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 Editor’s Letter 3 June 2010

The arrival of artificial life

Just because the DNA sequences are continuing to be have been made regarding the future technology itself but rather the intel-
a n n o u n c e m e nt developed at an amazing rate (over creation of synthetic genomes that will lectual property questions around it.
last week of the the last decade the estimated cost of allow eukaryotic systems (algae look Craig Venter has already introduced
creation of a viable synthesising one DNA base pair has like being the first) to be able to carry patent claims on his technology
bacterium, whose fallen from approximately $100 to out for, example, the photosynthetic which, if granted, could ultimately
entire genome had around one US cent), so extension of absorption of CO2 from power sta- give his lab monopoly rights to the use
been entirely syn- the new science of synthetic biology tions, or other vaguely defined worth- of this genetic engineering. The outcry
thesised from the basic chemical con- to non-prokaryotic systems is only while causes such as the production of against this has just started.
stituents of DNA, had been expected a matter of time. The real question is new drugs, vaccines or fuels.
for some time (after all the new bac- what the new technology will be used The real challenge of the recent
terium came from the laboratory of for. At the moment rough proposals announcement is not so much the
the master scientist/publicist Craig
Venter) doesn’t mean that it is any less
momentous. Several years ago Craig
Venter famously set the race for the
first initial sequencing of the human
genome alight by announcing that
his privately-funded enterprise would
sequence the human genome in three
years at the time when the multina-
tional collaborative, public-funded
human genome project was plod-
ding along three years into a planned
ten years programme. The effect of
Venter’s challenge was sufficient to
galvanise the public consortium into
revitalising their programme so that
in the end both groups achieved the
objectives at the same time. Since then
Venter has made no secret of the next
major objective of his lab which has
now been reached, namely the crea-
tion of a viable cell whose DNA has

concept: www.glamlab.it
been entirely chemically synthesised.
Of course many biologists rightly say
that for years now the insertion into
existing genomes of stretches of for-
eign DNA, whether extracted from

Anywhere,
other organisms or synthesised from
the base chemicals, has been rou-
tine practice in the world of genetic
engineering. In addition they point

when (you) need.

out that while Venter’s DNA was
chemically manufactured according
to a base sequence specified by scien-
tists, the new genome still had to be
inserted into an existing cell (specifi-
cally Mycobacterium mycoides) from
which existing native DNA had been Cardiovascular diseases are the world’s largest killers, claiming
removed, together with certain restric- 17.1 million deaths a year*. Over 40% are caused by heart attack
tion enzymes which could otherwise in the presence of a witness. Today the defibrillator is one of the
most effective solutions to help save life.
have degraded the inserted synthetic * World Health Organization, Fact sheet No. 317, Sept, 2009
nucleic acid. Nevertheless the demon-
strated viability of Venter’s mycobac- Rescue SAM Rescue Life
Public access defibrillator Professional monitor defibrillator
terium is indeed momentous, if only
because this is surely just the first of
a long series of other organisms that
will be created in the new discipline
www.progettimedical.com
of synthetic biology. Automated sys-
tems for the synthesis of specified
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 June 2010 6 Pediatrics

Renal involvement and injury

in obese children
In recent years, the prevalence of end stage renal disease (ESRD) , including ESRD the development of glomerular hyperperfusion
in the pediatric population, has been increasing in parallel with the rise of obes- and hyperfiltration, promotion of mesangial
ity and insulin-resistance. The clustering of cardiovascular risk factors (higher BMI, renal cell proliferation, increasing urinary albu-
min excretion rate, and augmented activity of
type 2 diabetes mellitus (T2DM), dyslipidemia, hypertension and insulin resistance
the renin-angiotensin-aldosterone system, thus
(IR), has been well documented in obese children and adolescents, suggesting that contributing to hypertension. Moreover, insulin
the effects of obesity on target organs in adults, including the kidneys are initiated stimulates the production of pro-inflammatory
during childhood. cytokines by the adipose tissue and seems to be
related to an impaired nitric oxide production
or action, and to the altered oxidant/antioxidant
by Dr A. Savino, Dr P. Pelliccia, Dr F. Chiarelli and Dr A. Mohn status observed in obese subjects [9, 10].

Impaired glucose tolerance (IGT)

The increasing prevalence of ESRD Currently there is increasing evidence that Elevated plasma glucose levels were found to
and childhood obesity obesity may also damage the kidneys; in par- be significantly associated with an increased
The prevalence of end stage renal disease (ESRD)
has approximately doubled over the past three
decades [1], in parallel with the increasing preva-
lence of obesity and insulin-resistance, which also
occur in the pediatric population throughout the
world [2]. Currently approximately one-fifth of
children and adolescents in industrialised coun-
tries are overweight or obese; obesity is thus a
real threat not only to the health of children and
adolescents, , but also for adults since the meta-
bolic, cardiovascular and renal impacts of obesity,
although generally not presenting symptomati-
cally until adulthood, have their origins in child-
hood [3]. This is alarming, since in most cases
the condition of being overweight/obese earlier
in life continues into adulthood, thus represent-
ing a major contributor to the adult obesity epi-
demic and to increased cardiovascular and renal
morbidity and mortality in adult life.
Even if the vast majority of studies that have
examined the association between obesity and
kidney disease (KD) have been carried out in
adults, a growing body of evidence suggests
that childhood obesity also increases the risk of
KD and its consequences, and that renal dys-
function may start long before the appearance
of hypertension or diabetes in adulthood [4].
ticular, central adiposity seems to be impor-
tant for renal function abnormalities, as it is
strongly associated with diabetes and hyper-
tension, the two most common causes of ESRD
[6]. Moreover, the metabolic syndrome (MS),
a major consequence of obesity, also seems to
be an independent risk factor for both chronic
kidney disease (CKD) and ESRD [4], with
accumulating data supporting the hypoth-
esis that increased insulin resistance (IR) and
hyperinsulinemia are among the most impor-
tant factors of MS contributing to renal injury
[7] [Figure 1].
Insulin resistance/hyperinsulinemia
Accumulating data suggest that IR, as well as
compensatory hyperinsulinemia, are independ-
ently associated with an increase prevalence
of CKD [8], and support the existence of sev-
eral pathways linking IR and hyperinsulinemia
with KD [Figure 2]. Insulin has been related to
prevalence of both CKD and microalbuminu-
ria, and with increased odds ratios of micro-
albuminuria [11]. Hyperglycemia is directly
related to hyperfiltration and renal hyperper-
fusion, and it has been causally linked to vas-
cular and glomerular dysfunction [12]. GFR
values increase across the spectrum of hyper-
glycemia among patients with IGT and newly
diagnosed diabetes. The decline in GFR was
greatest in patients with diabetes whereas it was
only modest in those with normal or impaired
glucose tolerance.
High blood pressure
Obesity is associated with the activation of
the renin-angiotensin-aldosterone system,
increased sympathetic nervous system activity,
IR and hyperinsulinemia, all of which contrib-
ute to tubular sodium reabsorption, associated
fluid retention and hypertension. A compensa-
tory lowered renal vascular resistance, elevated

From obesity and its metabolic

complication to renal involvement
and injury
The so-called “obesity-related glomerulopathy”
is clinically characterised by a higher serum
albumin, moderate proteinuria (with a lower
incidence of nephrotic-range proteinuria),
lower serum cholesterol and minimal edema;
morphologically it is defined as glomerulom-
egaly with or without focal segmental glomer- Figure 1. Obesity per se is a risk factor for renal complications. In addition, obesity is often associated with
ulosclerosis, due to functional and structural metabolic complications, such as diabetes, hypertension, dyslipidemia, and insulin resistance, which represent
renal changes [5]. well-known risk factors for the development of renal disease.

Figure 2. Through different pathways insulin resistance and hyperinsulinemia may lead to renal involvement
and injury. (Na = sodium; Na-Cl = sodium chloride; RAAS = renin–angiotensin–aldosterone system; GFR =
glomerular filtration rate; IGF-1 = insulin-like growth factor-1; TGF-ß = transforming growth factor beta; CTGF =
connective tissue growth factor; SNS = sympathetic nervous system; Ang II = angiotensin II; IL-1 = interleukin-1;
IL-6 = interleukin-6; TNF-a = tumor necrosis factor alfa; CRP = C reactive protein; NO = nitric oxide; IR =
insulin resistance) (adapted from Savino et al., Horm Res 2010, in press)
renal plasma flow, increased GFR and higher
blood pressure are important in overcoming
increased sodium reabsorption. In the presence
of other risk factors, such as hyperlipidemia
and hyperglycemia, these adaptive changes may
provoke glomerulosclerosis, proteinuria and
loss of nephron function, even before struc-
tural changes are evident [13]. Furthermore, in
obese subjects, visceral adipose tissue almost
completely encapsulates the kidneys and pen-
etrates into the sinuses of the medulla, causing
compression and increased intrarenal pres-
sure. Both increased intrarenal and abdominal
pressure may contribute to obesity-associated
hypertension [14, 15].
Hyperlipidemia
Obesity is commonly associated with hyper-
lipidemia and there is growing evidence that
abnormalities in lipid metabolism contribute to
renal disease progression. The mechanism has
not been fully elucidated, but triglyceride-rich
lipoproteins, free fatty acids (FFA) and metabo-
lites, and albumin-loaded FFA seem to play a
major role in renal cell injury. Hyperlipidemia
also causes mesangial proliferation and expan-
sion due to LDL cholesterol, development of
glomerulosclerosis and progressive renal failure
[16]. CKD patients also suffer from a secondary
form of dyslipidemia, which contributes to the
rate of progression of renal disease.
Metabolic syndrome (MS)
Several studies investigating the relationship
between factors of the MS and KD showed that
it can to a large extent be explained by the fact
7 June 2010
of puberty, due to the physiological decrease
in insulin sensitivity associated with normal
development in puberty [19].
The association between hypertension and
childhood overweight and obesity has been doc-
umented in several studies [9]. In general, blood
pressure values have been increasing in young
people over the last decade, in parallel with the
rise in obesity [20], and more children and ado-
lescents are falling into hypertensive ranges. The
risk of hypertension increases across the entire
range of BMI values and is not defined by a
simple threshold effect [21, 22]. Compared with
normal weight children, those with a BMI >90th
percentile were about three times more likely to
have hypertension [23]. Low insulin sensitivity
is also a well-known contributor to high blood
pressure in children: an insulin-mediated effect
on renal sodium reabsorption and on the sym-
pathetic nervous system (SNS), with a state of
hyperactivity characterised by increased heart
rate, BP variability, increased levels of catecho-
lamines and increased peripheral sympathetic
nerve traffic, are the main mechanisms that
have been suggested and described in obese
children [24, 25].
that most of the components of the metabolic The prevalence of microalbuminuria among
syndrome, namely T2DM, hypertension, obes- severely obese children was found to be 10%,
ity and low HDL-cholesterol levels, apart from which is consistent with previous findings in
predisposing to cardiovascular disease are also obese adults. This was not related to BMI or
strong independent risk factors for CKD [8].
Prospective data also suggest that the presence of
the MS is independently related to a greater risk
of developing CKD and microalbuminuria [17].
Obesity-related renal injury
in childhood
The sequelae of obesity, such as hypertension,
dyslipidemia and hyperinsulinemia are increas-
ingly being recognised in childhood. Clustering
of cardiovascular risk factors is seen in children
and adolescents, suggesting that adult conse-
quences of obesity on target organs, includ-
ing the kidney, are more likely to develop in
young people. Growing evidence also suggests
that childhood obesity may put young people
at increased risk for KD and its consequences.
One of the most important consequences of
obesity is the development of a state of insulin
resistance (IR). Obese children with a similar
BMI can differ in their risk for complications
on the basis of the degree of IR [18]. Hyperin-
sulinemia influences blood pressure and serum
lipoprotein concentrations, and often results in
hypertension and dyslipidemia. The presence
of these conditions, in addition to obesity, is
thought to play key roles in the pathogenesis
of obesity-related glomerulopathy. It is alarm-
ing that metabolic and cardiovascular compli-
cations are already found in obese prepuber-
tal children, as IR and related consequences
might be further exacerbated by the influence
www.ihe-online.com & search 45345
 June 2010
classical cardiovascular risk factors, but there
were significant associations with post-chal-
lenge glucose, insulin levels and whole body
insulin sensitivity index (WBISI), suggest-
ing that even slight abnormalities in glucose
metabolism may be a driving force for early
vascular damage in the toxic environment
of pediatric obesity [26]. Increased levels of
microalbuminuria and ß2-microglobulinuria
were also observed in obese children compared
to those of normal weight, indicating early
renal glomerular and tubular dysfunction as
a consequence of childhood obesity [27]. The
urinary albumin/creatinine ratio was associ-
ated with metabolic disorders linked to obesity,
and also with the clustering of features of the
MS. The relationship between microalbuminu-
ria and excess weight is more complicated in
adolescents, since overweight adolescents, with
presumably more coexisting cardiovascular
risk factors, had a lower prevalence of micro-
albuminuria [28, 29], probably due to the exist-
ence of important confounding variables, e.g.
orthostatic proteinuria. In any case, the associa-
tion of microalbuminuria with cardiovascular
risk factors differed according to BMI category,
being strongly modified by overweight.
The increasing prevalence of overweight closely
parallels the rise in type 2 diabetes among
children and adolescent [30]. In 1994, T2DM
accounted for one third of the newly diagnosed
diabetes cases among 10 to 19 year olds [31], 90%
of these subjects having BMI values at or above
the 90th percentile for age and gender. IGT and
IR are presenting early in life among overweight
and obese children and adolescents [32, 33],
suggesting that the metabolic process is acceler-
ated in these individuals and that the transition
between IGT and diabetes is shortened.
Obese children and adolescents have consistently
been observed to have a more unfavorable lipid
and lipoprotein profile than children and ado-
lescents with a normal body weight, with signifi-
cantly elevated total cholesterol concentrations,
higher LDL cholesterol and TG concentrations
and significantly lower HDL cholesterol con-
centrations [34]. At-risk lipoprotein concentra-
tions are of particular concern during the years
of growth because they tend to continue into
adulthood [35]. The best predictor of young adult
total cholesterol concentration is a measurement
taken 12 years earlier; approximately fifty percent
of children and adolescents who had total cho-
lesterol or LDL-cholesterol concentrations above
the 75th percentile had elevated concentrations at
follow-up in young adulthood [36].
Conclusions
Excess body weight is significantly associ-
ated with an increased risk for KD, not only in
adults, which is well documented, but also in
obese children and adolescents. A higher BMI,
8 Pediatrics
the presence of T2DM, hypertension and, of 21. Lee WWR. Pediatric Diabetes 2007;8(9):76–87.
particular importance, IR, are strong independ- 22. Sorof J, Daniels S. Hypertension 2002:40:441–447.
ent risk factors for CKD and ESRD, which may 23. Rosner B et al. Am J Epidemiol 2000;151:
be present even among overweight and obese 1007-1019.
children and adolescents. 24. Marcovecchio ML et al. J Hypertension
2006;24:2431–2436.
References 25. Lurbe E et al. Hypertension 2008;51:635–641.
1. USRDS: The United States Renal Data System. Am J 26. Burgert TS et al. Int J Obesity 2006;30:273–280.
Kidney Dis 2003;42:1–230. 27. Csernus K et al. Eur J Pediatr 2005;164:44–49.
2. Ogden CL et al. JAMA 2006;295:1549–1555. 28. Bangstad HJ et al. Acta Paediatr 1993;82:857–862.
3. Wang Y et al. Adv Chronic Kidney Dis 2006;13: 29. Mueller PW, Caudill SP. Ren Fail 1999;21:293–302.
336-351. 30. Hannon TS, Rao G, Arslanian SA. Pediatrics
4. Wahba IM, Mak RH. Clin J Am Soc Nephrol 2005;116:473-480.
2007;2:550-562. 31. Pinhas-Hamiel O et al. J Pediatr 1996;128:608-615.
5. Kambham N et al. Kidney Int 2001;59:1498–1509. 32. Sinha R et al. N Engl J Med 2002;346:802-810.
6. Pinto-Sietsma SJ et al for the PREVEND Study 33. Weiss R et al. Diab Care 2005;28:902-909.
Group. Am J Kidney Dis 2003;41(4):733-741. 34. Friedland O et al. J Pediatr Endocrinol Metab
7. Sarafidis PA, Ruilope LM. Am J Nephrol 2002;15:1011-1016.
2006;26:232–244. 35. Nicklas TA, Von Duvillard SP, Berenson GS. Int J
8. Chen J et al. J Am Soc Nephrol 2003;14:469–477. Sports Med 2002;23(1):S39-43.
9. Sarafidis PA, Ruilope LM. Am J Nephrol 36. Webber LS et al. Am J Epidemiol 1991;133:704-714
2006;26:232–244.
10. Savino A, Pelliccia P, Chiarelli F, Mohn A. Horm Res The authors
2010; in press. Alessandra Savino MD, Piernicola Pelliccia MD,
11. Chen J et al. Ann Intern Med 2004;140:167-174. Francesco Chiarelli MD, PhD, Angelika Mohn
12. Soper CP, Barron JL, Hyer SL. Diabet Med MD, PhD.
1998;15:1010–1014. Department of Pediatrics
13. Sandhu JS et al. JIACM 2004;5(4):335-338. University of Chieti
14. Hall JE et al. Am J Med Sci 2002;324:127–137. Chieti, Italy
15. Hall JE. Hypertension 2003;41;625-633.
16. Kasiske BL et al. Kidney Int 1998; 33: 667-72. Correspondence to:
17. Kurella M, Lo JC, Chertow GM. J Am Soc Nephrol Alessandra Savino, MD
2005;16:2134–2140. University Department of Pediatrics
18. Chiarelli F, Marcovecchio ML. Eur J Endocrinol Ospedale Policlinico
2008;159:S67–S74 Via dei Vestini 5, 66013 Chieti, Italy
19. Caprio S et al. J Pediatr 1989;114:963–967. Tel. +390871358015
20. Muntner P et al. JAMA 2004;291:2107-2113. e-mail: alessavino@katamail.com
BOOK REVIEW
Cardiorenal syndrome
Mechanisms, risk and treatment
Edited by Adel E. Berbari and Giuseppe Mancia
Published by Humana Press, 2010, 320 pp, 159,95 €
Accelerated cardiovascular disease is a frequent complication of
chronic kidney disease. Individuals with evidence of renal functional
impairment are more likely to die of cardiovascular events than to
progress to end stage renal disease. This relationship, which has been
termed the cardiorenal syndrome, exists whether impairment of renal
function is a consequence of primary renal parenchymal or primary
heart disease.
The mechanisms underlying the cardiorenal syndrome result from a complex interaction of
traditional and uremia related cardiovascular risk factors. Prevention and management of car-
diovascular disease include aggressive control of traditional risk factors as well novel approach
to prevent or reverse uremia related processes.
This book provides a comprehensive update analysis of our current understanding of
the cardiorenal syndrome, including epidemiology, pathophysiologic mechanisms, and
therapeutic approaches.
SPRINGER
Heidelberg, Germany
www.ihe-online.com & search 45609

Single site laparoscopy in children
Laparoscopy offers decreased post-operative pain and convalescence time with
improved cosmesis compared to open procedures. Single site laparoscopy repre-
sents the next wave of minimally invasive surgery. This article reviews applications
of single site procedures, the potential limitations and future directions in children.
by Dr S. D. St. Peter
Videoscopic approaches to operations have
allowed surgeons in every discipline to accom-
plish the goals of the procedures without the
large incisions traditionally necessary for expo-
sure. These approaches have rapidly expanded
over the last 20 years, and can be consid-
ered as one of the most significant surgical
advances of modern times, with documented
benefits including reduced post-operative
pain and convalescence with superior cos-
mesis. The minimally invasive approaches to
those operations with the most morbid inci-
sions, such as cholecystectomy, fundoplication,
splenectomy, nephrectomy and adrenalectomy
offer patients a tremendous decrease in their
physical investment.
While pediatric surgeons have trailed behind
their colleagues carrying out surgery on
adults in the widespread application of these
approaches, the gap is now closing with the
development of smaller instruments to facili-
tate performing the procedures. The evolu-
tion toward laparoscopy, however, was based
on the premise of maintaining the basic prin-
ciples of surgery including good visualisation,
comfortable ergonomics and the ability to
perform all the intended steps of the proce-
dure without struggling. Accomplishing these
goals requires well-triangulated separate
instrument sites for retraction, exposure, dis-
section, sewing and tying. Recently surgeons
have begun to challenge the means of accom-
plishing these goals and the goals of the
The set-up for bowel resection in Crohn’s disease,
with two instruments passed through stab incisions in
the fascia on each side of the camera port.
pediatrics
operation to allow for the entire videoscopic
procedure to be carried out through a single
incision in the umbilicus to further improve
the cosmetic results for the patient.
Single site limitations
Narrow distances between instruments
restrict the surgeon’s hands and limit the
range of motion. The parallel alignment of
instruments and scope limits triangulation
and the range of view, by making the field
of view dependent on the movements of the
instruments. While there is only one incision,
it is usually larger than any of those required
for standard laparoscopy. The literature avail-
able covers preliminary experience focus-
ing on feasibility, and comparative data are
still anticipated.
Equipment
Some equipment has been developed recently
to overcome some of the aforementioned
technical challenges. Several ports with
multi-channel capacity have been launched
on the market, allowing multiple instruments
to be placed through a single access device.
These offer some effective options for sur-
geons when more then three working instru-
ments are required. For example, we cur-
rently perform single site cholecystectomies
with a three channel port accomodating the
camera and two working instruments, while
an additional instrument is place alongside
the port to retract the gall bladder.
In an effort to overcome the loss of triangu-
lation, flexible instruments have been devel-
oped to adjust the angle of the instrument to
overcome the external parallel instruments.
However, because the instruments are often
crossed and the tip is at a different angle from
the shaft, the instruments often require coun-
ter-intuitive external movements by the sur-
geon. Likewise, flexible laparoscopes are now
available to allow a view outside the parallel of
the instruments.
Despite these advances, we have found that
single site appendectomy, cholecystectomy,
9 June 2010
splenectomy and bowel procedures can be per-
formed with standard laparoscopic equipment.
Pediatric considerations
Given the rationale that a single incision may
improve cosmesis, the margin of benefit may
be less in pediatric surgery where scarring is
typically less problematic and instrument sites
are currently 3 mm or less. Many abdominal
operations in small children and babies can be
carried out with a 5 mm umbilical port and
stab incisions so that 2.7 mm instruments
can be placed directly through the abdominal
wall. These incisions typically leave no per-
ceptible defects in the skin after a few months
[1]. Compared to the umbilicus of many small
children, the adult umbilicus provides a rela-
tively large skin surface for a longer incision to
be hidden. The current single incision multi-
ports require at least a 20 mm incision. This
is larger than the umbilicus in virtually all
infants and small children.
Single site approaches to infant operations that
require no exteriorisation, such as pyloromyo-
tomy, become quite inapplicable to single site
techniques. For example, the circumumbilical
open approach for pyloromyotomy leaves a
fairly obvious surgical incision. The single site
approach to this operation also leaves this scar
in addition to adding technical disadvantages.
Regardless, for the pediatric surgical popula-
tion to participate in the evolution of mini-
mally invasive surgery, we need to continue to
challenge our limitations, borrow from expe-
rience with adults, and apply the techniques
where possible.
Published experience
Single incision procedures have been reported
in adults for appendectomy, cholecystectomy,
gastrectomy, adrenalectomy, colorectal pro-
cedures, bariatric procedures and urologic
procedures. The number of procedures in
children has been more limited but includes
appendectomy, cholecystectomy, splenec-
tomy, intestinal operations, gastrostomy and
urologic procedures.
Appendectomy
The single incision laparoscopic approach
in children was first reported in 1998. The
described method included an infraumbili-
cal trocar with a 10 mm operative telescope.
The appendix was grasped with an instru-
ment introduced through a channel in the
scope allowing the appendix to be exteriorised
and excised with a traditional extracorporeal
method. A similar method was subsequently
 June 2010
Improved cosmesis. The image above shows the
umbilicus two weeks after an appendectomy.
reported in a series of 111 patients, which was
the first to introduce the concern for surgical
site infections with extracorporeal resection.
Utilising a grasper through the scope places
the working instrument and field of view
dependent on one another and such scopes
are not widely available. We have over-
come these limitations by placing a 5mm
port through the centre of the umbilicus
and using a stab incision through the fascia
above or below this port for insertion of the
working instrument. If the appendix requires
more tenuous dissection, a second working
instrument can be placed on the other side
of the camera port providing triangulation
similar to standard laparoscopy. Insufflation
is maintained by small fascial incisions and
keeping the flow at a high level. After the
appendix is mobilised, connecting the fascial
incisions allows for extracorporeal resection.
If re-insufflation is required, one can par-
tially close the fascia, insert a larger port or
place a finger in the residual space, which is
usually adequate to accomplish inspection
and suctioning of the cecal fossa.
Cholecystectomy
Single umbilical cholecystectomy has the
appeal of removing the visible incisions from
the epigastrum. Wide triangulation has been
the premise to usher in laparoscopy for safe
gallbladder removal, which is attenuated sub-
stantially with the single site approach. Flex-
ible instruments have been utilised to facili-
tate dissection. Recently, a few case series
have emerged in children, which utilised spe-
cialised equipment to perform the operation,
with results comparable to those previously
published with the standard laparoscopic
approach [2-4]. We currently use standard
instruments by placing two working instru-
ments through two of the three channels
offered by a multichannel port in scissor
fashion so that the infundibulum is retracted
laterally with the surgeon’s right hand and
dissection is done with the left. We place a
grasping instrument alongside the port to
retract the gallbladder so the operation is
done in the standard 3-instrument manner.
10 pediatrics
No prospective data exist in the literature on
single site procedures, however a recent sys-
tematic review of randomised controlled trials
comparing laparoscopic and minilaparoscopic
cholecystectomy found the same operating
time, morbidity, analgesia use and convales-
cence. The cosmetic advantage led to the con-
clusion that smaller is not necessarily better,
The lesson of the importance of good com-
parative data should be learnt before allowing
single site procedures to dominate the options
for the patient.
Intestinal diseases
In infants, we have previously applied the sin-
gle umbilical incisions to numerous intesti-
nal diseases without laparoscopic assistance,
since the entire small bowel can be eviscer-
ated through a small umbilical incision in
these patients. Operations using only the
umbilicus have been applied to conditions
such as necrotising enterocolitis, jejunoileal
atresia, midgut volvulus, meconium ileus
and stomas.
In older patients, Meckel’s diverticulectomy
and small bowel resection are simple tran-
sumbilical operations due to the mobility of
the intestine. A single grasper can be used
to identify and grasp the area for resection
and bring it up through the umbilicus for
extracorporeal resection.
Ileocectomy is the operation where the sin-
gle umbilical incision has intuitive advan-
tages. Standard 3-port ileocectomy uses two
working ports to mobilise the right colon
and terminal ileum to allow for extracorpor-
ealisation. The ultimate size of the umbili-
cal incision is limited by the size of the mass
being inverted, which is often large in Crohn’s
disease. The necessity to open the umbili-
cus offers the opportunity to make a larger
incision in the beginning so two working
The picture above shows how the multichannel port
can be used with a working instrument right along
side of it to replicate a standard 4 port technique.
instruments can be placed with good trian-
gulation. The umbical location allows for
simple takedown of the hepatic flexure to
ease extracorporealisation.
Other procedures
There are several of other procedures reported
in the literature using the single incision
approach in children, including single port
laparoscopy-aided gastrostomy tube placement,
varicocelectomy and neonatal ovarian cysts.
Summary
Single site laparoscopic operations appear to
be the next generation of procedures with the
potential to further minimise the impact that
the operations have on patients. Currently,
sound comparative data are lacking in the lit-
erature. Given that the margin of advantage
is likely to be small, and in any case certainly
not comparable to the leap that occurred from
open to laparoscopic surgery, we feel prospec-
tive trials are warranted for these procedures.
We are currently conducting three prospective
randomised trials for appendectomy, cholecys-
tectomy and splenectomy utilising a validated
scar assessment tool during follow-up to ana-
lyse whether the patients perceive the cosmetic
benefits these operations are reported to offer.
References
1. S t Peter SD, Holcomb GW 3rd, Calkins CM, Mur-
phy JP, Andrews WS, Sharp RJ, Snyder CL, Ostlie
DJ Open versus laparoscopic pyloromyotomy for
pyloric stenosis: a prospective, randomized trial.
Ann Surg 2006; 244(3): 363-70.
2. P onsky TA, Diluciano J, Chwals W, et al. Early
experience with single-port laparoscopic sur-
gery in children. J Laparoendosc Adv Surg Tech
2009;19(4):551-553.
3. R othenberg SS, Shipman K, Yoder S. Experience
with modified single-port laparoscopic proce-
dures in children. J Laparoendosc Adv Surg Tech
2009; 19(5): 1-4.
4. D utta S. Early experience with single incision
laparoscopic surgery: eliminating the scar from
abdominal operations. J Ped Surgery 2009; 44:
1741-1745
The author
Shawn D. St. Peter, MD
Department of Pediatric Surgery,
Children’s Mercy Hospital and Clinics,
2401 Gillham Road,
Kansas City, MO,
USA 64108
Tel: 816-983-6465
Fax: 816-983-6885
e-mail: sspeter@cmh.edu
Comments on this article?
Feel free to post them at
www.ihe-online.com/comment/SS_laparascopy
 NEWS IN BRIEF — PEDIATRICS
Gene variant raises odds of
mother-to-child HIV transmission
A correlation has been discovered between
specific variants of the gene that codes for a key
immune system protein, TLR9, and the risk of
vertical transmission of HIV. Researchers writ-
ing in BioMed Central’s open access Journal of
Translational Medicine studied three hundred
children born to HIV-positive mothers, find-
ing that those who had either of two TLR9
gene variants were significantly more likely to
acquire the virus.
Anita De Rossi from the University of Padova,
Italy, worked with a team of researchers to
carry out the study using samples taken from
children born between 1984 and 1996 to HIV
infected mothers who had not received antiret-
roviral prophylaxis. Two changes to the TLR9
gene have recently been linked to progression of
HIV-1 disease and viral load in adult patients.
This study found that children who have two
copies of either of these polymorphisms are
at significantly higher risk of catching HIV as
they are born.
TLR9 plays a pivotal role in the induction of
first-line defense mechanisms of the innate
immune system and triggers effective adaptive
immune responses to different bacterial and
viral pathogens. This study is the first to link
changes in the protein to vertical HIV trans-
mission. De Rossi said that the results con-
firmed the relevance of innate immunity in
perinatal HIV-1 infection, knowledge which-
may be valuable in the development of new
therapeutic strategies including the use the
specific adjuvants.
http://www.translational-medicine.com/
Genetic markers of adult obesity risk
are associated with infancy weight
gain and growth
In research pub-
lished recently in
PLoS Medicine,
Ken Ong of Adden-
brooke’s Hospital,
Cambridge, and
colleagues show an
association between
greater early-infancy gains in weight and length
and genetic markers for adult obesity risk.
The proportion of overweight and obese
11 June 2010
children is increasing across the globe. World-
wide, 22 million children under five years old
are considered by the World Health Organi-
sation to be overweight. The authors suggest
that weight gain and growth even in the first
few weeks after birth may be the beginning of
a pathway of greater adult obesity risk. How-
ever, this research does not provide advice for
parents on how to reduce their children’s obes-
ity risk. It does suggest that ‘’failure to thrive’’ in While endochrondal ossification is essential to
the first six weeks of life is not simply due to a the development of cartilage and long bones, it
lack of provision of food by the baby’s caregiver has not previously been shown to play a role in
but that genetic factors also contribute to early normal skull development. This research, implies
weight gain and growth. that endochondral ossification can induce skull
http://tinyurl.com/352u7af deformities. Alterations of the mesenchymal stem
cells have also been associated with osteoarthri-
Stem cell disruption tis, osteoporosis and osteoponia, and mutations
induces craniosynostosis in either the WNT or FGF pathways are often
In a study lead by Dr Wei Hsu, scientists at the detected in skeletal disorders and cancer.
University of Rochester Medical Center, USA http://tinyurl.com/38a6owl
have discovered a defect in cellular pathways
of mice that provides a new explanation for ULTRASOUND POWER & DEW-POINT METERS
the earliest stages of abnormal skull develop- WWW.OHMICINSTRUMENTS.COM
ment in newborns, namely craniosynostosis.
Mutations of the WNT and FGF signalling UTRASOUND POWER METER
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these individual plates of skull bone are sepa- • OTHER MODELS START AT $1160
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during the first 18 months of life that are
DEW-POINT METER
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the mesenchymal stem cells, and when these
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Cardiology special
Selection of peer-reviewed literature
on cardiology
The number of peer-reviewed papers
covering the vast field of cardiology
is huge, to such an extent that it is fre-
quently difficult for healthcare profes-
sionals to keep up with the literature.
As a special service to our readers, IHE
presents a few key literature abstracts
from the clinical and scientific literature
chosen by our editorial board as being
particularly worthy of attention.
Optical coherence tomography
assessment of in vivo vascular
response after implantation of
overlapping bare-metal and
drug-eluting stents.
A randomised trial was designed using opti-
cal coherence tomography (OCT) to assess
coverage and apposition of overlapping bare-
metal stents (BMS) and drug-eluting stents
(DES) in human coronary arteries. Overlap-
ping DES impair healing in animals. Optical
coherence tomography allows accurate in vivo
assessment of stent strut coverage and appo-
sition. Seventy-seven patients with long coro-
nary stenoses were randomised to overlapping
sirolimus-eluting stents (SES), paclitaxel-elut-
ing stents (PES), zotarolimus-eluting stents
(ZES) or BMS. The primary goal of the study
was to determine the rate of uncovered/malap-
posed struts in overlap versus nonoverlap seg-
ments, according to stent type, at 6-month
follow-up with OCT. A total of 53,047 struts
were analysed. As assessed by OCT the impact
of DES on vascular healing was similar at
overlapping and nonoverlapping sites. How-
ever, strut malapposition, coverage pattern
and neointimal hyperplasia differ significantly
according to DES type.
Guagliumi G et al. ODESSA Trial Investigators. JACC
Cardiovasc Interv. 2010 May; 3(5): 531-9.
Spontaneous left main coronary
artery dissection and the role of
intravascular ultrasonography.
Spontaneous left main coronary artery
(LMCA) dissection is a rare event with an
unknown incidence and high risk of sudden
cardiac death. The diagnosis of LMCA dis-
section is often challenging, given the limi-
tations of 2-dimensional angiography. The
3-dimensional perspective of intravascular
ultrasonography (IVUS) is often indispensa-
ble in confirming or excluding the diagnosis
International
hospital
Equipment & Solutions
June
2010
of spontaneous LMCA dissection. Two cases
of spontaneous LMCA dissection with unique
angiographic presentations are reported in
this paper wherein IVUS was essential in
defining the extent of LMCA involvement
and facilitated the subsequent referral for
Cardiology
emergent coronary artery bypass grafting. The
two patients presented with acute coronary
syndrome prompting coronary angiogra-
Special
phy, which was notable for an unusual angi-
ographic appearance of the LMCA. Intravas-
cular ultrasonography was performed in each
case, revealing spontaneous LMCA dissection,
enabling prompt diagnosis and facilitating
definitive surgical intervention.
Klein AJ et al. J Ultrasound Med. 2010 Jun; 29(6): 981-8. Doppler
echo-cardiography in
Intravascular radiation therapy
with a Re-188 liquid-filled balloon non-cardiac surgical
in patients with in-stent restenosis. patients: does it
This study evaluated the feasibility and safety of
intravascular radiation therapy (IVRT) using a
improve outcomes?
Re-188 filled balloon system in patients with
in-stent stenosis. A total of 39 patients with in-
Page 14
stent restenosis were enrolled as the IVRT (22
patients) and control groups (17 patients) after The changing
a successful coronary angioplasty. For irradia-
tion the angioplasty balloon was replaced by paradigm of stress
a noncompliant balloon of the same diameter, echo-cardiography:
but 10 mm longer, with a proximal and distal
radio-opaque marker to deliver the dose of 18
risk stratification,
Gy at 1.0 mm depth from the surface of the bal- prognosis and patient
loon into the vessel wall. Angiographic follow-
up was performed after 6 months. The length
outcomes
of the irradiated segment was between 9.14 Page 16
and 22 mm and the diameter between 2.5 and
3 mm. In the IVRT group, two patients who
did not receive antiplatelet therapy had myo- Getting to the heart
cardial infarction. Four patients who had pre-
sented with stable angina earlier also had angi-
of things
ographically documented in-stent occlusion
(two patients) and edge stenosis (two patients)
Page 20
of the target lesion and received angioplasty
(18.1%). In the control group, three patients
with recurrent angina and four asymptomatic
Bringing laboratory PT/
patients had documented in-stent occlusion INR testing standards to
angiographically at 6 months and these seven the Point-of-Care and
patients underwent target lesion revasculari-
zation (41.2%). The overall restenosis rate in the home
the IVRT and control groups were 23.91 and
39.86%, respectively (P=0.013). No complica-
Page 22
tions were documented, except anginal pain
and ST segment changes. The results indi-
cate that the Re-188 liquid-filled balloon is
feasible, safe and effective in patients with
in-stent restenosis.
Selcuk NA et al. Nucl Med Commun. 2010 May 20.
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 June 2010 14 cardiology

Doppler echo-cardiography in non-cardiac surgical patients:

does it improve outcome?
Echocardiography provides bedside and immediate insight in the post-operative Immediate bedside
ICU patient, whenever hemodynamic deterioration occurs. Both morphological and hemodynamic information
hemodynamic features can be diagnosed instantly and related to clinical practice. Performing a complete echocardiogram offers
a full picture of the heart as cardiac muscle
Furthermore, this tool is used as a functional hemodynamic monitoring device
and the circulation pump. As with each other
offering on line information on systolic function, preload and afterload of both the (invasive) hemodynamic monitoring tools, all
left and right sides of the heart.This review will provide an overview of the data tricks and flaws must be recognised to permit
available with respect to improving outcome utilising this particular technology. a comprehensive hemodynamic evaluation of a
hemodynamically unstable patient.

by Dr Jan Poelaert In a hypotensive patient, a quick investigation of

Doppler-echocardiography is now generally
accepted as an invaluable tool to assess cardiac
compromised patients. All morphological and
functional aspects of the cardiac chambers,
including valves and the respective connec-
tive tissue and major vessels, can be evaluated
in a physiological approach. Furthermore,
hemodynamic monitoring, revealing ventricu-
lar function, insufficient preload or excessive
afterloading conditions [1], may often be fine-
tuned utilising Doppler echocardiography [2].
In mechanically ventilated ICU patients, the
non-invasive transthoracic mode is often the
preferred technique of choice.
Nevertheless, the transoesophageal approach is
ideal, with much better visualisation possibili-
ties. Although the transoesophageal approach
is somewhat more invasive, it remains a safe
technique. Recent, still unpublished, guide-
lines from the European Society of Intensive
Care Medicine strongly suggest only to use this
technique with an advanced level of training in
echocardiography.
Modern medicine is driven by endpoints and
goals. Most often the outcome and length of
stay in the ICU and in the hospital are part of
these. A summary of the potential of Doppler-
echocardiography to improve the outcome of
critically ill patients is provided in this review.
From a morphological point of view, post-
operative Doppler-echocardiography is par-
ticularly useful in those patients with hemo-
dynamic instability, high PEEP-ventilation,
necessity of high doses of inotopic or vasopres-
sor drugs, or any situation where inadequate
perfusion is present, even with normal cardiac
output. One look permits the evaluation of the
function of both the left and right ventricles by
combining different views. Furthermore, tis-
sue Doppler imaging allows the assessment of
regional or more global evaluation of the func-
tion of these chambers [3,4]. The different tools
of Doppler-echocardiography provide insight
into functional hemodynamics, in conjunction
with other more invasively obtained data, on
the condition that these data are integrated and
interpreted by the human brain using a physio-
logical approach. In this way, it is perfectly pos-
sible to get information on systolic and diastolic
function of the ventricles, the actual preloading
conditions and even the afterload.
Echo-Doppler diagnostic tool
The unique combination of several echo-
Doppler tools facilitates the correct interpre-
tation of flows within a selected zone. These
tools comprise:
• t wo-dimensional imaging, offering insight
into morphology and function;
• c olour Doppler, exemplifying scattering and
directions of flows, within the selected area;
•D  oppler, providing information on direc-
tion, intensity and duration of flows. In
addition the morphology of the Doppler
pattern itself can provide indications of the
pathology present;
• myocardial Doppler imaging, demonstrating
the relative motion, direction and intensity of
the investigated myocardial wall segment. In
particular, this technique is useful when ana-
lysing systolic and diastolic function of the
left ventricle. Care should be taken that both
systolic and diastolic characteristic Doppler
waves are preload dependent.
The difficulty with Doppler-echocardiography
concerns both acquiring the different images
in conjunction with the correct interpreta-
tion: both practical issues and knowledge must
be combined to come to a correct evaluation
[5]. Hence, correct interpretation can only be
achieved when the physiological meaning
is fully understood, applied and integrated
with other data. This necessitates a prolonged
learning curve, although the user need not be
acquainted with all facets to permit a practical
approach [6,7].
cardiac function at the level of the short axis view
permits differentiation between a cardiac and a
non-cardiac cause of hypotension [1]. A small left
ventricle suggests hypovolemia [8] or a ventricle
loaded with a high sympathomimetic intrinsic or
extrinsic load [9,10]. In contrast, a dilated, barely
contracting left ventricle needs inotropic support.
Therefore, this initial short axis view and the cor-
rect interpretation has a direct impact on bedside
management and hence outcome.
The myocardial performance index (MPI) is a
variable of both systolic and diastolic function
[11], which is, however, load dependent. The fol-
lowing formula allows calculation of this index:
MPI = (ICT + IRT)/ET
(ET, ejection time measured at the Doppler sig-
nal of the aortic flow; ICT, isovolumic contrac-
tion time; IRT, isovolumic relaxation time).
Although this index has a prognostic power in
cardiology practice, this index adds little infor-
mation on the ICU patient in view of the load
dependency. This was shown both in an animal
experimental [12] and in a clinical [13] setting.
Another, more useful load-dependent variable
is the systolic velocity of the mitral annulus,
assessed with tissue Doppler imaging. Veloci-
ties lower than 8 cm/s suggest decreased systo-
lic function whereas velocities above 15 cm/s
imply normal left ventricular systolic function.
Both preload [4] and afterload [14] appear to
have impact on the amplitude.
Rapid diagnosis of LV failure permits immedi-
ate intervention, which is, indirectly, related to
improved outcome [15,16].
Right ventricle
A similar differentiation can be made with
respect to the right ventricle. A normal right
ventricle is depicted as a crescent-shaped struc-
ture. A dilated right ventricle (i.e. right ventricu-
lar diameter > 0,6 diameter of the left ventricle)
suggests either right ventricular myocardial
ischemia, or volume and/or pressure overload
[1], with typical management approaches.

Assessment of flow across cardiac valves reveals
transvalvular pressure gradients. Typically, a
pressure gradient can be assessed from a tricus-
pid regurgitant flow in order to calculate right
ventricular systolic pressure (RVSP) correctly if
right atrial pressure can be estimated [17,18].
The knowledge of the presence of a dilated right
ventricle in conjunction with increase RVSP may
also be important in the direct management of
ventilator settings [19], optimisation of preload
[20], or reduction of afterloading conditions
[21-24], with indirect impact on outcome.
Myocardial ischemia
The direct visualisation of the relative motion
of the different wall segments provides an ideal
window for detection of myocardial ischemia,
on the condition that no other interfering
factors occur and the regional wall motion
abnormality is detected after previous normal
motion of the segment in question. These two
conditions suggest the difficulties which can
be encountered when trying to detect myo-
cardial ischemia with Doppler-echocardiog-
raphy. Conversely, Doppler echocardiography
is a perfect tool to confirm the localisation of
an occluded coronary artery with respect to
a malperfused myocardial region after a posi-
tive ECG or ST segment monitoring, which
alerted the clinician. Newer technologies are
currently being developed utilising vector-
related technology to allow early diagnosis
of myocardial ischemia.
Preload and fluid responsiveness
Preload is the first issue to be assessed whenever
hypotension has to be managed, and has been
related to improved outcome [25,26]. Clini-
cally, the legs-up test is preferred for evaluating
Figure 1. Systolic ventilation induced variation of flow, assessed at the level of the aortic valve.
optimal preloading conditions: it does no harm
and provides immediate information about the
filling status.
From a short axis view, the left ventricular end-
diastolic area (LVEDA) < 5.5 cm² was shown
to be associated with low preloading condi-
tions. Although a purely static variable of load,
the legs-up test brings this LVEDA as a truely
dynamic descriptor of fluid responsiveness.
Other variables are used in conjunction with
mechanical ventilation and they rely on the
variation of intra-thoracic pressures with
ventilation. Both inferior [27] and superior
vena cava [28] variations with ventilation can
be utilised. Care should be taken that these
variables only provide insight into right ven-
tricular preload. Acute right ventricular fail-
ure in conjunction with a hyperdynamic left
ventricle will be associated with an absence
of ventilation-induced variation of the diam-
eter. Commencing the echocardiographic
investigation with the short axis view will
already eliminate right ventricular dilata-
tion. Variation of stroke volume exemplified
by variations of the time-velocity-integral
(TVI) will provide the same information
[29], [Figure 1].
Conclusions
Doppler echocardiography provides immedi-
ate insight into the morphological and hemo-
dynamic functional aspects of cardiac and
circulation-related issues. The most impor-
tant advantage is that appropriate use leads to
direct action depending on the findings, even
with a limited number of views [30]. The adage
‘do not harm your patient’ can be followed by
introducing the TTE tool in conjunction with
15 June 2010
a really knowledgeable echocardiographer-
intensivist. ICU clinicians responsible for
the daily management of hemodynamically
unstable patients should be convinced to uti-
lise echocardiography as primary diagnostic
and monitoring tool.
References
1. Poelaert JI, Schupfer G. Chest 2005; 127: 379-390
2. Vignon P et al. Crit Care 2007; 11: R43
3. Edvardsen T et al. Circulation 2002; 105: 2071-2077
4. Amà R et al. Anesthesia Analgesia 2004; 99: 332-8
5. Poelaert J, Mayo P. Intensive Care Med 2007
6. Cholley BP, Vieillard-Baron A, Mebazaa A. Intensive
Care Med 2006; 32: 9-10
7. Charron C et al. Intensive Care Med 2007;
33: 1712-8
8. L eung JM, Levine EH. Anesthesiology 1994;
81: 1102-9
9. B oden WE et al. Cathet Cardiovasc Diagn 1978; 4:
249-63
10. Giacomin E et al. Cardiovasc Ultrasound 2008; 6: 9
11. Tei C et al. J Am Soc Echocardiogr 1997; 10: 169-78
12. Haney MF et al. Acta Anaesthesiol Scand 2007; 51:
545-52
13. Poelaert J et al. Acta Anaesthesiol Scand 2004; 48:
973-9
14. Borlaug BA et al. J Am Coll Cardiol 2007;
50: 1570-7
15. Faris R, Coats AJ, Henein MY. Am Heart J 2002;
144: 343-50
16. Poelaert J, Roosens C. Crit Care 2007; 11: 167
17. Sagie A et al. J Am Coll Cardiol 1994; 24: 446-53
18. Yock P, Popp R. Circulation 1984; 70: 657-62
19. Vieillard-Baron A et al. Am. J. Respir. Crit. Care
Med. 2002; 166: 1310-1319
20. Vieillard-Baron A et al. Am J Respir Crit Care Med
2003; 168: 671-6
21. Jardin F, Vieillard-Baron A. Intensive Care Med
2003; 29: 1426-34
22. Schmitt J et al. Crit Care Med 2001; 29: 1154-1158
23. Poelaert J et al. . Chest 1993; 104: 214-9
24. Poelaert JI et al. J Cardiothorac Vasc Anesth 1992;
6: 438-43
25. Feissel M et al. Intensive Care Med 2004; 30:
1834-7
26. Michard F, Teboul JL. Crit Care 2000; 4: 282-9
27. Barbier C et al. Intensive Care Med 2004; 30:
1740-6
28. Vieillard-Baron A et al. Anesthesiology 2001; 95:
1083-8
29. Slama M et al. Am J Physiol Heart Circ Physiol 2002;
283: H1729-33
30. Beaulieu Y. Crit Care Med 2007; 35: S144-9
The author
Jan Poelaert, MD, PhD
Department of Anesthesiology and Perioperative
Medicine
Acute and Chronic Paintherapy
UZ Brussel, VUB
Laarbeeklaan 101
1090 Brussels
Belgium
 June 2010 16 cardiology

The changing paradigm of stress echocardiography:

risk stratification, prognosis and patient outcomes
Stress echocardiography has evolved considerably over the last three decades. to catheterisation only for refractory symptoms.
The prognostic value of stress echocardiography is now well established, with the In addition, resting Ejection Fraction (EF) should
ability to risk-stratify patients into low (<1%), intermediate (1-5%) or high (>5%) have an important influence on the appropriate
management approach in such patients. An initial
risk groups. This article addresses the current role of stress echocardiography in
noninvasive management strategy may be cost-
stratifying risk, its influence on patient outcome and management decisions. effective and avoid unnecessary invasive proce-
dures. Conversely, high risk patients with WMSI
>1.7 and especially those with EF ≤45% are at a
by Dr S. S. Yao, Dr S. Bangalore, Dr X. Zhang, & Dr F. A. Chaudhry significant risk of cardiac events [Figure 1]. Such
high risk patients should be appropriately referred
for consideration of cardiac catheterisation and
Stress echocardiography was first introduced in Risk stratification and prognosis in potential coronary revascularisation in order to
1979 and represents the natural merger of car- patients with known or suspected modify and reduce their cardiac risk.
diovascular stress testing with two-dimensional ischemic heart disease.
echocardiography. The rationale for its use is An important objective of noninvasive test- Extent and severity of myocardial
that either physical exercise (treadmill or bicy- ing is to identify patients at risk for future wall motion abnormality as
cle) or pharmacologic (dobutamine or dipyri- cardiac events. The application of prognostic predictors of prognosis.
damole/adenosine) stress will result in ischemia. testing is based on the premise that in patients The prognostic utility of stress echocardi-
Myocardial ischemia is manifested as a regional identified as being at highest risk for adverse ography derives from its ability to quantify
wall motion abnormality, which then serves as outcomes, there can be intervention to alter the magnitude of “jeopardised” (i.e. poten-
a marker for the location, severity and extent of the natural history of their disease process, tially ischemic) myocardium during exercise
obstructive coronary stenoses. The applications thereby reducing subsequent risk. or pharmacologic stress testing. Specifically,
of stress echocardiography have broadened sub- stress echocardiography measures two indices
stantially since its introduction as a diagnostic test We and others have demonstrated that the pres- of ischemia: a) ischemic extent and b) maxi-
for CAD. Primarily, the expanded applications of ence of normal wall motion (peak wall motion mal severity. Ischemic extent reflects the area
stress echocardiography relate to its prognostic score index, WMSI = 1.0) during stress echocar- of myocardium (number of segments) that is
efficacy and influence on clinical outcomes. diography confers a benign prognosis [1]. abnormal, whereas maximal severity reflects the
These low risk patients generally only require maximal magnitude of abnormal wall motion
Table 1 summarises the different variables, counseling in regard to risk factor modification. within a designated segment, both quantified at
important in identifying risk and predicting peak stress. Ischemic extent reflects the number
prognosis, which will be discussed in detail in Patients with mild to moderate wall motion of new stress-induced wall motion abnormali-
the following sections. abnormalities (peak WMSI = 1.1-1.7) have an ties, and corresponds roughly to the number
intermediate risk of cardiac events. The ideal of stenosed coronary arteries. Maximal sever-
management strategy for these patients is unclear. ity reflects the magnitude of ischemia within
Achieved heart rate (%MPHR) / Heart Rather than an invasive management approach a designated myocardial segment and reflects
rate reserve (exercise stress) of catheterisation and revascularisation with its the severity of a subtending coronary stenosis
inherent risks, patients with an intermediate risk within a given coronary artery vascular terri-
Heart rate when wall motion abnormality of cardiac events may, perhaps, experience low- tory. Estimation of both ischemic extent and
first seen (pharmacologic stress) ering of their risk for future cardiac events by maximal severity variables by stress echocar-
aggressive risk factor modification, and referral diography provides a functional depiction of a
Resting left ventricular ejection fraction

Extent and severity of new wall motion

abnormalities
Multi-vessel disease pattern
(peak WMSI>1.7)
Transient ischemic LV cavity dilatation
(TID)
Left atrial size
Right ventricular wall motion
abnormalities
Table 1. Stress echocardiography variables important
in identifying risk and predicting prognosis.
Abbreviations: LV = left ventricular; %MPHR = percent
maximum predicted-heart rate; TID = transient Figure 1. Cardiac event rate per year as a function of wall motion score index. The number of patients
ischemic cavity dilation; WMSI = wall motion within each wall motion score index category is shown underneath each column (left). Statistical significance
score index. increases as a function of wall motion score index result (right).
Two scenarios, one solution
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 June 2010
Figure 2. Cumulative effect of ischemic extent and maximal severity (jeopardised myocardium) of wall motion
abnormalities on event rate/year. Event rate increases as a curvilinear function of both extent
and severity combined.
“noninvasive” coronary angiogram, and accu-
rate prognostic assessment of the amount of
jeopardised myocardium.
We have demonstrated that prognostic risk
stratification by stress echocardiography can
be established using both separate and com-
bined functions of the extent and severity of
wall motion abnormalities [2]. Ideally, a con-
tinuum of risk can be defined based upon
varying degrees of extent and severity of wall
motion abnormalities. Stable patients with nor-
mal stress echocardiography or those with mild
and non-extensive wall motion abnormalities
(single vessel CAD or mild ischemia) are at low
(<1%/year) to intermediate (1-5%/year) car-
diac risk, and may be considered for an initial
strategy of aggressive risk factor modification
and optimal medical therapy.
On the contrary, patients manifesting severe
and/or extensive stress-induced wall motion
abnormalities are at intermediate-high car-
diac risk (>4%/year) and should warrant con-
sideration for referral to catheterisation and
potential coronary revascularisation in order
to modify and reduce their risk [Figure 2].
Moreover, a prognostic model of risk stratifica-
tion is important since a defined threshold for
aggressive management can be applied indi-
vidually according to a given patient’s clinical
characteristics and other co morbidities.
Prediction of MI vs cardiac death by
stress echocardiography.
Stress echocardiography is an effective tech-
nique for differential risk stratification of
patients for the outcome specific endpoints of
cardiac death and non-fatal myocardial inf-
arction (MI) [3]. Patients with EF <30% are at
very high risk of cardiac death (>4%/year) and
18 cardiology
these patients should be managed actively with
aggressive medical management, assessment of
viability, revascularisation if needed and early
consideration of device therapy and cardiac
resynchronisation therapy. In patients with EF
≥30%, peak wall motion score index can fur-
ther risk-stratify this subgroup. There are three
risk categories, namely a high-intermediate risk
group (WMSI >1.7) (cardiac death rate 2.5-4%/
year) who may benefit from aggressive medical
management and consideration for revascular-
isation; a low-intermediate risk group (WMSI
1.1-1.7) (cardiac death rate 1.0-2.5%/year)
may benefit from aggressive medical man-
agement and consideration for revascularisa-
tion for symptom relief only. Finally there is a
low-risk group (WMSI 1.0) (cardiac death rate
Figure 3. Schematic for the risk stratification of patients undergoing stress echocardiography. CD, Cardiac
death; CRT, cardiac resynchronisation therapy; EF, ejection fraction.
<1.0%/year) who may benefit from risk factor
modification [Figure 3].
Impact of stress echocardiography on
patient outcome
Stress echocardiography is now an established
technique for diagnosis, risk stratification and
prognosis of patients with known or suspected
coronary artery disease. However, the impact of
stress echocardiography on patient outcomes
and coronary revascularisation was previously
unclear. In our study, we assessed 3121 patients
(60 ± 13 years, 48% male) undergoing stress
echocardiography (41% treadmill, 59% dob-
utamine) [4]. Follow-up data were obtained
(2.8 ± 1.1 years) for subsequent coronary
angiography, revascularisation: percutaneous
coronary intervention (PCI) or coronary artery
bypass surgery (CABG), and confirmed hard
events: non-fatal myocardial infarction (n =
76) or cardiac death (n = 83). Stress echocar-
diography studies were normal (pWMSI = 1.0)
in 66% and abnormal (pWMSI >1.0) in 34%
of patients. Early coronary angiography (30
days following stress echocardiography) was
performed in only 35 patients (1.7%) with nor-
mal stress echocardiography and 267 patients
(25.5%) with abnormal stress echocardiogra-
phy (p<0.0001). Late coronary revascularisa-
tion (2 years following stress echocardiogra-
phy, PCI% or CABG%) occurred in 80 patients
(2.8%, 1.1%) with pWMSI = 1.0, 123 patients
(13.5%, 7.3%) with pWMSI = 1.1-1.7 and 102
patients (12.7%, 9.6%) with pWMSI >1.7 [Fig-
ure 4]. Multivariate logistic regression analysis
identified pWMSI as the strongest predictor
of coronary angiography (RR 2.04, 95% CI
1.67-2.5), revascularisation (RR 1.91, 95% CI
1.68-2.17) and cardiac events (RR 2.45, 95% CI
2.09-2.88). All data were statistically significant

50
Angiography Rate (%/yr)
40 p<0.0001
30
22.
20
10
0
1.
1.0
Figure 4. Left: coronary angiography rate per year as a function of wall motion score index. The number of
patients within each wall motion score index category is shown underneath each column. Right: coronary
revascularisation rate per year as a function of wall motion score index. The number of patients within each
category is indicated below each column.
p <0.0001. Patients with markedly abnormal
stress echocardiography (pWMSI >1.7) had
a significantly higher cardiac event rate than
those who did not undergo coronary revascu-
larisation (9.6%/year vs. 2.9%/year, p < 0.05).
Stress echocardiography is an effective gate-
keeper for coronary angiography and revascu-
larisation. A normal stress echocardiography
study (pWMSI = 1.0) confers a benign prog-
nosis (0.8%/year), and is associated with a low
rate of early coronary angiography (1.7%) and
late revascularisation (2.8% PCI, 1.1% CABG).
Stress echocardiography impacts clinical deci-
sion making in higher risk patients (pWMSI
≥1.1) with significantly increased coronary
angiography, PCI and CABG rates. Patients
with markedly abnormal stress echocardiogra-
phy (pWMSI >1.7) were most likely to benefit
from coronary revascularisation.
Conclusions
Stress echocardiography has evolved during
the past 30 years to become a mainstay in the
diagnostic and prognostic armamentarium of
clinical cardiologists. Stress echocardiography
provides diagnostic and prognostic informa-
tion in a broad range of patient subsets and
plays an integral role in the management of
patients with known or suspected CAD. Stress
echocardiography has demonstrated significant
incremental prognostic value when added to
clinical and adjuvant testing information. Stress
echocardiography is an essential tool in defining
cardiac risk and in identifying patients who are
most likely to benefit from additional invasive
diagnostic testing. Stress echocardiography sig-
nificantly influences clinical patient outcomes
while impacting clinical decision making and
use of limited cardiology resources.
Future developments
In stress echocardiography future develop-
ments are likely to be targeted at refinements
in methodology and quantitation in order
to increase reproducibility of interpretation,
decrease subjectivity and improve accuracy.
19 June 2010
extent and severity of wall motion abnormality
for risk stratification and prognosis. Am J Cardiol
2004; 94(6): 715-719.
15
3. Bangalore S, Yao S, Chaudhry FA. Prediction of
Revascularization Rate (%/yr)
13.
PCI CABG 12.
41.
12 myocardial infarction versus cardiac death by
p<0.0001 9. stress echocardiography. J Am Soc Echocardiogr
9
7. 2009; 22(3): 261-7.
6 4. Yao S, Bangalore S, Shah A, Silva-Encisco J,
3 2. Chaudhry FA. Impact of Stress Echocardiog-
1. raphy on Patient Outcome: An Effective Gate-
0
keeper for Coronary Angiography. Circulation
1.1-1.7 1.0 1 2008; 118S849 (abst).
The authors
Siu-Sun Yao, MD, FASE,
Sripal Bangalore, MD,
Xiaoqian Zhang, MD,
Farooq A. Chaudhry, MD, FASE
These potential enhancements include the
incorporation of myocardial strain, strain rate Department of Medicine,
imaging, tissue Doppler and 3D/4D imaging. Division of Cardiology,
Furthermore, advances in myocardial con- St. Luke’s-Roosevelt Hospital Center,
trast echocardiography would ideally allow Columbia University College
the simultaneous evaluation of myocardial of Physicians and Surgeons,
function and perfusion. New York, NY,
USA
References
1. Yao S, Qureshi E, Sherrid MV, Chaudhry FA. Contact address: Farooq A. Chaudhry, MD, St.
Practical applications in stress echocardiography: Luke’s-Roosevelt Hospital Center, Division of
risk stratification and prognosis in patients with Cardiology, 1111 Amsterdam Avenue, New York,
known or suspected ischemic heart disease. J Am NY 10025. Tel (212) 523-4298.
Coll Cardiol 2003; 42: 1084-1090. Fax (212) 523-5989.
2. Yao S, Qureshi E, Syed A, Chaudhry FA. Novel E-mail chaudhr@chpnet.org
stress echocardiographic model incorporating the
BOOK REVIEW
Cardiology: Clinical Cases Uncovered
by Tim Betts, Jeremy Dwight, Sacha Bull
Pub. by Wiley-Blackwell February 2010,
256 pages, 28.80 e
Cardiology: Clinical Cases Uncovered is the ideal integrated
text that helps in the recognition, understanding, investi-
gation and management of many heart-related disorders
and conditions. Written by three practising cardiologists, it
uses a clinical approach to management problems with the
help of 26 real-world cardiovascular cases. There is strong
emphasis on high-quality figures, particularly 12-lead
ECGs, as these play such a major role in the evaluation of
the cardiac patient.
Following a question-answer approach throughout the nar-
rative, with self-assessment MCQs, EMQs and SAQs, the book includes sections on cardiac
anatomy, physiology and pathology, which provide the essentials required to understand
clinical cardiology. The book is ideal for medical students and junior doctors on the Foun-
dation Programme, specialist nurses and nurse practitioners, and in general for those with
plans for a career in cardiology.
Wiley
Hoboken, NJ, USA
www.ihe-online.com & search 45603
 June 2010 20
Getting to the heart of things
Not only is heart failure one of the single biggest causes of morbidity and mortality
in man, but the incidence of the condition is steadily increasing. Rising to this chal-
lenge, innovative medical diagnostic techniques with ever greater performance are
constantly being introduced so that early, unambiguous detection of the underlying
condition is now possible, enabling the prompt initiation of targetted therapies.
This article presents a brief review of the most relevant diagnostic techniques, their
current status and their indications.
By O. Ekinci, M.D.
Some 14 million people in Europe currently suffer
from heart failure with the number predicted to
increase to no fewer than 30 million by 2020. The
medical impact of heart failure is huge — in partic-
ular, the condition is associated with high mortality.
After the first incident of cardiac decompensation,
as many as around 40 percent of patients will die
within one year. Of those who survive the first year
only one third will actually live longer than a fur-
ther 5 years. In addition to such alarming medical
statistics, the social impact of heart failure is also
significant and is understandably associated with
immense costs, which put an additional financial
strain on already tight healthcare budgets.
For all these reasons, the early detection and
adequate treatment of cardiac diseases is of the
greatest importance, since this is the only way
to prevent subsequent damage to the myocar-
dium and to avoid permanent limitations on
the quality of life of the patient.
The latest developments in imaging and in
vitro diagnostics offer new opportunities for
Figure 1. Cardiovascular MRI provides a 40-fold
higher voxel resolution when compared to the current
standard of myocardial scintigraphy and allows
unprecedented visualization of even smallest areas of
scar in the myocardium. The short axis image above
shows contrast enhancement (white area) in the infe-
rior wall caused by myocardial infarction.
Image source: Okan Ekinci, DKD Wiesbaden
cardiology
detecting heart failure not only much earlier
but also with great precision.
Echocardiography: from 2D to 4D
Ultrasound examination of the heart, i.e. echocar-
diography, is the basic imaging technology (and
also the least expensive one) in cardiology, and,
in the vast majority of patients, plays the role of a
“Gatekeeper” controlling access to eventual addi-
tional diagnostic procedures that may be needed.
The latest echocardiography systems now enable
real-time three-dimensional images of the beat-
ing heart so that the heart can be imaged as a
whole organ easily and rapidly, and not just in 2D
images, but in full volumes. The latest echocardi-
ography systems can display and analyze the heart
in full after a single heartbeat. Such echocardiog-
raphy results are the prerequisite for other, more
expensive examinations, which may be necessary.
Echocardiography is widely available in hospi-
tals and in nearly all cardiology practices, while
newer imaging technologies such as cardiac CT
or MRI, which may be indicated for further diag-
nostic investigation are in general found mostly
in larger facilities.
The heart in the magnet:
cardiac MRI
One of the most recent imaging techniques being
used to analyze the heart is magnetic resonance
imaging (MRI), which, in addition to the fact
that it does not involve the use of ionizing radia-
tion, in contrast to CT, provides a comprehensive
(and highly accurate) assessment of the heart.
Cardiac magnetic resonance imaging (CMR) can
also yield penetrating insights into the underly-
ing pathology of a failing heart. Known as the
gold standard for the assessment of cardiac func-
tion, cardiac MRI is used as the most accurate
non-invasive tool to measure parameters like ejec-
tion fraction, based on which patients may get a
drug therapy alone or even devices implanted
(such as pacemakers or defibrillators). CMR also
provides a special imaging approach for the visu-
alization of even the smallest scars in the myo-
cardium [Figure 1], which is important since
the presence and extent of myocardial scarring
O. Ekinci, MD.
is a major risk factor for sudden cardiac death
[Ref. 1]. It has been shown in many recent clini-
cal studies, that CMR allows accurate assessment
of myocardial scar formation with extremely high
diagnostic accuracy. CMR is the best non-invasive
approach to address this important clinical ques-
tion [Ref. 2]. For this reason, a growing number of
cardiologists are using the procedure to identify
patients with severe heart failure who are in need of
an implantable defibrillator, which protects against
cardiac arrest through targeted shock delivery.
Until recently, because of the high magnetic fields
used in the technique, CMR was contraindicated
in patients with pacemakers. Thanks to coopera-
tive development between the manufacturers of
MRI systems on the one hand and pacemaker
devices on the other, MRI-conditional pacemak-
ers* are beginning to become available (e.g. from
Medtronic). Since MRI scanners may cause tra-
ditional pacemakers to misinterpret MRI-gener-
ated electrical noise and withhold pacing therapy
or deliver unnecessary pacing therapy, the new
generation of pacemakers include features that
set the device into an appropriate mode for the
MRI environment. Such pacemakers also include
hardware modifications to the device and leads
that are designed to reduce or eliminate the influ-
ence of the MRI environment.
At the practical level, MR examinations of the
heart are no longer complicated or time-consum-
ing. In general, a CMR examination for the evalu-
ation of cardiac anatomy, function and scarring
can now be carried out within 20 minutes.
Coronary vessels in view: cardiac CT
Computed tomography (CT) has long had a
valuable role in early disease detection over the
years. Steady technological development over
the years means that the latest generation of
CT scanners can now carry out coronary CT
angiography (CTA) with significantly reduced
radiation dose [Figure 2]. The most recent inno-
vation, namely the use of ECG-triggered high-
pitch spiral data acquisition using dual source
CT as implemented in the Definition Flash sys-
tem from Siemens can carry out CTAs at radia-
tion doses as low as below 1 mSv, which is less
than in conventional coronary angiography.
[Ref. 3] (By comparison, one mSv is less than
half of the annual natural background radia-
tion on earth, to which everyone is exposed).
* “MR-conditional” is a term used to indicate that a
device may be used in the MRI environment under
certain conditions, such as a particular type of MRI
scanner and scanner settings.
 21
……
Eff. dose of novel
high-pitch spiral
imaging (<1 mSv)
Figure 2. The introduction of technological advances over the years has resulted in a steady decrease in the
amount of ionizing radiation to which the patient is exposed in cardiac CT examinations. The above graph
shows dose levels of the multi-center multi-vendor PROTECTION I study involving 50 sites and 1965 coronary
Modified from:
CTA exams (data from Hausleiter et al, JAMA 2009;30:500). The bars reflect the mean eff. radiation dose at
each of the sites respectively. Most scanners on the market still require a mean effective dose between 6 and
37 mSv, whereas the most recent generation of scanners with high-pitch spiral scanning can perform at mean
doses of 1 mSv - a new benchmark (Flash, dotted line).
Unlike a cardiac catheter examination, CT can not Of course, such innovations inevitably have their
only visualize the coronary lumen, but also display price. However, it is important to realize that the
deposits (plaque) in the coronary wall. The calcium appropriate use of these new technologies may
load of the coronary vessels (known as the Calcium save overall health care expenditure over the
Score) can be quantified in CT without the use of long term: thanks to better diagnostics, treat-
contrast agent. An age-adapted increased calcium ment can be initiated much sooner. As a conse-
load of the coronary arteries is as much a risk factor quence, quality of life can be preserved and loss
as smoking or increased cholesterol. Recent studies of productivity avoided.
have shown that high Calcium Score can modify
predicted risk obtained from traditional risk strati- Minimally invasive therapy:
fication tools (e.g. Framingham Risk Score) alone, intervention instead of surgery
especially among patients in the intermediate risk Some underlying diseases of heart failure —
category in whom clinical decision making is most such as severe valvular disease — often require
uncertain [Ref. 4]. In practice, using the latest tech- therapeutic interventions beyond drug therapy
nology coronary CT examinations can be carried involving cardiologists and surgeons at the same
out in less than a second and are therefore espe- time. The cardiac cath. lab of the future is already
cially useful in patients with cardiac arrhythmias being implemented in some centers in the so-
and older patients since the short time-span means called Hybrid-ORs which, by bringing together
that the patients can breathe normally [Figure 3]. the features of the surgical room with those of a
The procedure is also optimal and time-efficient cath lab, make possible innovative therapies, such
for the physician, since now a single mouse click as in the treatment of severe aortic valve steno-
generates a meaningful image, where previously sis. Until now, valve replacement by open-heart
lengthy image processing was necessary. surgery was the recommended therapy approach
in these cases, but in many elderly patients with
concomitant diseases this can be too risky. Inter-
ventional implantation of an aortic valve pros-
thesis has become an alternative in such patients,
and can give rise to rapid improvement of cardiac
parameters. In this procedure the valve pros-
thesis is placed via the femoral artery or, if this
is not possible, by a small incision in the apex of
the heart. Such a ‘minimally invasive’ interven-
tion puts much less stress on the patient, than an
open heart operation. Overall, providing techni-
cal equipment needed to accommodate multiple
specialties in one lab may allow for better quality
of care as well as better time and cost efficiency,
both for the patient and the institution.
Figure 3. CTA image acquisition can be carried out Drop by drop to
in less than a second today, making breath-holding
unnecessary. Even patients with arrhythmia can now
diagnosis: biomarkers
be imaged as all data are captured within a single The presence and course of heart failure can
heart-beat. Image courtesy of Erasmus Medical also be assessed using in vitro lab tests, through
Center Rotterdam, NL. the use of new biomarkers which, especially
June 2010
in emergency care, can influence and support
clinical decisions. In heart failure the use of
circulating B-Natriuretic peptide (BNP) is
particularly relevant, since the level of this
biomarker is a good indicator of the degree to
which the cardiac function is impaired. BNP
is used both for initial diagnosis and for ther-
apy monitoring. Recent studies have shown
that in the presence of other risk factors and
known HF, BNP has also a prognostic value,
i.e. patients with BNP above a certain level
will be candidates for more aggressive risk
management [Ref. 5].
In many patients, a heart attack is the direct
cause of cardiac insufficiency, so fast detec-
tion of a myocardial infarction (MI) is
extremely important in order to prevent
severe myocardial damage and subsequent
heart failure. To do this, more and more
emergency rooms routinely use high sensi-
tive troponin I tests as an early and precise
indicator of MI [Ref. 6]. Significant time
can be saved in this way so that the recom-
mended therapy, such as the reopening of the
occluded coronary artery by cardiac cathe-
terization can be initiated immediately. Since,
for every second that the coronary artery
remains occluded muscle cells will die (in
the classical dictum “time is muscle”) rapid
intervention is of course vital.
References
1. Assomull et al. Cardiovascular Magnetic Reso-
nance, Fibrosis, and Prognosis in Dilated Cardio-
myopathy. J Am Coll Cardiol 2006; 48: 1977-85.
2. K im HW et al. Cardiovascular magnetic reso-
nance in patients with myocardial infarction: cur-
rent and emerging applications. J Am Coll Cardiol
2009 Dec 29;55(1):1-16
3. Achenbach et. al. Coronary computed tomography
angiography with a consistent dose below 1 mSv
using prospectively electrocardiogram-triggered
high-pitch spiral acquisition. Eur Heart J. 2010
Feb;31(3):340-6
4. Polonsky TS et al. Coronary artery calcium score
and risk classification for coronary heart disease
prediction. JAMA 2010 Apr 28;303(16):1610-6.
5. McKie et al. The Prognostic Value of N-Termi-
nal Pro–B-Type Natriuretic Peptide for Death
and Cardiovascular Events in Healthy Normal
and Stage A/B Heart Failure Subjects. J Am Coll
Cardiol. 2010;55:2140–7.
6. B onaca M et al. Prospective Evaluation of the
Prognostic Implications of Improved Assay Per-
formance With a Sensitive Assay for Cardiac
Troponin I. J Am Coll Cardiol. 2010;55:2118–24
The author
A cardiologist by training, Okan Ekinci, M.D.,
is a Cardiac Imaging Expert and
Lecturer for Cardiovascular MRI
at the Medical University of Vienna (Austria)
and University College Dublin (Ireland).
Contact: okanekinci@yahoo.de
 June 2010 22 Cardiology
Two scenarios, one solution
Bringing laboratory PT/INR testing
standards to point-of-care and the home
Oral anticoagulation therapy (OAT) is one of the most common medication regi-
mens, with warfarin being by far the most frequently used drug. Its narrow thera-
peutic range however means that there is a risk on the one hand of bleeding
caused by excess drug or, on the other hand, of thrombosis when there is subop-
timal anticoagulation. Laboratory monitoring of OAT using prothrombin time (PT)
tests is vital. One way to improve the management of OAT, especially for those
patients on chronic long-term warfarin therapy, is through the use of handheld
point-of-care (POC) testing devices. This article describes such a system for the
monitoring of PT/INR.
by Evette Duncan
Warfarin is a commonly used medication for window; it has a wide variability of responses
oral anticoagulant therapy (OAT) in patients from patient to patient due to metabolic rate,
predisposed to thromboembolism or thrombo- pharmacodynamics, lifestyle, compliance and
sis due to atrial fibrillation (AFIB), mechanical its sensitivity to diet and drugs. These factors
heart valve replacement or congenital throm- can markedly increase or decrease the level of
bophilia. Warfarin is a coumarin-based vitamin effective anticoagulation for any given dose. As
K antagonist, which decreases blood coagulation a result, patients treated with Warfarin have
by inhibiting the enzyme vitamin K epoxide always been forced to not only comply with a
reductase. This enzyme recycles oxidised vitamin difficult dosage regimen, but also undergo PT/
K to its reduced form after it has participated in INR testing, which can vary from as often as
the carboxylation of several blood coagulation once a week to once every couple of months, to
proteins, mainly prothrombin and factor VI. ensure that their regimen is adequate. Regular
monitoring is required to minimise the risk of
Patients taking warfarin require regular moni- a thromboembolic event resulting from inad-
toring using Prothrombin Time (PT) tests. equate anticoagulation, as well as the risk of
PT and the derived International Normalised bleeding due to overanticoagulation [1]. An
Ratio [INR] are measurements of the extrinsic INR result of less than 2 increases the risk of
pathway of coagulation and are used to deter- thromboembolism whilst an INR of more than
mine the clotting of blood, thus measuring the 4.5 increases the risk of bleeding.
clinical effectiveness of OAT.
Typically, patients on OAT are required to have
Warfarin is, unfortunately, a less-than-ideal a venous blood sample taken on each appoint-
medication due to its narrow therapeutic ment at their local clinic, hospital or anticoag-
ulation clinic. This sample is then sent to the
laboratory for analysis. The PT/INR results are
provided to the clinician and then telephoned
to the patient, at which point they are given
their daily dose regime. This process is not ideal
as there are delays with reporting, it is time-
consuming and costly for both the patient and
healthcare professional.
Point-of-care testing
One way to improve the management of OAT,
especially for those patients on chronic long-
term warfarin therapy, is through the use of
There is a risk of a thromboembolic event from handheld point-of-care (POC) testing devices,
inadequate anticoagulation unless warfarin therapy is such as the INRatio2 platform from Alere.
monitored regularly. Such devices allow lab-accurate INR/PT test
results to be generated in just 60 seconds dur-
ing a clinic appointment. A small volume of
fresh capillary whole blood obtained from
a finger stick (as low as 10µL) placed on a
disposable test strip that is inserted into the
device provides results that are clearly visible
on a digital display.
POC testing of INR/PT can eliminate the draw-
backs associated with a centralised laboratory
approach. The quicker turnaround means that
results are not only available at a single patient
visit, but enables patients and clinicians to
engage in face-to-face testing and consultation
of treatment regimes.
Clinicians and health authorities can also ben-
efit from a reduction in short and long term
healthcare expenditure as patients remain in
the therapeutic range for longer, improving the
clinical effectiveness of OAT, and have less side-
effects from therapy. Hospital readmissions and
treatment costs are significantly reduced, while
a quicker turnaround of results requires fewer
resources and simplifies workflow. Research
has demonstrated, from the perspective of the
healthcare provider, that a care model which
utilises POC PT/INR testing devices would
provide a cost-effective alternative to more tra-
ditional care requiring venous blood sampling
and laboratory analysis [2].
Home testing
There are two recognised methods of home
testing and monitoring of PT/INR:
1) Patient self-testing (PST). With PST, patients
measure their own PT/INR with a home test-
ing device and transmit the results to their
clinician, often by telephone or via an online
system. The clinician then determines the
appropriate OAT dosage and provides instruc-
tions to the patient on how to proceed.
2) Patient self-management (PSM). Using a
home testing device, patients following PSM
are able to measure their own PT/INR and,
using an agreed protocol, interpret the results
and adjust their OAT dosage themselves.
Local healthcare policy often determines
whether it is the patient or their clinician who
interprets the results and determines the dose of
medication. For example, in Germany patients
may adjust the medication dose themselves,

The management of OAT, especially for those patients
on chronic long term Warfarin therapy, is through the
use of handheld point-of-care (POC) testing devices,
such as the INRatio2 platform from Alere.
while in the UK and the USA, this remains in
the hands of a healthcare professional. Home
testing however, is not suitable for every patient
and selected patients must participate in a
structured educational programme [1]. Patients
must be able to understand and show compe-
tency in the testing procedure, in addition to
demonstrating a basic theoretical knowledge of
blood coagulation, PT/INR interpretation and
the adverse effects of over- or under-dosing.
Documentation and results should always be
communicated to healthcare professionals [1].
Devices such as the INRatio2 system can
empower patients to become more knowledge-
able and look after their own condition. By pro-
viding the freedom of home testing, patients
require fewer visits to specialist clinics saving
time, money and improving the patient’s qual-
ity of life. Home testing allows for more fre-
quent PT/INR testing, proven to increase time
in the therapeutic range [3], therefore reducing
the risk of clinical complications.
Quality assured results
The INRatio2 monitoring device now has
new heparin-insensitive test strips which have
recently been CE marked. Heparin is a natu-
rally occurring anticoagulant and is the most
commonly used therapy for the initial man-
agement of acute cardiovascular diseases prior
to starting warfarin therapy. Due to its short
half-life of one hour, heparin must be admin-
istered regularly or as a continuous infusion. It
is therefore only used until OAT with warfarin
becomes effective, or in emergency and trauma
situations. The heparin insensitivity of the
INRatio2 monitoring system means that the
management of OAT is improved, resulting in
quicker initiation, stabilisation and bridging of
warfarin therapy with overall cost saving.
It is important that POC monitoring devices
offer high accuracy, precision and quality
control (QC). The INRatio2 system utilises
a unique 2-level quantitative on-board QC
system and does not require any additional
23
control measures. The monitor uses the test
strip’s 3-channel technology to perform the PT
test and two QC tests (normal and therapeutic)
simultaneously. This determines whether the
controls are within range before the patient’s
INR result is displayed. The unique technol-
ogy of the INRatio strip enables the two QC
tests to be performed alongside the test sample,
following laboratory procedure and ensuring
that accurate and reliable results are generated
every time.
According to guidelines issued by the World
Health Organisation (WHO), working throm-
boplastins used in the prothrombin time (PT)
test for the control of OAT must be calibrated
against International Reference Preparations
to determine the International Sensitivity
Index (ISI) necessary to convert PT results
into INR [4]. If correctly calibrated, results of
tests from different testing devices are repro-
ducible and comparable. The INRatio2 sys-
tem adheres to these international standards
by utilising a thromboplastin reagent with
an ISI of 1.0.
Summary
Point-of-care and home testing can significantly
increase the time in the therapeutic range and
improve a patient’s quality of life. Ultimately,
devices such as the INRatio2 can improve the
clinical effectiveness of OAT, preventing hospi-
tal readmissions due to adverse complications
and saving hospital expenditure and resources.
Healthcare professionals can now test and
obtain results in 60 seconds, enabling them
to immediately advise the patient in one
appointment, thereby simplifying work-
load, and saving time and resources. This
saved time allows patients to have face-
MRI research highlights high-risk
atherosclerotic plaque hidden in the
vessel wall
Researchers from the Boston University School
of Medicine (BUSM), USA have shown that use
of magnetic resonance imaging (MRI) in an ani-
mal model can non-invasively identify danger-
ous plaque. The findings, which appeared in the
May issue of Circulation Cardiovascular Imag-
ing, offer possible applications in the diagnosis
and treatment of patients with atherosclerosis.
Rupture of vulnerable atherosclerotic plaque,
which often occurs without prior symptoms, is
responsible for a substantial number of deaths
and disabilities worldwide. Identification of
atherosclerotic plaque with a high risk for
disruption and thrombosis would allow pre-
ventive therapy to be initiated before thrombi
begin to clog arteries and cause stroke or MI.
The BUSM researchers examined diagnostic
June 2010
to-face consultations with their healthcare
professional, which can improve patient
compliance and therefore increase the
clinical effectiveness of OAT.
Patients can now be empowered to look after
their own condition, as home testing allows for
more frequent testing in the comfort of their
own homes. This is proven to increase the time
in the therapeutic range and results in fewer
clinical complications. Waiting for results,
venous blood sampling and regular clinic
appointments are no longer necessary.
The Alere INRatio2 PT/INR monitoring system
brings laboratory standards to point-of-care
and the home
References
1. B
 raun S, Spannagl M, Voller H. Patient self-test-
ing and self-management of oral anticoagula-
tion. Anal Bioanal Chem 2009; 393:1463-1471
 afata J et al. The Cost-Effectiveness of Dif-
2. L
ferent Management Strategies for Patients on
Chronic Warfarin Therapy. J Gen Intern Med
2000; 15(1): 31–37
3. B
 ernado A, Hahuber C, Horskotte D. Home pro-
thrombin estimation. Thrombosis, embolism
and bleeding 1992; 325-30
4. Th
 e World Health Organization. Regulation of
in vitro diagnostic devices: Thromboplastin rea-
gents. http://www.who.int/bloodproducts/ivd/
thromboplastin_reagents/en/ (2010)
The author
Evette Duncan BSc
Alere International
International Product Manager
info.cardiology@alere.com
www.alere.com
www.ihe-online.com & search 45602
protocols in an animal (rabbit) model of human
disease with procedures that never could have
been applied to humans. Plaque disruption was
stimulated at a precise time to allow MRI imag-
ing before and after the rupture. According to
researchers, plaque that was hidden within the
vessel wall and pushing the vessel wall outward
instead of occluding the lumen had a very high
chance of forming a thrombus; plaque that
caused vessel narrowing was almost always sta-
ble, which could explain why the most danger-
ous plaque generally escapes detection by X-ray
angiography. The study finds accurate, non-inva-
sive MRI can identify stable and unstable plaque.
It also reports that enhanced gadolinium uptake,
which is associated with histological findings of
inflammation, tissue necrosis and the prolifera-
tion of blood vessels in tissue not normally con-
taining them, can predict dangerous plaque.
http://www.bmc.org/
 June 2010 24 Medical Imaging

Science-fiction becomes reality:

Europe’s first full-body PET/MR system

When the radiology department at the University Hospital of Geneva was
approached in 2008 by a major international medical imaging company look- Osman Ratib is
ing for a site to test its new imaging modality, it seemed like science fiction had Professor and
Head of Nuclear
become reality. The company had combined a magnetic resonance imaging (MRI)
Medicine, as well
functionality with that of positron emission tomography (PET) into one single system as chair of the
capable of scanning the entire body. In this article Prof O. Ratib describes the Department of
installation of Europe’s first PET/MRI at the University Hospital of Geneva and the Radiology at the
early results that are being produced by the new system, its benefits as well as its University Hos-
future potential. pital of Geneva,
Switzerland.
Dr Ratib is a
by Prof. O. Ratib board-certified
Osman Ratib, MD, PhD,
FAHA, is Professor and cardiologist and
Chief of Nuclear Medi- radiologist who
It has been a long-held belief that combining PET in conjunction with the anatomy and tis- cine and chair of the has gained an
an MRI scanner and a PET scanner would be sue characterisation of MRI will enable us to Department of Radiology i n t e r n a t i o n a l
technically impossible due to the incompat- see the function and metabolism of tissue more at the University Hospital reputation in the
of Geneva.
ibility of the ultra-sensitive electronics of PET precisely than ever before. development of
scanners with the powerful magnetic field computer-aided diagnosis in cardiac imag-
generated by the MRI. Recent technological The clinical cases we have examined so far have ing and in the development of picture
advances (see side-bar) have however now already shown the advantages of being able archiving and communication systems
made such an integrated system a reality — the to perfectly superimpose the PET over MRI (PACS). He became one of the active figures
University Hospital of Geneva in Switzerland images to detect lesions. Previously, this has in medical imaging research in Europe and
now houses Europe’s first combined full-body not been possible because the two studies took is a member of several societies of com-
PET /MR system. place at different times, different conditions puted radiology and telemedicine and the
and different patient positions. former president of the EuroPACS soci-
We performed the first scan in April 2010 and ety. In July 1998 he moved to Los Ange-
by the end of the April we had performed 25 The results of the early cases examined so far les where he was appointed as Professor
patient examinations. Initially, we concentrated by PET/MRI compare favourably with more and Vice Chairman of the Department of
on oncology cases of patients originally sched- traditional PET-CT studies performed in the Radiology at University of California Los
uled for a PET-CT study and we compared the same patients. PET-MR provided identical Angeles (UCLA). He was responsible for
results of the PET-MR studies with the PET-CT PET quality with the added value of perfectly
data. We believe the new combined PET-MRI matched MR images. These encouraging results ... The results of the early cases
technique will significantly improve our diag- confirm that both modalities function perfectly
nostic accuracy in areas where patients already together and provide diagnostic quality results examined so far by PET/MRI
undergo separate PET and MR studies as part of when used together in a hybrid system. The compare favourably with more
their workup such as in prostate cancers, breast studies we performed so far showed that they
cancer and head and neck cancers. Our early benefitted from additional high definition MRI traditional PET-CT studies ...
results show that bringing the two modalities sequences providing soft tissue characterisa-
together improves the quality and accuracy of tion that is not possible with CT images of coordinating the deployment of an enter-
diagnoses. The molecular imaging provided by traditional PET-CT scanners. prise-wide strategy and infrastructure for
image management and communication.
In July 2005 he returned to Geneva to take
the position of Head of Nuclear Medicine,
responsible for new molecular and func-
tional imaging techniques and, in particular,
hybrid positron emission Tomography–
computed tomography (PET-CT). His clini-
cal activities and areas of expertise include
cardiovascular magnetic resonance and CT
imaging procedures, combined PET-CT
imaging and advanced cardiovascular imag-
ing. He obtained his medical degrees at the
University of Geneva and a further degree
in biophysics and a PhD in medical imaging
Figure 1. Example of a whole body PET-CT and whole-body PET-MR acquired in a patient with lung metastases from UCLA in 1989.
of a head and neck cancer.

Advantages of combined PET/MRI
for patients
There are many immediate advantages for
patients with the new system. Generally, patients
receiving MRI and PET scans as part of their
clinical work-up and follow-up undergo these
two studies hours or even days apart, frequently
requiring separate visits to the clinic. Now we
can provide both studies and repeat scans, such
as an MRI focus on areas identified in the PET
scan, in one single visit. And for both patients
and staff, MRI has the advantage of there
being no exposure to ionising radiation, which
is a particularly important benefit for our
pediatric patients.
Combined PET/CT scanners have only been
available in the past decade and they have
already made a significant impact. However, we
believe that PET/MR is the next quantum leap
in imaging technology. Even though the PET/
MR combination is promising for both cardi-
ology and neurology applications, in Geneva
we have decided to focus on the benefits it
provides in oncology.
Although personalised medicine has been dis-
cussed at symposia for years, PET/MR may help
us close the gap between science fiction and
reality by providing a means to track whether
a drug is reaching a tumor and monitor on a
cellular level whether it’s working and tailor the
treatment plan for each patient accordingly.
Installation of the new system
Developing the combined PET/MRI sys-
tem was certainly an exciting and challeng-
ing project, but the work did not end with the
development of the system itself. Like many
hospitals, the University Hospitals of Geneva
has infrastructure restrictions so it was diffi-
cult to find a suitable and large enough space
The combination of PET/MRI (lower frame) can give
more info than PET/CT (upper frame) without the
radiation dose issues associated with CT.
25
within the hospital for the system or a way of
transporting the new system to the hospital. In
addition, construction of any new building to
accommodate the new system could of course
not disturb or interfere with the surrounding
infrastructure of the hospital.
Fortunately, a small Swiss company was able
to design a room-size container where the
system was pre-installed. The unit was then
transported directly to the hospital build-
ing and the container positioned adjacent
to the outside wall of the building. The only
actual construction that was needed was
a door between the building and the new
container container.
Whole-body PET/MR in the US
In parallel to the installation of the first PET/
MRI in Europe in the University Hospital of
Geneva, Switzerland, another combined sys-
tem from Philips Healthcare was installed
in the Translational and Molecular Imaging
Institute (TMII) of the Mount Sinai Hospital
in New York City, NY, USA. Founded in 1852,
the Mount Sinai Medical Center is a 1,171-bed,
tertiary-care teaching facility internationally
acclaimed for excellence in clinical care. As
a leader in cardiology research, Mount Sinai
is specifically interested in PET/MR since the
combination is expected to provide a more
advanced understanding of the processes
taking place in vascular beds. Multimodality
imaging synergistically enhances the power
of the separated modalities by automatically
combining functional and anatomical infor-
mation. The use of PET/MR scanners instead
of PET/CT scanners would not only reduce the
extra radiation dose to the patient but would
also offer higher soft tissue contrast, allowing
better visualisation and understanding of the
underlying disease.
Under the leadership of Prof Zahi A. Fayad,
who is the Professor of Radiology and Medi-
cine (Cardiology) at Mount Sinai and is also
Director of the Translational and Molecular
Imaging Institute, the Mount Sinai Medical
Center is currently performing a clinical and
a preclinical study to test the performance
of the new PET/MR scanner. The prelimi-
nary images are already showing promising
and valuable results and Prof. Fayad and col-
leagues will soon begin a study to profile the
development of vulnerable/high-risk athero-
sclerotic plaque in patients with high risk
of cardiovascular disease.
The author
Osman Ratib, MD, PhD, FAHA,
Professor and Chief of Nuclear Medicine,
Department of Radiology,
University Hospital of Geneva,
Geneva, Switzerland
June 2010
Building a whole-body
PET/MR system
The greatest technical challenge in developing
the new system was ensuring that the electron-
ics of the PET scanner were not affected by the
powerful 3 Tesla magnet of the MRI system.
The new Philips PET/MR system (equipped
with a 3 Tesla MRI and PET using latest
Time of Flight (ToF) technology) is a sophis-
ticated device, providing both MRI and PET
modalitites. In order to accomplish the PET/
MR imaging, the scanners are situated face-
to-face, together with a translational bed that
accurately positions the patient inside each
scanner. However, the concept was not the
arduous part. In this case, overcoming mag-
netic interference was the greatest obstacle
because a new magnetic shield was needed.
All current PET & PET/CT systems today
use PMT (hotomultiplier tube) systems
or ‘light sensors’. These PMT systems are
incompatible in a magnetic field and will not
operate in a PET/MR configuration. Philips
research and engineering teams worked
closely to develop a very novel, yet accurate
shielding programme for the new system.
As part of this development, it was neces-
sary to ensure the PET and MRI devices
were situated three metres apart, as
increasing the distance reduced the mag-
netic interference. As for the PMTs, each
photomultiplier tube was fitted within a
shield made of a nickel-iron alloy called
mu metal. And finally, a laminated steel
cover was installed at the side of the
PET gantry that faces the MRI device to
protect it against the magnetic field.
By first installing the PET/MRI system in a
special off-site container and then shipping the
container as a whole, there was minimal infra-
stuctural disturbance to the University Hospital
of Geneva.
 June 2010 26
Regional differences in C-section
rate not a result of maternal
request in Canada
Fewer than two per cent of cesarean births in
British Columbia, Canada were a result of mater-
nal request, but the number of cesarean and
assisted vaginal deliveries varied widely across
health regions in B.C., according to a new study
by University of British Columbia researchers.
The UBC study examined all deliveries in B.C.
between 2004 and 2007 and found an aver-
age of 21.2 per 100 deliveries were first-time
C-sections and 14.2 per 100 deliveries were
assisted vaginal deliveries involving the use of
forceps and/or vacuum devices. Dystocia – or
abnormal or difficult childbirth – was the most
common reason for cesarean deliveries (30 per
cent), followed by non-reassuring fetal heart
rate (19.1 per cent).
Canada’s cesarean delivery rate has increased
dramatically over the past two decades, reach-
ing an all time high of 26.3 per cent of in-hos-
pital deliveries in 2005-2006. Until recently,
B.C. had the highest cesarean rate in the
country, according to the Canadian Institute
for Health Information. The study also found
significant regional variations in cesarean and
assisted vaginal delivery rates across B.C.’s 16
Health Services Delivery Areas that could not
be explained by accounting for medical indica-
tions for these procedures. Cesarean delivery
rates ranged from 27.5 per cent in the South
Vancouver Island area to 16.1 per cent in
Kootenay Boundary. Assisted vaginal delivery
rates ranged from 18.6 per cent in Vancouver
to 8.6 per cent in East Kootenay.
The researchers suggest potential reasons may
include the differences in practitioners’ responses
to similar medical situations, such as dystocia,
including how they interpret and respond to
the condition, and how they factor the resources
available to them into their decisions.
http://www.ubc.ca/
Genes associated with throat
cancer found
Scientists from Singapore, China and USA have
identified three new susceptibility genes in a
genome-wide association study of nasopha-
ryngeal carcinoma (NPC). The reseacrh , led
by the Genome Institute of Singapore (GIS), a
biomedical research institute of the Agency for
NEWS IN BRIEF
Science, Technology and Research (A*STAR),
and the Sun Yat-Sen University Cancer Cen-
tre, identified genetic risk factors of NPC that
advance the understanding of the impor-
tant role played by host genetic variation in
influencing the susceptibility to this cancer.
NPC is a type of cancer that forms in the epi-
thelial lining of the nasopharynx. It is par-
ticularly prevalent in southern China, with an
occurrence rate about 25 times higher than that
in most regions of the world. NPC is therefore
referred to as the Cantonese Cancer.
To search for the genetic risk factors for NPC, a
comprehensive genetic analysis of the human
genome in a large clinical sample of southern
Chinese descent was carried out in approximately
5,000 patients and 5,000 controls. The research-
ers found that the genetic variation within the
human leukocyte antigen (HLA) and the three
genes TNFRSF19, MDSIEVI1 and CDKN2A/2B
can significantly influence a person’s risk of devel-
oping NPC. The researchers also noticed that
these three susceptibility genes for NPC have been
reported to be involved in the development of
leukemia, suggesting there might be some shared
biological mechanism between the developments
of these two diseases. This finding provides an
important opportunity for biologists to understand
the molecular mechanism underlying the develop-
ment of this cancer, and its unusual pattern of high
prevalence in southern China.
http://www.a-star.edu.sg/
Researchers develop test to
identify ‘best’ sperm
A team of researchers at Yale School of Medicine,
USA led by Gabor Huszar, M.D have discov-
ered a method to select sperm with the highest
DNA integrity in a bid to improve male fertility.
The method is comparable to that of the egg’s
natural selection abilities. Past semen analysis
focussed on sperm concentration and motility.
It was assumed that if a man had a high sperm
count and active sperm, he was fertile, but there
was no information on the sperm’s fertility or
its ability to attach to the female gamete. In an
ideal case, the egg naturally selects the optimal
sperm, but during in vitro fertilisation treat-
ment of men who had only a few sperm, clini-
cians did not know whether they were injecting
the correct sperm into the egg for fertilisation.
Huszar and his colleagues tested the idea that
binding sperm to hyaluronic acid selects sperm
with high DNA integrity. They studied semen
samples from 50 men, and a part of the sperm in
the semen was allowed to bind to hyaluronic acid.
These sperm were isolated, and the DNA chain
integrity was compared to the original sperm
in semen. The team used a reagent that stained
sperm with high DNA integrity green, whereas
sperm with fragmented DNA, and diminished
DNA integrity were stained red. The nuclear
and cytoplasmic attributes of various sperm
were identified, and a key relationship between
the ability of sperm to bind to hyaluronic acid
and between high sperm genetic integrity was
found, which enhances the sperm’s contribution
to normal embryo development.
http://tinyurl.com/34cnt7a
Many people with HIV start care
too late
Despite growing evidence that the earlier people
are diagnosed with HIV and get access to care,
the better their clinical outcomes, many HIV-
infected people in the United States and Canada
are not receiving the care they need early enough.
A recent study of nearly 45,000 patients in both
countries highlighted this trend.
Researchers analysed patients’ CD4 cell counts,
a critical measure of immune system strength,
when these patients first began clinical care for
HIV from 1997 to 2007. Although the median
CD4 count at first presentation increased
annually over this period, from 256 cells/mm3
to 317 cells/mm3, it still remains below the
level currently recommended for patients to
start antiretroviral therapy, 350 cells/mm3. The
median age at which patients first received HIV
care increased over the study period from 40 to
43 years of age.
http://tinyurl.com/2ufsj3n
 1. P
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 June 2010 28 Orthopedics

SPECT-CT in imaging foot & ankle pathology:

the demise of other co-registration techniques
Given the complex anatomy and function of the foot, the management of chronic to the appropriateness criteria published by the
pathologies of the ankle and foot remains a challenge. Imaging plays a crucial role American College of Radiology. Advances in the
and recent appropriateness criteria have been published for the use of the currently strength of magnets (>1.5 T ) and the imaging pro-
tocols offer the potential of a better signal-to-noise
available investigating modalities, which are broadly classified into anatomical
ratio, improved resolution, and faster scan times
and functional imaging methods. The recent introduction of SPECT/CT scanners [7]. MR imaging is routinely used in the evalua-
which are capable of combining functional and anatomical images is an excit- tion of soft tissue pathology of the feet including
ing and important development. This article describes our clinical experience with tendinosis, bursitis, fasciitis and for the diabetic
SPECT/CT and discusses its potential applications in the imaging of complex foot foot. It allows for the examination of the vascula-
and ankle pathologies. ture as well, which has been successfully used in
the management of diabetes-related osteomyeli-
tis. Optimal evaluation of tendinous pathology
by Dr H K Mohan, Dr G Gnanasegaran, Dr S Vijayanathan and Dr I Fogelman however remains elusive [8], and ultrasonography
remains the investigation of choice in this popu-
lation. The potential disadvantages of which one
Chronic disorders of the ankle and foot are a acquires data that may be reconstructed in any must be aware in MRI are metallic artifacts asso-
significant clinical challenge given the complex plane; advances in technology allows sub-milli- ciated with hardware or micrometallic material
anatomy and function of the foot, which makes it metre resolution for the evaluation of the bones in an operative bed, which are more pronounced
difficult to localise origin of pain by routine clini- and related complications, articular cartilage in high field systems and worse with increasing
cal examination. In recent years, there has been lesions, and even limited assessment of tendon field strength. Postoperative follow-up imaging
a significant development of imaging techniques disease [4]. This enhances the ability to detect in the presence of micrometallic artifacts may not
to aid the clinician in the management of this fractures, osteochondral lesions [4,5] and also be carried out using a high field system. Imaging
complex group of problems. Anatomical imag- provides high resolution images essential for parameters are not transferable from 1.5 to 3.0-T
ing (X-ray, MRI, Ultrasound and CT) and func- presurgical planning. Whilst CT arthrography systems and must be modified to take advantage of
tional imaging (Bone scan, MRI and Ultrasound) may prove to be superior to MR for the post- the potential benefits of high field strength imag-
techniques have been used in the management of operative assessment of chondral repair [5], its ing [7,9]. Also, claustrophobia requiring the use of
patients with chronic foot pain. role in the assessment of tendinous and liga- general anaesthesia has been seen in up to 10% of
mentous pathologies in the feet has not been patients imaged in a closed high field MR system
The technique of co-registering anatomical and proven and remains the main limitation when and obese patients frequently cannot be imaged in
functional images of the feet has already been compared to MRI or ultrasound [6]. the constrained geometry of closed systems.
described [1] and more recently the clinical value
of co-registering of bone single photon emission Magnetic resonance imaging (MRI) Ultrasonography
computed tomography (SPECT) images of the This remains the imaging method of choice for Ultrasound is used in patients with foot pain, to
wrist with multislice CT images using software has complex ankle and foot pathology according examine the soft tissue and is often the preferred
been described [2,3]. CT images provide exquisite imaging modality when Morton’s neuroma or
details of the bone anatomy whilst the bone scan Achilles tendinosis is suspected [8]. Advan-
provides the functional information. Combined tages of sonography include direct correlation
SPECT/CT study proves to be an excellent tech- of findings with the patient’s symptoms, com-
nique for the evaluation of complex bony pathol- parison to the asymptomatic ankle, dynamic
ogy in the feet although at present MRI remains imaging of the foot in multiple planes and posi-
the most widely used technique for the evaluation tions, wide availability, and lower cost of and
of chronic foot pain. In this article, we describe the portability of the equipment to the bedside of
current techniques available for imaging pathol- an unwell patient. Disadvantages of ultrasound
ogy in the feet, describe our clinical experience include unfamiliarity with the scanning tech-
with the new SPECT/CT technique, and discuss nique and appearance of ultrasound pathology,
its potential applications. operator dependence and limitation of imaging
structures superficial to the bony cortex.
Conventional radiography (X-ray)
This remains the most widely used, accessible Nuclear medicine
and cost effective imaging modality for evalua- Figure 1. Non union: 59 year old patient with previ- A bone scan is a highly sensitive technique
tion and management of acute and chronic foot ous Talo-Navicular fusion complaining of continuing which has been used in the diagnosis and man-
pain. This has a particularly important role in pain. Clinically joint immobile. X-rays not conclusive agement of skeletal pathology for nearly three
the management of acute trauma while its role On the delayed images there is focal increased tracer decades [10], and the role of bone scintigraphy
in chronic injuries remains limited and at best uptake (Arrow) in the right mid foot and on the blood in the management of specific conditions result-
pool images there is increased vascularity noted to
complementary to other techniques. ing in foot pain has been described [11]. Whilst
this site. (Arrow) On the SPECT CT study this area
of uptake corresponds to non union of talo-navicular the sensitivity of the bone scan in the diagnosis
Computed tomography joint (CT image) causing continued pain post surgery of bony pathology in the foot remains high, spe-
Multidetector computed tomography (MDCT) in the patient. cificity remains suboptimal. SPECT studies have

Figure 2. Osteochondral defect: 27 yr old male with
pain in left hind foot – Previous history of fall. Delayed
images show increased focal uptake of tracer in left
ankle medially with increased vascularity on the early
images [Arrows pointing]. SPECT CT study confirms
focal uptake in the Talar dome and on the CT images
(Arrow) there are cystic changes noted in keeping
with an osteochondral defect in the talus.
demonstrated improved sensitivity and spe-
cificity although only limited benefit has been
shown in the evaluation of foot pathology.
Co registration of bone scan images with X-ray
[1] and CT have been performed using software
[3,12] and low dose CT systems [13]. More
recently, hybrid systems capable of acquiring
high-resolution multislice CT image sets that
directly match SPECT findings in the same
sitting have been developed. This is expected
to further increase the diagnostic accuracy of
this already highly sensitive but generally non
specific study [14].
Potential applications
Postoperative evaluation of joint fusion
and related complications
Joint arthrodesis has long been used for the treat-
ment of painful mal-alignment or arthritis of the
hind foot [15]. Successful osseous union after joint
arthrodesis is usually expected to occur within six
months of the procedure [16] and is confirmed if
no joint motion is detected on clinical examina-
tion and there is evidence of trabeculation across
the arthrodesis site as observed on plain film radi-
ographs. Delayed union is defined as a successful
fusion 6 to 9 months after surgery. In patients who
continue to suffer from pain following arthrod-
esis, non-union is suspected. Other complications
include development of arthritis in the adjacent
joints due to biomechanical overload in about
30% of patients [17] and infection in about 3-5%
of patients [19].
Post-operative assessment of the success of
fusion has been routinely evaluated using X-ray
and CT techniques. However, exact localisation
of the site of the origin of pain in these patients
remains suboptimal on X-ray and CT [18]. MRI
would be unsuitable in this situation due to in
situ metal hardware or the presence of microme-
tallic artifacts and in diabetic patients in whom
there is the additional risk of nephrogenic
fibrosis associated with gadolinium contrast.
29
SPECT-CT would be a valuable technique for
the evaluation of continuing pain in the con-
text of arthodeses as sites of altered metabolic
activity on the bone scan would allow a more
focussed examination of the area on the CT
study. This improves the accuracy of identify-
ing non-union / malunion [Figure 1], subja-
cent arthritis or infection as the cause for con-
tinuing pain. A combination of SPECT/CT
Bone scan / white cell study would be useful in
confirming bone and soft tissue infection and
also in monitoring response to treatment.
Talar osteochondral defect (OCD)
Osteochondral lesions are a result of acute and
sub-acute injuries of the articular cartilage and
underlying subchondral bone resulting in the
aseptic necrosis observed on histopathology.
Although uncommon, this remains one of the
treatable causes of unexplained chronic ankle
pain [20]. Medial talar dome OCD is more
common and bilateral lesions may occur in
approximately 10% of cases [20].
The role of bone scintigraphy in the diagno-
sis of talar OCD [21] has been described. CT
scans provide high quality anatomical images
for accurately assessing the location and size
of the OCD lesions and the diagnostic value
is very similar to an MRI study [22]. In addi-
tion CT provides information as to loose frag-
ments within the lesion which makes surgical
intervention a necessity [23]. The combination
of highly sensitive bone SPECT images with
a highly specific CT study would provide the
clinician with an excellent tool for the diagno-
sis and management of talar OCD [Figure 2].
It would also be beneficial in the post opera-
tive assessment particularly where MRI images
may be difficult to interpret.
Achilles tendonitis, bursitis and
plantar fasciitis
MRI remains the imaging of choice in these
conditions as it can demonstrate more anatom-
ical detail including disruption of the soft tissue
structures, associated soft tissue and reactive
bone oedema [24]. Typically, plain radiogra-
phy is not helpful, but is always done to rule
out other conditions. Although the role of bone
scintigraphy remains limited in this group of
patients SPECT-CT may provide useful coin-
cidental imaging information for the clinician.
The SPECT study would demonstrate the met-
abolic abnormalities associated with the bone
(edema/enthesophyte trauma etc) whilst the
CT would be useful in demonstrating the asso-
ciated bony (calcaneal spurs) and soft tissue
abnormalities (plantar fascia, Kager’s fat pad
and retrocalcaneal bursa) [Fig ure 4].
Stress fracture
Plain radiography although having poor sensitiv-
ity remains the first investigation that is ordered
June 2010
in patients with suspected stress fracture. Bone
scan [25] and recently MRI have demonstrated
high sensitivity in identifying early stress injury.
[26] Interestingly Gaeta et al [27] in their recent
article suggest that the earliest finding of abnor-
mal repetitive stress may be osteopenia which
can only be demonstrated by dedicated high
resolution CT studies. In view of these recent
findings, one would anticipate that SPECT/CT
may find a more prominent role to play in the
early diagnosis and management of patients
with suspected stress fractures by combining the
advantages of the two modalities [Figure 3].
Painful accessory bones
Potentially painful normal bony variants, such
as accessory tarsal navicular and os trigonum,
have been described with chronic foot pain
[28]. The mechanism of pain in the presence
of an accessory tarsal bone has been attributed
to traumatic or degenerative changes at the
synchondrosis or to soft-tissue inflammation.
Symptomatic accessory tarsal bones have been
studied with bone scanning and MRI. Symp-
tomatic lesions are reported to show increased
radiotracer uptake or marrow edema across
the synchondrosis. SPECT/CT study provides
an excellent technique for the evaluation of
the cause of chronic pain in this situation with
the SPECT study elegantly demonstrating any
altered metabolic activity in the joint whilst
the CT demonstrates the associated anatomical
abnormalities [Figure 4].
Tarsal coalition
Tarsal coalition is a rare deformity [29] that
results from abnormal bridging (fibrous / carti-
laginous or osseous) across two or more tarsal
bones resulting in painful deformity of the hind
foot with restricted motion. Calcaneonavicular
and talocalcaneal (middle facet at the level of the
Figure 3. Stress fracture: 36 year old with previous left leg
amputation in a road traffic accident underwent bone
scintigraphy to evaluate the cause of severe pain in the right
mid foot. Delayed planar images show focal increased
uptake in the right ankle / mid foot with increased vascular-
ity (Arrow) on the early blood pool images. SPECT images
confirm uptake in the midfoot which on the SPECT CT
images correspond to a stress fracture.
 June 2010 30
Figure 4. Painful accessory bone, Os Trigonum: 47
year old lady with pain in right ankle and known to
have bilateral Os trigonum. There is increased uptake
in the delayed images and increased vascularity on
the early blood pool images noted within the poste-
rior aspect of right ankle. (Arrow) On the SPECT-CT
study the increased tracer uptake is seen correspond-
ing to the syndesmosis between the Os Trigonum and
the Talus. (Arrow) Although the CT study shows only
minor asymmetrical sclerosis and irregularity along the
joint margin, the increased uptake on the SPECT study
helps confirm the site of symptoms allowing
appropriate surgical management.
sustentaculum tali) coalition are the most com-
mon sites. CT, although often diagnostic and
MRI are not the imaging studies of choice for
tarsal coalition and plain radiography remains
the main mode of investigation [30]. SPECT/CT
may be an improved alternative to CT alone with
addition of supplementary functional informa-
tion from the bone scan [Figure 5]. The area of
uptake on the SPECT study may also help guide
intra articular injections.
Our experience
We have assessed the additional value of
SPECT/CT in 16 patients referred from a spe-
cialist orthopedic clinic and it was observed
that SPECT/CT provided additional informa-
tion in 13/16 (81%) patients and was unhelpful
in 3 (19%) cases. A specific diagnosis was made
in 6/13 (46%) patients which included mal-
union, osteochondral defect, osteomyelitis and
inflammatory arthritis. More accurate localisa-
tion of degenerative or post surgical changes
was observed in the remaining 7 patients.
When compared to conventional bone scin-
tigraphy, SPECT/CT provides more specific
information (malunion / non-union / stress
fractures/ impingement etc) as well as allowing
more accurate localisation of the abnormalities
detected [31,32]. It was found that in more than
50% of patients, management was changed fol-
lowing the findings of the SPECT/CT study
and many patients did not undergo any fur-
ther investigation. We have also demonstrated
the value of SPECT/CT in the investigation of
heel pain [33] in a patient with retrocalcaneal
bursitis and plantar fasciitis.
Orthopedics
The limitations of SPECT-CT imaging however
are the additional radiation exposure and the
increased cost compared to planar bone scintigra-
phy. The ACR has previously made recommenda-
tions regarding the appropriateness of each inves-
tigation in evaluating pathology of the foot and
ankle. The role of a bone scan however remains
limited with best use seen in identifying patients
with reflex sympathetic dystrophy syndrome.
However, with the combination of functional and
structural information in a single study, SPECT/
CT may prove to be a very useful technique for
the evaluation of foot pain especially in patients
with previous surgery or in situ metal work. This
would also reduce the inconvenience of extra
hospital visits for patients who previously may
have had a standalone bone scan and / or a CT
study performed. This would also result in a more
efficient use of resources and likely to be cost
effective for the health provider. We believe that
the ACR recommendations will need to be revis-
ited to incorporate the role of SPECT/CT as more
evidence becomes available as to its benefits.
Conclusion
Imaging of chronic foot pain remains complex and
challenging. Currently MR remains the favoured
modality although with increasing evidence,
SPECT/CT could prove to be a valuable addition
to the imaging armamentarium, particularly in
the evaluation of pathology following surgery or
in patients not suitable for MR, and may also play
a role in guiding intra-articular injections.
References
1. Robinson AH et al.The Journal of Bone and Joint
Surgery 1998; 80(5):777-80.
Figure 5. Tarsal coalition: 33 year old lady with right
ankle pain. The delayed images of the ankles show
increased tracer uptake within the right ankle (Arrow)
which on the SPECT CT images corresponds to the
lateral aspect of the subtalar joint. The cortical irregu-
larity and sclerosis along the margins in the medial
aspect are consistent with the clinical suspicion of
a fibrous coalition. (Arrow) The increased uptake in
the lateral aspect of the joint (Arrow) was thought
to be due to associated alteration in biomechanical
load. This area was injected with steroids, which has
resulted in improvement of pain.
2. Groves, A et al. Nuclear Medicine Communications:
Volume 5(11)November 2004 1151-1155
3. Ashley M et al. Am J Roentgenol 2005; 184:1470.
4. Haapamaki V et al. Am J Roentgenol 2004; 183:615.
5. Schmid MR et al. Skeletal Radiol 2003; 32: 259.
6. Choplin RH et al. Radiographics 2004; 24: 343.
7. Gold GE et al. Am J Roentgenol 2004; 183: 1479.
8. Premkumar A et al. Am J Roentgenol 2002; 178: 223.
9. Gold GE et al. Am J Roentgenol 2004; 183: 343.
10. Holder LE. J Bone and Joint Surg 1982; 64-A:1391
11. Groshar D et al. Semin Nucl Med 1998; 28: 62
12. D Utsunomiya et al. Radiology 2005; 238:264
13. Even-Sapir E et al. J Nucl Med 2007; 48: 319
14. Romer W, et al. J Nucl Med 2006; 47: 1102.
15. Graves SC: In Myerson MS (ed): Foot and Ankle
Disorders. Philadelphia, WB Saunders, pp. 1040 –
1058, 2000.
16. Catanzariti AR et al. J Am Podiatr Med Assoc
2005; 95: 34
17. Rammelt S et al. Orthopade 2006;35:428.
18. Mitchell MJ et al. Am J Roentgenol 1995;
164: 1473.
19. Graves SC et al. J Bone Joint Surg 1993; 75: 355.
20. Ferkel RD et al. Orthop Clin N America 1994
25: 17
21. Pavlov H. Radiologic Clin North Am 1990; 28: 991
22. Verhagen RA et al. J Bone Joint Surg Br 2005; 87 41
23. Madi F et al. Pediatr Radiol 2005 35: 823.
24. Joong MA, El-Khoury GY. Am Fam Physician
2007;76(7):975-83.
25. Ammann W et al. Clin J Sport Medicine 1991;
1:115
26. Sijbrandij ES et al. Eur J Radiol 2002;43:45-56.
27. Gaeta M et al. Radiology. 2005; 235: 553.
28. Karasick D et al. Am J Roentgenol 1996;166:125
29. Stormont DM et al. Clin Orthop Relat Res 1983;
181: 28.
30. Crim JR et al. Am J Roentgenol 2004; 182: 323.
31. Langroudi B et al. J Nucl Med 2007; 48 :122P
32. Mohan H et al. Eur J Nucl Med Mol Imaging
2007;34: S166.
33. Breunung N et al Clinical Nuclear Medicine 2008;
33: 705.
The authors
Hosahalli K Mohan, M.D.1, Gopinath
Gnanasegaran,M.D.1 Sanjay Vijayanathan,
M.D. 2 Ignac Fogelman, M.D. 1
1
Department of Nuclear Medicine,
2
Department of Radiology
Guys & St Thomas Hospitals NHS trust,
London,
United Kingdom
Correspondence to :
Dr. Hosahalli.K.Mohan
Department of Nuclear Medicine,
Ground Floor, New Guys House,
Guys Hospital,
St Thomas Street,
London, SE1 9RT.
UK.
Tel: +44 207 1887188
e-mail: mohanhk@hotmail.com
 PRODUCT NEWS 31 June 2010

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32 PRODUCT NEWS
Improved laryngoscopes
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PRODUCT NEWS 33
of years that fevers can kill cancer cells, only
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shown that 37.4% of patients had a complete
tumor regression while an additional 24.5% had
greater than 50% tumor regression and a total
of 83.7% of patients had some tumor regression
after hyperthermia therapy. The primary types
of tumors included in the study were recurrent
chest wall, recurrent head and neck, recurrent
melanoma and recurrent sarcoma.
BSD Medical
Salt Lake City, UT, USA
www.ihe-online.com & search 45594
Combined defibrillator monitor
The Rescue Life combined defibrillator/monitor
device is designed to be used by both out-of-
hospital and hospital users. With its innovative
design, the portable device has a brilliant high
contrast, wide-angle TFT LCD colour display
that allows the simultaneous visualisation of up
to 3 ECG channels. Information such as heart
rate, SpO2 values, alarms and operational func-
tions are clearly displayed even in low visibil-
ity conditions. In AED or Advisory mode, text
messages and voice prompts guide the operator
during the CPR procedure. Users can choose
between ergonomic reusable paddles, suitable
for manual defibrillation in both adult and pae-
diatric patients or disposable pads for AED defi-
brillation. Both are equipped with a single fast
lock connection for reliable rescue operations.
Progetti
Mocalieri, Italy
www.ihe-online.com & search 45588
June 2010
FRONT COVER PRODUCT
Closed loop ventilation system
The result of 16 years intensive develop-
ment, the newly launched INTELLiV-
ENT-ASV device incorporates the world’s
first fully closed loop ventilation technol-
ogy and is now available for clinical use.
Optimised ventilation therapy in inten-
sive care generally requires the continual
adjustment of parameters so that the
patient can be weaned off the device as
quickly as possible. Unfortunately in most
cases it is not possible for personnel to
stay permanently at the patient’s bedside.
As a result, in many cases settings are only
adjusted whenever some alarm threshold
indicates a change in lung physiology.
This situation looks set to change from
now on with the introducton of the new
closed loop ventilation system for oxy-
genation and ventilation which covers all
applications from intubation till extuba-
tion. By bringing expert knowledge to the
bedside, even in the absence of experts,
the new system gives clinicians assistance
on complex decision making by display-
ing complex information in an intuitive
way. Adjustments are made automatically
following carefully established protocols
based on the measurement of lung physi-
ology, respiratory monitoring, capnogra-
phy (etCO2) and pulse oximetry (SpO2).
By reducing the burden of regular manual
adjustments through the application of
lung protective rules and the use of set-
tings adapted to each individual patient,
the overall time of ventilation can be
reduced. This lowers stress for the entire
staff, increases the availability of staff at
the bedside and reduces the potential for
mistakes and errors.
HAMILTON MEDICAL
Bonaduz, Switzerland
www.ihe-online.com & search 45595
 June 2010 34 PRODUCT NEWS

The new soft tissue probe provides the same

FRONT COVER PRODUCT unprecedented imaging quality as the existing Calendar of events
topical probe, giving real-time, in vivo images
Point-of-care imaging at better than 7.5 µm lateral resolution. The July 24 – 27, 2010 October 9-13, 2010

probe is 9 cm long and provides both 2D and 15th World Congress EANM 2010 - Annual Congress
on Heart Disease of the European Association of
Roughly the size 3D images over a 5 mm x 5 mm area. For sterile
Vancouver, B.C., Canada Nuclear Medicine
of a smart phone, applications, the probe is used with a dispos-
Tel. +1 310 657 8777 Vienna, Austria
the new Vscan able transparent sheath which covers the probe, Fax +1 310 659 4781 Tel. +43 1 212 80 30
scanner from handle and upper connecting cable. Several e-mail: Klimedco@ucla.edu Fax +43 1 212 80 309
GE Healthcare studies suggest that the new probe should be www.cardiologyonline.com e-mail: info@eanm.org
is a pocket-sized http://eanm10.eanm.org/

visualisation tool August 24-26, 2010

Medifest South Africa 2010 October 18-21, 2010
developed to
Capetown, South Africa Phar/MedExpo 2010
provide physi-
Tel. +91 11 30580444 Amman, Jordan
cians with imag- e-mail: info@vantagemedifest.com Tel. +962 6 552 7066
ing capabilities www.vantagemedifest.com Fax +962 6 552 7311
at the point-of- e-mail: info@me-medexpo.com
care. The system Aug. 28 – Sept. 1, 2010 www.me-medexpo.com

houses power- ESC Congress 2010

Stockholm, Sweden November 17-20, 2010
ful, ultra-smart
Tel. +33 492 947 600 MEDICA
ultrasound technology that enables physi- particularly useful to clinicians in the diagno-
Fax +33 492 947 601 Düsseldorf, Germany
cians to provide more rapid diagnoses by sis and treatment of oral and cervical cancers. www.escardio.org/congresses/ e-mail: info@medica.de
enhancing the physical exam. By leveraging For example, ex vivo trials on excised oral tissue esc-2010 www.medica.de
GE’s high-quality black and white image have already shown that the system can visu-
technology and colour-coded blood-flow alise structures such as the epidermal/dermal September 14-15, 2010 Nov. 28 – Dec. 3, 2010

imaging in a device that weighs less than junction and areas of cellular crowding that are MHealth 2010 RSNA 2010
Dubai, UAE Chicago, IL, USA
500g, the system provides image quality characteristic of early stage tumors. A blinded
Tel. +44 20 7067 1830 Tel. +1 630 571 2670
that until recently was only available with a assessment of OCT images of 125 excised oral
www.m-healthconference.com www.rsna.org
console ultrasound. The device can easily be lesions showed that a sensitivity of 80 per cent
taken from room to room and can be used in and specificity of 81 per cent could be obtained September 15-17, 2010 December 10-12, 2010
many clinical, hospital or primary care set- in the diagnosis of oral cancer. It is expected Medical Fair Asia 2010 Medifest India 2010
tings. The ability to take a quick look inside that in vivo imaging will give even better results Suntec Singapore New Delhi, India

the body using Vscan may help clinicians and could even eliminate the need for a biopsy. Tel: + 65 6332 9620 Tel. +91 11 30580444
Fax: +65 6332 9655 / 6337 e-mail: info@vantagemedifest.com
detect disease earlier and could prove invalu-
4633 www.vantagemedifest.com
able in today’s busy practice environments Michelson Diagnostics
e-mail:
such as those involving primary care physi- Orpington, Kent, UK medicalfair-asia@mda.com.sg January 24-27, 2011
cians, specialists in cardiology, critical and www.ihe-online.com & search 45590 www.medicalfair-asia.com Arab Health 2011
emergency care and women’s health. Oper- Dubai, UAE
ated via an intuitive user interface that is con- October 5-7, 2010 Tel. +971 4 336 5161

trolled using the thumb, the new system has Five MP Grayscale monitor Clinical Excellence Asia e-mail: info@iirme.com
Marina Bay Sands, Singapore www.arabhealthonline.com
applications in the examination of abdomi- The Radiforce GS520
www.iirme.com/clinicalasia
nal, cardiac (adult and pediatric), urological, monitor displays
February 24-27, 2011
fetal/OB and pediatric cases. It is also suitable radiological images October 9-13, 2010 International Conference on Pre-
for thoracic/pleural motion and fluid detec- using a high resolu- 23rd ESICM Annual Congress hypertension & Cardio Metabolic
tion and for basic patient examination in tion image matrix Barcelona, Spain Syndrome
primary care and in special care areas. with a perfect (1:1) Tel. +32 2 559 03 55 Vienna, Austria

pixel representa- Fax +32 2 527 00 62 Tel. +41 22 5330948

e-mail: Barcelona2010@esicm.org Fax +41 22 5802953
GE Healthcare tion. Fine structures
www.esicm.org e-mail:
Chalfont St Giles, Bucks, UK are shown precisely,
Secretariat@prehypertension.org
www.ihe-online.com & search 45592 making the moni- October 13-16, 2010 www.prehypertension.org
tor ideal for thorax CMEF Autumn 2010
and mammography Shenyang, Liaoning Province, China March 3-7, 2011
Soft tissue probe for in vivo applications. The use Tel. +86 10 6202 8899 ext 3825 ECR 2011

imaging using OCT of a 13.5 bit Look-Up-Table avoids unwanted Fax +86 20 6235 9314 Vienna, Austria
e-mail: Tel. +43 1 533 40 64 - 0
The VivoSight Multi-Beam optical coherence artefacts which could otherwise emerge after
jin.liu2@ReedSinopharm.com Fax +43 1 533 40 64 - 448
tomography (OCT) imaging system from calibration, so that the image data are shown
http://en.cmef.com.cn/ e-mail: communications@myESR.org
Michelson Diagnostics can now be used with without any crushing of greyscales or loss of http://myESR.org
a probe developed especially for imaging soft quality. The system has a pallet with 13771 grey-
tissue that allows in vivo imaging of oral and scales and incorporates a sensor for automatic
gynecological tissue. The OCT system provides and constant brightness. For more events see
sub-surface cross-sectional images at a far www.ihe-online.com/events/
higher resolution than is possible with ultra- Eizo Dates and descriptions of future events have been obtained from
sound, CT or MRI, and much deeper and wider Ishikawa, Japan usually reliable official industrial sources. IHE cannot be held
responsible for errors, changes or cancellations.
than is possible with confocal microscopy. www.ihe-online.com & search 45591
 How can we make sure
that our patients always
get the best care?

By being able to employ every clinical advancement.

Cardiology Solutions from Siemens.
Cardiovascular diseases are the leading cause of death worldwide. And the number of chronic cardiovascular disease patients is rising.
The consequence? An increasing demand for best possible quality of care in the most effective and efficient way. We offer you a
comprehensive portfolio along the entire cardiovascular care continuum. Siemens commitment to excellence provides best-in-class
support for your diagnostic and therapeutic decisions within your department, across your institution – and beyond.
www.siemens.com/cardiology

Answers for life.

A91CC-9108-A1-7600
www.ihe-online.com & search 45544