment: you’d fire a efforts and support throughout the last 2 remaining three chapters provide an beam of photons in the general direction of years, which has helped develop this overview of quality assurance programmes the tumour and hope. Needless to say, section to what it is today. Thank you for a variety of modalities. radiotherapy these days is far more once again and I wish you all the very The book contains viewpoints and advanced, but with advancement taking best for the future! examples from Europe, North America, place at different rates across different Australasia and International Organisations centres it can be hard to get a full picture of Usman I. Lula (e.g. the IAEA), hence it is a relevant the current status. This is where this series ([email protected]) reference for physicists and managers of books under the theme ‘Imaging in Marium Naeem around the globe. Medical Diagnosis and Therapy’ steps in. It

44 | DECEMBER 2011 | SCOPE BOOK REVIEWS | SCOPE

is aimed at today’s radiotherapy physicists understanding of the storage and processing who ‘must refresh their knowledge of of the images they work with, or as an advances in medical imaging or radiation introduction to students of medical imaging therapy, and must be prepared to work at and related fields. the intersection of these two fields’. Adaptive Radiation Therapy is the second Michelle Footman, Radiotherapy Physicist at topic in the series which is proving to be a Guy’s and St. Thomas’ NHS Foundation Trust, UK high-quality reference. The authors have succeeded in creating a single compendium FUNDAMENTALS OF DIGITAL IMAGING IN which covers nearly every aspect of this MEDICINE complex subject. There is a great need for ROGER BOURNE Publisher: Springer such a book given the scope and variety of Fundamentals of ISBN: 978-1-84882-086-9 techniques involved, and the lack of any Pages: 200 clear consensus on how to implement Digital Imaging in adaptive therapy regimes. Medicine It is aimed primarily at radiotherapy physicists; however, it would also be useful This book is intended as a descriptive for oncology clinicians and therapy overview of digital medical images, aimed radiographers who wish to study the subject at radiographers, nuclear medicine in more depth. The format of this book technologists or other health professionals, follows that set by the first book in the series i.e. those without detailed mathematical (Quality and Safety in Radiotherapy) in which knowledge. A lot of information is packed a selection of (mainly US-based) authors into some 200 pages, with chapters covering write short yet detailed essays on each topic digital image composition and storage which are compiled into different sections. (including a useful summary of the more This means that no single topic is covered in common file formats), acquisition methods Applied Medical any great depth, however the breadth of the of digital images in medicine, frequency coverage is what makes this book so useful. domain processing, measures of image Image Processing: It is well laid out, with lots of diagrams, quality, contrast adjustment, filtering and worked examples and case studies as well as spatial transformation. A Basic Course referencing of all the key documents on the Each chapter concludes with a summary In Applied Medical Image Processing, the author subject. A particular feature I liked was that of the important points. Numerous figures aims to provide an overview of the basic although colour diagrams are limited to 16 are included to illustrate points made in the methods of image processing with tangible pages of colour inserts, the pictures are also text, with the intention that the figures and examples rather than long theoretical reproduced in the body of the text in black captions can be used as a revision guide or derivations. The text is aimed at and white, meaning that the flow is not lost reminder without reference to the text, and undergraduate and early PhD students and whilst reading the text. The topics are wide- a CD of these images is provided with the requires the reader to have little more than ranging, covering (amongst others): book. Many of the images and illustrations basic algebra and programming skills. imaging, biological need for adaptive (largely black and white, with colour used The book begins with a chapter looking at therapy, radiobiological comparisons of to enhance the point being illustrated) are of how medical images are acquired. This plans, biomarkers for radiotherapy authentic medical images and serve to chapter is a brief introduction in order to response, treatment delivery, online and demonstrate not only the effects of various allow the reader to grasp the basics of medical offline plan adaptation strategies and image processing methods, but also their image acquisition. As such, a broad range of tumour tracking. potential usefulness in medical imaging imaging modalities are covered, providing an The last section is extremely useful, as it applications. overview of the basic theory and safety covers the application of adaptive Information boxes are provided considerations for each. Later chapters of the radiotherapy on a clinical site-by-site basis throughout the book, containing book cover different image processing and will be an invaluable reference for instructions on the use of ImageJ, a freeware techniques including filtering operations, centres adopting these strategies. I could see image processing and analysis program, to segmentation, spatial transforms, registration, it being used as a first reference which will carry out the image processing steps reconstruction and surface rendering. then guide the reader towards what to focus described in the book. For those who wish The book works well as an introduction to on in depth and where to go to get more to experiment with this software, a very medical imaging as it introduces and explains information. In summary, this is an excellent brief overview is given in an appendix at the key ideas and concepts. The compromise one-stop resource for any centre considering the end. Others can skip over these parts of that goes with this is that it is likely to prove implementing adaptive radiotherapy the book without interrupting the flow of unsatisfactory to anyone wanting to look in techniques. the text. detail at any of the methods discussed as none Despite some technical terminology that of them are covered in much depth. The topics Keri Owen, Principal Clinical Scientist at the makes it heavy going at times, the book is covered are clearly explained, including Queen Alexandra Hospital, Portsmouth, UK surprisingly readable and the author does explanations of the mathematical operations an admirable job of introducing such (such as matrix multiplication) that are ADAPTIVE RADIATION THERAPY (IMAGING IN concepts as image processing in the required, therefore making it an ideal text for MEDICAL DIAGNOSIS AND THERAPY SERIES) frequency domain with the minimum of anyone who is new to medical image EDITED BY: X. ALLEN LI Publisher: Taylor & Francis complicated mathematics. This book will be processing. ISBN: 978-1-4398-1634-9 of interest to those working in the medical The illustrations in the book are of variable Pages: 427, hardback

imaging field who desire a better quality, with plenty of good-quality images to ▼

SCOPE | DECEMBER 2011 | 45 SCOPE | BOOK REVIEWS ▼ demonstrate the image processing that has be encountered when implementing such from the chapter. At the end of each been carried out. There are also a number of techniques in a radiotherapy department. chapter, the authors have given a relatively poor-quality schematic diagrams The report commences with a brief concluding section which we found very which demonstrate the point discussed but overview of problems and issues with helpful when revisiting the report. look more like diagrams from a student small field dosimetry. It then expands on However, there was quite a bit of repetition project than what I would normally expect to several areas including small field throughout the report (e.g. summary find in a textbook. The explanations covered characteristics, dosimetry and detector sections), although the reader is warned of are also supported by the inclusion of computer requirements, TPS modelling, quality this in advance in the introductory chapter. code which the reader can use to try out the assurance and reference dosimetry. The There is also a lot of emphasis of important techniques discussed themselves. The code is booklet covers both conventional linac points in the report. There did seem to be written in such a way that it is very easy to delivery and specialised treatment an overuse of bullet points in the later understand and will run in either MATLAB delivery equipment including chapters of the report. or the free Octave software supplied on the CyberKnife, Gamma Knife and The level of detail throughout would accompanying CD-Rom. The result of this is Tomotherapy. It also (albeit briefly) assist any advanced trainee wishing to that it is accessible to all readers and will discusses the QA aspects of a scanning understand the fundamentals of small field provide a useful aid to understanding; water tank. The text is mainly based photon dosimetry and the differing however, it is inefficient so is unlikely to around SRT/SRS and SBRT and generally characteristics of chamber design for use in provide a viable source of code for those refers to collimator sizes of less than 4 the measurement of photon fluence. looking to implement any of the techniques. cm2, but many of the points raised Likewise, the chapter on Monte Carlo In general, I found this book to be an throughout the report are also applicable calculations is written in a way such that interesting and helpful introduction to to IMRT-based solutions. Thus, it also anyone without prior experience in this medical image processing. However, in some serves as a useful source of information area can gain some understanding of the places the poor layout of text and images on for IMRT centres. processes inherent in modelling and the the page did reduce the readability. This text The report focuses on advantages it represents when dealing with is likely to be of interest to students starting recommendations of how to reduce small field dosimetry. work in medical image processing and uncertainties that are introduced by There are around half a dozen typos in would be a useful library text for hospital employing small field sizes. The the report, with unevenness between the 12 departments offering training in medical illustrations throughout the report are chapters. Also, this report, published in imaging. generally clear, the labelling and legends 2010, states that ‘there are no published are appropriate for a scientific publication recommendations on machine QA on Sarah Cade, Imaging Physicist & a part time of this nature. Illustrations, on some specialised treatment systems such as PhD student in Medical Science of Imaging occasions, did contain text that could have Tomotherapy...’. This is now partly not true (The Institute of Nuclear Medicine at UCL) been resized to make it easier on the eye. – as an AAPM report on the QA of helical based at the Department of Medical Physics and Tomotherapy (AAPM Task Group 148) was Bioengineering, Royal United Hospital, Bath, UK published in 2010 (also discussed in a 2004 The report gives a paper by Fenwick et al. in Physics in Medicine and Biology). There is now a 2011 APPLIED MEDICAL IMAGE PROCESSING: A BASIC COURSE thorough description AAPM report on robotic radiosurgery (the WOLFGANG BIRKFELLNER and allows the reader CyberKnife), with QA recommendations Publisher: CRC Press already discussed by CRCPD H-26 Task ISBN-13: 9781439824443 “to gain an excellent Pages: 403, hardback Force in 2007. understanding The report is concise, with sufficient illustrations and the use of varied reference sources, and it has good internal There is a helpful level of detail in the referencing. Also, the contents page is report regarding what parameters are detailed enough to not require an index! ideally required to allow TPS” modelling to The reference list appears at the end of the reliably be used, though it is not booklet and is certainly extensive for a extensive. On a positive note, however, it booklet of this size, at 404 references. does require the reader to perform further At £35 to IPEM members and £50 for reading and research. The section on non-members, we feel the report would be current detectors available for small field a very useful purchase for any department measurements was informative, though it planning on introducing IMRT, SRT/SRS was felt that a table highlighting the pros or SBRT. IPEM Report Number and cons for each would have been very 103: Small Field MV useful. The report is fairly current with Rob Chaldecott & Usman I. Lula, Clinical modern technological advancement and Medical Physicists in the Department of Photon Dosimetry treatment delivery techniques. The points Radiotherapy Physics, Dorset Cancer Centre, IPEM Report Number 103 covers an extensive highlighted in each chapter were clearly Poole Hospital NHS Foundation Trust, UK range of issues that are encountered within explained and relevant to that section. radiotherapy when dealing with small field Each chapter has been written so that it IPEM REPORT NUMBER 103: SMALL FIELD MV sizes. The report gives a thorough can be consulted independently from the PHOTON DOSIMETRY EDITED BY: MARIA M. ASPRADAKIS description of small field dosimetry and rest of the report. The introductory section Publisher: IPEM allows the reader to gain an excellent in each chapter focuses on some ISBN: 978-1-903613-45-0 understanding of situations that are likely to background, purpose and what to expect Pages: 186

46 | DECEMBER 2011 | SCOPE BOOK REVIEWS | SCOPE

white throughout but is generously intelligent lay person can understand. I peppered with graphs, equations, tables, shall find this most useful in lectures to diagrams and photographs. Other selling senior schools. points of this textbook are the extensive The author, Michael Brooks, is a references at the end of each chapter and the quantum physicist who is also a meaty 21-page index. In places, I noticed journalist and broadcaster. His articles syntax that reminded me that English is have appeared in the New Scientist, The likely the second (or more) language for Guardian, The Observer and other many of the authors and editors. Though newspapers. The ‘big questions’ some may find it distracting, I don’t believe discussed here start with ‘What is the that this detracts from the book’s educational point of physics?’, which provides a Charged Particle and value. useful way of dealing with dinner party I think that PhD students, postgrads and questions of this nature. ‘What is time?’ Photon Interactions pure physics researchers will get most use answers questions such as why car from this text, particularly those who have headlights coming towards the observer with Matter read the earlier 2004 publication. However, I do not have the light coming towards My first inkling of the task ahead of me think that some of the chapters covering him at more than the speed of light. In occurred when I lifted the Taylor & Francis newer areas of research (e.g. environmental my opinion, ‘What happened to parcel from the doorstep – I needed to use conservation) should provide any reader Schrodinger’s cat?’ is not so both hands! After competing with my two starting out with a comprehensive straightforward but this is the only small eager helpers to open the box, the joy introduction with references. It may well be example of a complicated concept which of receiving a (free) shiny new hardback worth the $300 (currently £182 on Amazon) any layman would find difficult to grasp. book was slightly marred by the realisation investment for a library or diverse research that I had offered to lose my book-reviewing department, but perhaps limited to cherry to this weighty tome. individuals with either a substantial research Once I had summoned up the courage to grant or a generous aunt. The publisher’s It is full of insight into start reading the book’s 34 chapters and website states that the text is also available as how to explain very 1,045 pages, I found that the preface was a an e-book. complicated physics in very clear and concise explanation of the P.s. Science geek that I am, I weighed the “terms which a lay person rationale behind the creation of this text. It’s book – 1.988 kg. I wouldn’t recommend a follow-up to a 2004 publication with the popping it in your backpack for the can understand same title, and a different subtitle: commute. ‘Chemical, Physicochemical, and Biological Consequences with Applications’. Jennifer Lowe (formally known as Jen Gravity is the first of nature’s Apparently, the response to the first book Stratford), currently on a career break fundamental forces to penetrate the indicated demand for ‘more detailed consciousness. The author” suggests an scientific contents’ which the editors aimed CHARGED PARTICLE AND PHOTON experiment with a 6-month old baby, and to meet in this second publication. The first INTERACTIONS WITH MATTER: RECENT a toy suspended from the ceiling at a chapter reviews what was covered in the ADVANCES, APPLICATIONS, AND INTERFACES height that leaves it resting on a chair in EDITED BY: YOSHIHIKO HATANO, YOSUKE 2004 publication and explains that the KATSUMURA AND A. MOZUMDER. front of the baby. Remove the chair, subtitle’s ‘recent advances’ cover research Publisher: CRC Press, Taylor & Francis Group watching the baby’s eyes. The baby will since 2000 that was not covered in the first ISBN: 9781439811771 show astonishment that the toy does not Pages: 1,064 release. This text comprises contributions fall to the floor. This experiment appears from a great many authors. The majority of in the chapter ‘Why does the apple fall?’. the 73 contributors are in Japan (47) and the Popular Science The saying that ’there’s no such thing USA (14) but also the rest of the world as a free lunch’ is questioned. One can including K. Prise and G. Schettino closer to argue that the ‘free lunch’ is the universe home, at Queen’s University Belfast. This which ultimately provides all of our publication brings together research in such energy needs. This is another of the 20 diverse fields as chemistry, medical physics, chapters in the book. astrophysics, nuclear power, environmental I recommend this to all our readers as conservation and biotechnology. an inexpensive and delightful volume. The chapters that would be of most The hard cover contains an elasticated interest to the majority of medical physicists book mark, which can also be employed are Chapter 13 (briefly refers to heavy ions to hold the book shut. A very useful in the context of cancer treatments), Chapter touch if you are reading this at the 14 (radiation chemistry of heavy ions, poolside when on holiday. including Monte Carlo simulation), Chapters The Big Questions: 18 and 19 (radiation damage to DNA), Angela Newing, Gloucestershire NHS Chapter 21 (the use of microbeams to study Physics Foundation Trust (retired) the biological effects of low dose irradiation I have taken some time to review this book at a cellular level), Chapter 23 since receiving it 6 weeks ago, chiefly THE BIG QUESTIONS: PHYSICS (computational phantoms used in radiation because it is so fascinating and full of MICHAEL BROOKS Publisher: Quercus Popular Science dosimetry) and Chapter 24 (cancer therapy insight into how to explain very ISBN: 9781849161466 with heavy ion beams). The text is black and complicated physics in terms which an Pages: 208, hardback

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for me, this is where the book starts to bow to the pressures of politicians who unravel. Initially fired along with colourful would have preferred his views not to pictures, interesting stories and witty appear in the final investigating commission anecdotes, Muller drops these techniques in report. The ‘real pain’ Feynman (in the favour of a baron ‘pictureless’ desert full of words of chairman Rogers) got his wish black and white text when explaining with the inclusion of ‘Appendix F – quantum physics. One can only feel Sarah Personal Observations on Reliability of Palin and co were left like the reviewer, Shuttle’, a brilliant piece of writing on scratching their head in disappointment and reliability in engineering. confusion. Richard Feynman was without a doubt a Despite the let-down of the last few genius who could have graced many fields Physics and chapters – after all, we were given of science but applied his mind to permission to leave – Muller provides a solid theoretical physics. According to his protégé Technology for Future and entertaining education for any aspiring Stephen Wolfram, he was ‘perhaps the best leader, covering topics of interest that may human calculator there’s ever been’, but this Presidents be long forgotten by many physics majors. is hardly why he is remembered and loved On 11th March 2011, a tsunami hit the He even breezes over some medical imaging, by so many. Feynman is one of this rare Fukushima Nuclear Power Plant forcing the although his decision to include ultrasound breed of scientists that transcend the safety of nuclear power on to the global in a chapter about light for the sake of scientific community and become known to political agenda, but how can political convenience may upset some people. Still, the general public. His fame is largely built leaders deal with such issues with a limited the purpose of this book is to inform and on his amazing public lectures (available at knowledge of physics? Is the climate inspire the next future president and given a click of a button in the days of the changing and what technology should a the success of his Berkley lecture series, he Internet) and his capacity to connect with president invest in to deal with it? Are aliens may just succeed. audiences. The fact that he could tell jokes, real or was the Roswell incident a botched play the bongos (check it out on YouTube) CIA cover-up of a physics experiment? It’s Stephen Battershill, MSc Student in Medical and that his private life was well publicised these questions and more that Richard A. Physics at the University of Surrey, UK probably rendered him more human and Muller sets out to deal with in his book accessible to the public. But, all of that has Physics and Technology for Future Presidents. PHYSICS AND TECHNOLOGY FOR FUTURE been told so many times, from his With a straight-out attack on the poor PRESIDENTS: AN INTRODUCTION TO THE reminiscences transcribed in two books quality of physics teaching in schools, ESSENTIAL PHYSICS EVERY WORLD LEADER (Surely You’re Joking, Mr Feynman! and What NEEDS TO KNOW Muller sets his stall as the humourous and RICHARD A MULLER Do You Care What Other People Think?) to his sagacious teacher tomorrow’s future Publisher: Princeton University Press countless biographies. This begs the presidents never had. More conceptual in ISBN-13: 978-0691135045 question, do we really need a new Feynman Pages: 532 focus, the book tackles a wide range of biography? material that would be covered in an The answer would have been a undergraduate course alongside some of the resounding ‘NO’ if it was just another book more practical and quirky aspects of physics about the dancing, bongo-playing – ‘even most physics majors will be womaniser who spent countless hours in surprised’ is a much-used quip in the first strip clubs and also happened to be a chapter – with all maths either ignored or genius; but this is a different book. Like actively discouraged. Some of the side Feynman, Lawrence Krauss happens to be a stories are genuinely fascinating: Edison’s theoretical physicist and he decided to personal battle against Tesla and the ill-fated retrace the great man’s life through his Topsy the elephant, over the issue of AC or work. The result is a highly enjoyable book DC, gives an interesting account of how that strikes the right balance between decision makers can affect the course of scientific explanation and personal technology in society. anecdotes. This is as much a popular science But to portray this book as just an Quantum Man book on theoretical physics as it is a account of funny stories about physics As a teenager, a poster of the scorpion-like biography of one of last century’s greatest wouldn’t be fair. Muller has gone to great cloud of the exploding space shuttle minds. It might put some readers off but lengths to ensure that any future president Challenger was hanging over my desk. It this is why, I think, it makes such a good read. reading this book – or attending the lecture was a grim homage to anyone who lost Quantum Man might not be the first try at series from which the book is derived – will his or her life in the pursuit of human a scientific biography of Feynman but receive a valuable insight into many aspects advancement and a grimmer reminder thanks to Krauss’ very polished style and of physics. that even the grandest of projects can be genuine insight into the subject, this is The subjects are deemed fit for a derailed by something as trivial and probably the best. president by Muller as all have some topical anodyne as an o-ring. This small o-ring claim for existence, but he uses this well to was how I first came across Richard Marc E. Miquel give a good discussion on the fundamental Feynman. To my impressionable young aspects of physics. Towards the end – giving mind, he appeared to be a scientific knight QUANTUM MAN: RICHARD FEYNMAN'S LIFE IN less enthusiastic readers permission to leave (I wasn’t aware of his more colourful past SCIENCE (GREAT DISCOVERIES) if they wish – Muller does stray into more at the time) willing to carry out basic LAWRENCE KRAUSS Publisher: W. W. Norton & Co. complicated and challenging topics such as experiments to clearly demonstrate his ISBN: 978-0393064711 quantum physics and relativity. However, point to common mortals and unwilling to Pages: 350, hardback

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R. Price (Taylor & Francis, Inc.) provides a Just Published! self-contained overview of different types New Reports Dynamics of Biological Systems by of quantitative MRI techniques. Its n Decommissioning of Small Medical, Michael Small (Taylor & Francis Ltd) may introduction covers both the basics of Industrial and Research Facilities: A be a useful text for those involved in cancer biology and the theory of MR Simplified Stepwise Approach. IAEA mathematical modelling of human physics before going on to provide Nuclear Energy Series, STI/PUB/1517; organs. The book contains exercises and examples of the types of assessment 2011. projects using MATLAB. techniques available. n Commissioning of Radiotherapy Advanced Bayesian Methods for The Physics, Clinical Measurement and Treatment Planning Systems: Testing for Medical Test Accuracy by Lyle D. Equipment of Anaesthetic Practice for Typical External Beam Treatment Broemeling (Taylor & Francis, Inc.) the FRCA, 2nd Edition by Patrick Magee Techniques (CD-Rom). IAEA-TECDOC- addresses the use of Bayesian methods to and Mark Tooley (OUP Oxford) is aimed at CD-1583; 2011. promote the accuracy and efficiency of anaesthetists wishing to improve their clinical trials and tests, which some knowledge of physics applied to n On-site Visits to Radiotherapy Centres: researchers may find helpful. anaesthetic equipment. It covers the Medical Physics Procedures, Quality physical principles in line with the FRCA Assurance Team for Radiation Oncology Electromagnetic Fields in Biological syllabus and may also appeal to those (QUATRO) (CD-Rom). IAEA-TECDOC- Systems by James C. Lin (Taylor & Francis, involved in training this staff group in the CD-1543; 2011. Inc.) explores the range of potential use of such equipment. effects that EMF has on the human body. n Risk of Solid Cancers Following Radiation There are contributions from experts The Complete Correspondence of Exposure: Estimates for the UK within the field, which cover interactions Michael Faraday (6 volumes) by Frank Population. RCE 19 Report of the in cells and dosimetry, and also discusses James (Institute of Engineering and Independent Advisory Group on Ionising the exposure associated with MRI. This Technology). This 4,600 page series may Radiation. Health Protection Agency; 2011. text may be of interest to members of the appeal to those who have the luxury of non-ionising radiation community. time to read the correspondence between n Radiological Consequences Resulting from the nineteenth-century scientist and a Accidents and Incidents Involving the NMR Primer by Supriyo Ghosh (Taylor & number of high profile figures, including Transports of Radioactive Materials in the Francis, Inc.) focuses on the practical James Clerk Maxwell. Interested UK – 2010 Review. HPA-CRCE-024, MP applications of nuclear magnetic reviewers would be given extra time to Harvey and AL Jones; 2011. resonance and may prove to be a useful write their review!! reference for readers without a technical n Recommendations of the American background and those who wish to avoid For the Love of Physics by Walter H.G. Association of Physicists in Medicine on the complex maths and physics of NMR. Lewin (Free Press), a professor at MIT, Dosimetry, Imaging and Quality takes readers on a journey of Assurance Procedures for 90Y Microsphere Quantitative MRI in Cancer by Thomas encountering physics as you may never Brachytherapy in the Treatment of Hepatic E. Yankeelov, David R. Pickens and Ronald have done so before! Malignancies. AAPM Report 144; 2011.

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SCOPE | DECEMBER 2011 | 49 A HISTORY OF MEDICAL PHYSICS THE SUBJECT OF MEDICAL PHYSICS REACHES BRITAIN

FRANCIS DUCK has the fourth instalment in his series on the history of medical physics t took almost a century for the ▼ FIGURE 2. compare the contributions made in diverse as tidal motion and capillary physique médicale of Paris to The East Britain during the early nineteenth action, life expectancy and become medical physics in Indiaman Surat century in these areas by two very hieroglyphics. Britain. There were two distinct Castle. Neil different men, Thomas Young and Young was born on 13th June 1773 reasons for this. The first is Arnott was ship’s Neil Arnott. in Milverton, Somerset, into a strict semantic. Natural philosophy was surgeon between Quaker family. He was the eldest of Ithe term used generally for the part of 1807 and 1811 (© THOMAS YOUNG (1773–1829) 10 children, and of precocious talent. science that we now know as physics. National Thomas Young was a scientist of He was introduced to experimental Maritime Without common usage of the word outstanding talent and depth of physics at school in Dorset. During Museum physics, translation of the phrase Greenwich). understanding. He was also a his later youth he was essentially physique médicale held little meaning or medical doctor, though not, by all self-taught, living with a Quaker content. Secondly, the French were not accounts, a very good one.2 He is family in Hertfordshire and London. held in high regard in Britain, with remembered still as the man who He then commenced medical training considerable resistance to any ideas overturned Newton’s corpuscular in London, attending lectures and arising from the French Republic. It theory of light, demonstrating its dissection sessions in the Hunterian would be several decades before the wave nature through his classical school and other London hospitals. new system for medical education in two-slit experiment. He defined Continuing his medical education in France, created after their revolution, ‘passive strength’ in his Natural Edinburgh, Göttingen and would alter medical training in Philosophy, a magnificent two-volume Cambridge, he was finally appointed London. work based largely on his course in 1811 as physician at St George’s The emergence of medical physics given as Professor of Natural Hospital. He subsequently divided in Britain may be best traced by Philosophy at the Royal Institution.3 his time between a home and returning to Hallé’s 1805 definition of This fundamental property of a medical practice in Worthing and medical physics: physics in material is still known as Young’s responsibilities in London. Young’s physiology; in environmental health; modulus of elasticity. He also carried outstanding life is well described and in therapy.1 In this article I will out fundamental studies into areas as elsewhere (for example, reference 2),

50 | DECEMBER 2011 | SCOPE HISTORICAL FEATURE | SCOPE

so in this article I will concentrate just arterial dilatation, and that pulse East India Company ship Surat on his contributions to physics in transmission from the heart to the His Castle as ship’s surgeon (figure 2), physiology. capillary bed was instantaneous. On responsible for the medical care of 10th November 1808, Young linguistic the 120 crew. He made two voyages, PHYSICS OF VISION delivered the Croonian Lecture to the skills both to China, and his adventures His first scientific paper was Royal Society, On the Functions of the “would provided fertile material in his later presented to the Royal Society by his Heart and Arteries. Building on an career. great-uncle and mentor, Richard associated paper4 he demonstrated facilitate Brocklesby (1722–1797), when Young how consideration of the elastic his role as SETTLED IN LONDON was only 19 years old. It concerned properties of the artery could explain foreign Returning to regency London in the accommodation of the eye, its the pulse as a transmitted pressure 1811, he set up in medical practice. ability to focus at a variety of depths, wave. His analysis is difficult to secretary He gained his qualifications: MD which he attributed to muscularity of follow, but leads to an expression for of the from Aberdeen, MRCS, and finally the lens. As a direct result he was the wave speed , in which E is Royal LRCP. Now confident and qualified, elected to be a member of the Society. the modulus of elasticity of the wall, he moved to 38 Bedford Square, A few years later he returned to this ρ is the density of blood and e/D the Society from where he practiced for the next topic and, in November 1800, read On ratio of wall thickness to wall 40 years. But he already had much the Mechanism of the Eye, reporting his diameter.5 His estimates of pulse wider interests, and in the spring of own investigations and conclusions of wave velocity (15.5 ft/s) and aortic 1813 he gave a series of 20 lectures the mechanism of focussing (figure 1). dilatation (7 per cent) closely on natural science applied to He showed for the first time that approximate reality. Moreover, he medicine at the Philomathic accommodation must be attributed to predicted the presence of reflected ” Institution. This seems to have been the lens. By experimenting on his own waves from the capillary bed. His a small debating club: its rules eyeball, he excluded alterations in its medical colleagues noted his work, excluded discussion of religion and diameter during focussing by direct but did not understand or accept it. It politics. Here he started to develop measurement using a mechanical would be 70 years before Korteweg his talent to make scientific topics, calliper. He excluded refractive effects (1848–1941) completed the expression particularly physics and medicine, from shape changes of the cornea by for wave speed by including the accessible and interesting to a investigating focussing under water. effects of elasticity of the liquid. general audience, drawing liberally He was also the first to report and on traveller’s tales from his freshly- explain astigmatism. About a year NEIL ARNOTT (1788–1874) remembered journeys. later he proposed his three-colour Neil Arnott’s contributions to theory of vision, rediscovered half a medical physics lay primarily in ARNOTT’S ELEMENTS OF century later by Helmholtz, and public health and in education.6 He PHYSICS anticipating its experimental was born in Arbroath, a coastal town By the early 1820s, Neil Arnott had verification by about a century and a 50 miles south of Aberdeen, on the become a well-established doctor in half. 15th May 1788. Misfortune obliged London’s society, known by his his father, Alexander, to leave his contemporaries for his interest in SPEECH successful farm to become a the links between physics and Young spent the year 1795/6 at the merchant in Aberdeen, a business medicine. During 1825, news University of Göttingen, attending that also failed. Neil gained his arrived from Paris of Sir David medical lectures and preparing a Catholic faith from his mother, Ann Barry’s experiments on the effect of thesis concerning the organs of MacLean, and he retained a deeply atmospheric pressure on venous speech. Written in Latin, it proposed a religious view of nature that is return – the respiratory pump. universal alphabet of 47 letters, which evident throughout his later writing. Arnott’s opinion was sought, and it together would be capable of The MacLeans were traditionally did not support Barry’s. He used expressing the whole gamut of Jacobite, and Ann was born in the this as the stimulus to give a series possible sounds. His analysis of tiny remote Hebridean islet of of lectures on medical physics, to a acoustics would be developed later in Bororay. There were at least 6 largely medical audience, at his his Lectures in Natural Philosophy, and children in the Arnott family, of home in Bedford Square. For all his linguistic skills would facilitate his whom two, Neil and James, became Arnott’s undoubted talents in other role as foreign secretary of the Royal doctors. areas, he was no physiologist and, Society. Exploitation of speech Neil was taught at first by his both here and elsewhere, he analysis and synthesis would have to mother, and later attended grammar preferred to align himself with wait until the digital age. school and Marischal College in mainstream medical thinking, Aberdeen where he followed Patrick tending to be very cautious about THE PULSE Copeland’s course in experimental new insights, even when they were For the physician in the early natural philosophy. Graduating with correct. nineteenth century, the pulse was one MA in 1805, he then followed a 1- Using material from these and of very few diagnostic techniques, year medical training, supporting his previous lectures, he set about interpreted from its frequency, himself as a chemist’s shop assistant. writing the book that would place regularity and strength. The preferred Leaving Scotland, he gained hospital his name firmly in the public eye.7 explanation was that the pulse arose experience for 6 months at St Elements of Physics was a huge from arterial muscular contraction: it George’s Hospital, London. In April success, with four editions being

was believed that there was no 1807, and still only 19, he joined the published between 1827 and 1829. ▼

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In fact, these first editions fell short Arnott’s fluency in French had translations, from the Latin physica, of the intended scope, including only His enabled his appointment as the French physique or the German sections on dynamics, mechanics and extensive physician at the French Embassy. physik. By giving preference in an hydrodynamics (including acoustics). Given his lively interest in education, English text to the word physics over Sections on heat and light were use of it seems likely that he knew of, and the more widely-used natural added into the 5th edition in 1833. “familiar may have taken inspiration from, philosophy, his Elements of Physics The book also gained popularity in examples Pelletan’s Traité Eléméntaire de may be seen as a first bold step in Europe, and was translated into Physique, Générale et Médicale, establishing the subject of physics in several European languages. sets it published just 3 years earlier. He may the English-speaking world. In the introduction, Arnott says apart also have been aware that Physique From the popularity of his book, that he had intended to supply a from Médicale was a subject being taught and the accessibility of its ideas and treatise on Medical Physics for the to medical students in Paris. concepts, Arnott placed the idea of medical literature. But, finding ‘that more However, the two books were physics firmly in the public mind. the preliminary investigation of academic intended for two very different His extensive use of familiar General Physics required to suit the texts readerships – Pelletan’s was for examples of difficult concepts sets it work for medical readers, would medical students whilst Arnott’s was apart from more academic texts. have to be nearly as extensive as if it clearly aimed at the general public. Who could resist learning about were for general readers, he (the Inspection of the British Library inertia when illustrative paragraphs author) determined to make the catalogue shows that, up to this date, started: ‘A servant carrying a tray of work as complete and as extensively ” use of the word ‘physics’ had been glasses or china in the dark…’ or useful as possible’. restricted almost totally to ‘On the awful occasion of a ship in

52 | DECEMBER 2011 | SCOPE ▼ rapid motion being suddenly efficient heating and healthy FIGURE 1. from a lead-lined trough, 11 inches arrested by a sunken rock…’? This ventilation.9 (Perhaps he wrote it TOP LEFT] deep, half-filled with water. It was clearly was not a dry, academic text. using the spring-loaded pens from Young’s figure of covered by an India-rubber sheet His use of examples from medicine his own patent, shown in figure 4.) the eye, showing (available from Mackintosh and Co., its component and physiology emphasised for He criticised the inefficiency and 58 Charing Cross Road) secured in a parts3 (Wellcome public and medical colleagues alike pollution of the open grate, and Library, London). water-tight manner to the top of the the intimate connection between described the principles and box. A mattress was laid on top to ▼ medicine and physics. Occasionally construction of a smokeless, FIGURE 3. make a bed that had ‘most his enthusiasm for a dramatic thermostatically-controlled domestic [BOTTOM surpassing softness or yielding’. illustration stretched scientific truth. stove. He cited 14 advantages, one CENTRE] When the first patient was laid on it For example, the benefits of a long being that the evil of sweeping-boys Arnott’s Stove ‘she was instantly relieved in a carriage ride were attributed to the might be ended. He was oddly coy design, showing remarkable degree; sweet sleep inertial effects of the jolting on about his first industrial patent,8 the boiler E within came to her; she woke refreshed’. venous return. Such occasional errors even though it included a an outer metal Similar beds were quickly installed were the only criticisms from an description of a smokeless stove and case ABCD with in St Bartholomew’s and St George’s thermoregulator otherwise enthusiastic press. the book speaks of potential Hospitals. g.9 industrial applications. Much was

PHYSICS AND ENVIRONMENTAL subsequently made of his ▼ JAMES ARNOTT (1797–1883) HEALTH – ARNOTT’S STOVE philanthropy, noting that the new FIGURE 4. Neil’s brother James, 9 years his [BOTTOM LEFT] Hallé had included the conservation design for his domestic stove was junior, followed him into medicine Spring-loaded of health as the second component of never patented, allowing several and into the East India Company as 1 pens. Detail from medical physics, and it is in this field manufacturers the freedom to sell a Arnott’s 1835 a ship’s surgeon. James built on his that we may see Arnott’s variety of stoves based on the Arnott patent.10 brother’s interests in applying contribution, rather than in his more design (figure 5). physical methods to medical ▼ conservative approach to He was an enthusiast for the FIGURE 5. treatments. On one of his voyages, physiological physics. healthy benefits of fresh air, and [BOTTOM RIGHT] Neil had devised a dilator to treat an In 1821, Arnott was granted an supported the belief that fevers, One of the acute urethral obstruction, possibly industrial patent for the design of including those from smallpox, manufactured for the ship’s captain. Untreated, furnaces and engines.8 One claim measles and typhoid, were all air- designs of Arnott’s this would have been fatal. Around concerned a ‘means of burning or borne, or mal-arial. Arnott Stove. 1819, James spent some time with destroying smoke, and thereby unfortunately compounded this his brother in Bedford Square, where converting it into so much additional false view by writing a letter to The ▼ FIGURE 6. [TOP he developed and used the dilator.11 fuel’. He remained extremely Times during the 1849 cholera RIGHT] He describes it as ‘a tube of oiled interested in fuels, engines and epidemic, recommending the Neil Arnott in his silk lined with catgut, to make it ventilation, and this is evident in his installation of a high vent into the later years. airtight, attached to a cannula or Elements of Physics. He even included chimney, to release noxious gasses Frontispiece from catheter, by which it is distended an astonishingly prescient as a means of protection from the 7th and with air, so as to press on the part to description of the internal cholera. As one commentator said posthumous be dilated’. A contemporary report edition of combustion engine. ‘any expression of opinion by him … describes how ‘Mr Astley Cooper Elements of Following the publication of the must be deemed of so much Physics, 1876. was thereby enabled to extract a 5th edition, his attention turned to importance that we are anxious … to stone, nearly the size of a walnut, other matters and, in particular, to keep it before the world’. from the bladder of a Gentleman public health. The 1830s are now Companies quickly exploited the aged 60 – he suffered no pain, and in considered to mark the start of the opportunity. Dean’s, at the Arnott’s nine days he went abroad’. Neil public health movement in Britain Chimney Valve Depot, offered free described the dilator in the first and its leader, the lawyer and social reprints (though not, apparently, edition of his Elements of Physics, in reformer Edwin Chadwick cut-price chimney valves). During the section on hydrostatics. By this (1800–1890), became known to Arnott the same epidemic, John Snow was time James had returned to the East as one of his patients. Arnott soon carefully gathering data on cholera India Company as superintendent contributed to several official reports deaths in Bermondsey, which would surgeon. By 1843 he had settled in on the prevalence and causes of lead to his demonstration during the Brighton where he developed urban diseases. He saw these as next epidemic, 5 years later, that another therapeutic application of resulting from lack of ‘air, warmth, cholera was in fact water-borne. physics, the ‘use of a very low or aliment and exercise’, aspects of benumbing temperature in cancer, urban life evident in Charles Dickens’ THE HYDROSTATIC BED neuralgia, rheumatism etc.’, novels, written at about the same Arnott was also interested in apparently the first to use cryo- time. therapeutic devices, and in the 5th surgery and cryo-analgesia.12 He On 11th March 1836 he delivered a (1833) edition of Elements, oddly used a small pig’s bladder filled lecture at the Royal Institution, placed between ‘The force of the with tepid water, applied it to the showing a new invention of his heart’ and ‘The velocity of the skin and then slowly added ice and which became known as Arnott’s circulating blood’, Arnott added a salt to achieve a temperature below Stove (figure 3). Two years later, in section headed ‘The HYDROSTATIC freezing. He went on to oppose the the year of Queen Victoria’s BED for invalids’. Here he describes introduction of chloroform as an coronation, he published a book in a water-bed for the treatment of anaesthetic, considering cryo-

which he developed his ideas about pressure sores. He had a bed made analgesia to be much safer. ▼

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▼ NEIL ARNOTT AND EDUCATION and at London in chemistry. In total, edition was completed in 1876, and its Arnott was deeply committed to the Arnott prize money still amounts Such frontispiece is a photograph of Arnott education, of the public, of his to about £3,000 per annum. in his older years (figure 6). His body colleagues, of students and in moves was taken to Edinburgh, where it was medicine. He considered becoming ARNOTT’S LATER LIFE into the interred in the family grave in Dean an academic, in 1827 applying In 1837, Arnott received the honorary “public Cemetery, with his parents and four of unsuccessfully for a chair at the new award of Physician Extraordinary to his siblings. He is identified as the son University College. He gave evidence the Queen, placing him firmly arena for of Ann MacLean. to the Select Committee on Medical amongst the leaders in London a catholic Education in 1834, suggesting that, medical society. His address in were YOUNG VS. ARNOTT since army surgeons were paid by Bedford Square placed him in a key Thomas Young and Neil Arnott the Government, so should be position for professional networking. becoming influenced the development of medical ‘practitioners in parishes’. Such One close neighbour was Thomas easier at physics in very different ways. Young, moves into the public arena for a Wakley (1795–1862), who moved to this time brilliant polymath, well-connected, catholic were becoming easier at this Bedford Square in 1828, 5 years after free-thinking Quaker, created profound time, after the passing of the Catholic founding The Lancet. Arnott held knowledge and understanding in Reform Act in 1829. He was involved weekly dinner parties, and the guest physiological optics, phonetics and with the formal establishment of the lists suggest his wide circle of friends, haemodynamics. Arnott, inventor, University of London in 1836 from acquaintances and interests. We find educator, self-made man, conservative the amalgamation of University scientists, Michael Faraday and James ” Catholic, was the first to use the phrase College and King’s College, and was Wheatstone, publishers William and medical physics in English, and has been appointed to its Senate in 1838. From James Chambers, social reformers called the first medical physicist.13 He this position of influence he was able Rowland Hill and Robert Owen. At 67 wrote an international best-selling to help steer a decision in June 1843 years old, after a lifetime as a bachelor, book of popular science, created a that the BA degree should include he married Marianne Knight, the public understanding of the intimate natural philosophy and physiology. widow of an old friend. He retired link between medicine and physics, He advised on the syllabus of the from medicine, and prepared for a 6th and an efficient, clean domestic stove. first Bachelor of Science degree in edition of his Elements of Physics. This Others followed these visionary men. 1859. Two years later, natural was published in 1864, and a short The ways in which physics continued philosophy was finally introduced as supplementary text, Arithmetic to affect medicine and its training part of the London University Simplified, was published 3 years later. during the nineteenth century, and medical degree. Neil Arnott died in London, aged some of the scientists and doctors To this day, Neil Arnott’s legacy 88, on 2nd March 1874. In his will involved, will be described in the next may still be found in a number of (worth around £5 million at today’s article in this series. British universities, in the form of values) he stipulated that his friends prizes and scholarships from and executors, Alexander Bain and ABOUT THE AUTHOR Francis Duck is Honorary Consultant bequests made by him and his wife. Alfred Taylor, should revise and Medical Physicist in the Department of Arnott awards are still offered at St republish further editions of his Medical Physics and Bioengineering at Andrews, Aberdeen and Edinburgh Elements of Physics ‘to be extensively the Royal United Hospital Bath NHS Trust and visiting professor at the Universities in physics, at Glasgow in spread amongst the industrious University of Bath. physiology and in clinical physics, classes of the community’. The 7th Email: [email protected]

REFERENCES

1 Duck F. A history of medical physics. Defining medical 7 Arnott, N. Elements of Physics or Natural Philosophy, physics: 1794–1822. Scope 2011; 20(2): 50–4. General and Medical, Explained Independently of Technical 2 Robinson A. The Last Man Who Knew Everything. Oxford: Mathematics. London, 1827. Oneworld Publications, 2006. 8 Arnott, N. British Patent 4615. Furnaces; Steam and Air , 3 Young T.Course of Lectures on Natural Philosophy and the Engines; Distilling, Evaporating, and Brewing Apparatus Mechanical Arts, 1807. 1821. 9 4 Young T.Hydraulic investigations, subservient to an Arnott, N. On Warming and Ventilation; with Instructions for , 1838. intended Croonian lecture on the motion of blood. Phil Making and Using the Thermometer-Stove Trans Roy Soc 1808; 98: 164–86. 10 Arnott, N. British Patent 6549. Metal Pens and Penholders, 5 Tijsseling AS, Anderson A. Thomas Young’s Research on 1834. Fluid Transients: 200 Years On. CASE Report, April. 11 Arnott, J. A Treatise on Stricture of the Urethra, 1819. Eindhoven: Centre for Analysis Scientific Computing and 12 Bird HM. James Arnott, MD (Aberdeen) 1797–1883: a Applications, 2008. pioneer in refrigeration analgesia. Anaesthesia 1949; 4: 6 Bayliss RA, Ellis CW. Neil Arnott, FRS: reformer, innovator 10–17. and popularizer of science 1788–1874. Notes and Records 13 Lenihan J. Neil Arnott: the first medical physicist. Med Phys Roy Soc Lond 1981; 36(1): 103–23. 1994; 21: 1837–8.

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