Applied Radiology

The theme of the 83rd Scientific Assembly and Annual Meeting of theRadiological Society of North America (RSNA), held at McCormick Place inDecember 1997, was "critical pathways." The Eugene P. Pendergrass NewHorizons Lecture gave an idea of where some of those critical pathways may leadas radiology enters the next century. ln "Medical lmaging in the NewMillennium," Bruce J. Hillman, MD, of the University of Virginia HealthSciences Center (Charlottesville, VA) predicted dramatic changes in the scopeof medical imaging.

Advances in genetics, cellular engineering, and pharmacogenetics will opennew worlds to radiology. "Very soon, radiologists must find ways to useinformation technology to integrate imaging data with new information in theseareas and place the results in a functional context," said Dr. Hillman."This will allow us to participate in the new style of interdisciplinarymolecular medicine. Our residents are ill-prepared to work in this environment,so we must train them and retrain ourselves. We must be more collaborative andfocus in on the biological and physical foundations underlying the radiologicimages," he explained.

Just as biomedical advances are changing the practice of radiology,electronic advances are moving ahead with lightning speed. Computers aregetting smaller and more powerful, leading to numerous innovations in medicalimaging. PC power.

The personal computer (PC) is becoming a more and more useful tool forvarious radiology applications. The small upstart companies at the RSNA canoffer more powerful radiology products every time Microsoft, Intel, or Netscapeupgrade the "off-the-shelf" technologies used in today's medicalimaging devices.

E-mailing image display capability

There's a new type of e-mail that enables the recipient to download,display, manipulate, and transmit annotated radiology studies-essentiallyturning any PC into a medical imaging workstation. According to Medweb (SanFrancisco), the Medweb E-Mail Plug-in is free to facilities that buy the Medwebserver. "Because our plug-in is very small and costs nothing, physicianscan include a copy of the software in their e-mail," said Berta Hyken ofMedweb. They can send that e-mail to any consultant worldwide who has aninternet browser (specifically Netscape Navigator, Microsoft Explorer, or LotusNotes). The consultant can then annotate selected studies, includevoice-dictated and/or written comments, and e-mail the study back to thesender.

The E-Mail Plug-in (an investigational device pending FDA clearance)includes more than 40 image viewing and manipulation tools, such as pan, zoom,digital edge enhancement, window/level, interactive window/level, magnify,flip, rotate, measure, arrow annotation, and a freehand annotation pencil. TheMedweb server with wavelet compression, "typically saves users $50,000 perworkstation," said Ms. Hyken.

PC-based ultrasound

Perception Ultrasound (Issaquah, WA) offers the 5000, a PC-based ultrasoundscanner, recently cleared by the FDA for marketing.

It's the first general-use ultrasound system using the Windows® NToperating system, explained Martin E. Doyle, chairman and CEO of Perception, acompany established in 1993 by several ultrasound engineers. The system usesIntel hardware and Microsoft software that generates "'virtual knobs' thatcontrol the ultrasound image, unlike traditional scanners that arehardware-based and sometimes use dozens of knobs, levers, and switches,"explained Mr. Doyle.

Applications for the ultrasound system include obstetrics/gynecology,vascular imaging, urology studies, and family practice and emergency-roomimaging. According to Perception, the average system cost is approximately$40,000. Combined with the PC, the Perception ultrasound scanner becomes a"virtual console" that can store up to 5,000 patient files. With astandard modem, ultrasound images can be sent from the scanner via internet,e-mail, or local area networks.

"We told one radiologist that, with our system, he could networkultrasound scanners in various hospital departments for about $72,000. Theclosest quote he got from other ultrasound manufacturers for the same setup was$350,000," said Mr. Doyle.

DICOM: "Buyer beware"

At RSNA 1994, DICOM (Digital Imaging and COmmunications in Medicine), thestandard for electronic image data transfer, made a big splash; 39 exhibitorssaid they were linked on RSNAnet, a network located at McCormick Place, with anarchive of 128 sets of images that could be retrieved from a server. At RSNA1997, however, some attendees were disillusioned with how DICOM has evolved.There is too much room left for individual interpretation, and today two"DICOM-conformant" devices may still need a little extra help tocommunicate.

"We've actually built DICOM-to-DICOM gateways betweendevices," said Wayne DeJarnette, PhD, president of DeJarnette ResearchSystems (Towson, MD). "When investing in PACS, it's 'buyer beware' whenyou hear that components are DICOM-conformant," he added. The electronicgateways and interfaces are the key components that determine the success of aPACS, noted Dr. DeJarnette. His company is now providing PACS components toPicker.

DeJarnette Research Systems also is expanding its role in PACS with a newline of imaging display stations, now in joint development with ColumbiaScientific, Inc., a company known for reconstructive and dental implantsimulation and surgery-planning software.

DICOM-compliant platform

"While other manufacturers are struggling to convert their existingimaging systems over to DICOM, Hitachi chose to start with a totally compliantplatform," said Gary Enos, general manager for Hitachi's nuclear medicinedivision. The SPECTRADigital 300SS, a nuclear data and image processing system,is configured with Hewlett Packard's open-architecture UNIX RISC workstation.Hitachi is a member of the Andover Working Group, a consortium of medicalmanufacturers that reviews HL7-DICOM communication protocols for radiologyinformation systems (RIS), hospital information systems (HIS), and centralinformation systems (CIS).

Kodak offers DICOM interface for non-DICOM equipment

The Eastman Kodak Company (Rochester, NY) introduced the Kodak DigitalScienceTM medical image manager 100, a hardware/software package that enablesmedical images from non-DICOM-compliant equipment to be routed toDICOM-compliant workstations and archives. The package also provides aninterface to RIS and HIS, allowing patient demographic data to be linked withradiology images before those images are sent to archives and workstations.This package provides a convenient, low-cost means of linking any medicalimaging device to a DICOM-compliant network. It's ideal for devices that cannotbe upgraded to DICOM compliancy, or for devices where such upgrades arecost-prohibitive," said Mike Cullinan of Kodak.

"Enterprise-wide" image management

Fuji Medical Systems (Stamford, CT) is developing an"enterprise-wide" image management and information system, theSynapseTM, designed to "expand the definition and functionality ofPACS," announced the company. "Enterprise-wide" is the term usedtoday to describe a system that encompasses the whole hospital or institution,beyond the radiology department. The first components of the system will becomputed radiography (CR) workstations, based on a Windows NT platform and openarchitecture that uses "cost-effective, off-the-shelf" hardware. Theworkstations will feature "native DICOM output," and some will bedesigned for upgrades to "full multimodality functionality,"according to Fuji.

RIS with web report browsers

Per-Sé Technologies (Atlanta) introduced a new radiology informationsystem (RIS) that includes a "web-enabled report browser that givesreferring physicians access to reports from anywhere, any time, withoutinstalling or maintaining software," according to the company. ProgRIS 98also allows for simultaneous viewing of images and report text, as well astwo-way communication with PACS (picture archiving and communication systems)to support tracking of complete film histories, both digital and on hard copy.Other features of ProgRIS 98 include electronic signature, automatic reportrouting, and voice recognition integration.

Flat-panel technology from NEC

NEC Technologies, Inc. (Itasca, IL) introduced its 14.1" MultiSync®LCD400VTM, an active-matrix, thin-film transistor (AM-TFT) flat-panel monitor,with an estimated street price of $1998. The total depth of the monitor is6.6", making the monitor well suited for radiology environments with spaceand weight limitations. Access patient records with fingerprint scan. Inaddition, NEC demonstrated Positive IDentification, a technology that usesfingerprints to speed patient registration. When a patient places a thumb onthe fingerprint scanner, any file from a previous visit is brought up on thescreen. The system is being used at La Porte Hospital (Indiana).

New MRI liver contrast agent from Nycomed

Nycomed Amersham (Princeton, NJ) introduced a new contrast agent,mangafodipir (Teslascan®), for liver imaging with magnetic resonance (MR).Mangafodipir is a complex formed between a chelating agent (fodipir) and aparamagnetic metal ion, manganese. It shortens the spin lattice (longitudinal)relaxation time (T1) of targeted tissues during MR, leading to an increase inthe signal intensity (brightness) of the tissues. Mangafodipir is indicated fordetection, localization, characterization, and evaluation of liver lesions.

In clinical trials involving 105 histopathologically confirmed liverlesions, paired comparisons of unenhanced MR and Teslascan-enhanced MRcorrectly characterized 49% of the lesions, compared with 30% by unenhanced MRalone, and 21% by contrast-enhanced x-ray computed tomography (CT). Accordingto Nycomed, Teslascan is the first hepatocyte-specific contrast medium.

New injection system from Bracco

Bracco Diagnostics Inc. (Princeton, NJ) announced an exclusive agreementwith ACIST Medical Systems (Eden Prairie, MN) to distribute the ACISTTMInjection System, a contrast-delivery system. The system gives physiciansconstant interactive control of contrast administration through the use of aremote handpiece and a touch-screen monitor. In comparison, current injectiondevices can be used only at predetermined injection rates, explained Bracco.The agreement also includes the ACIST line of proprietary disposableangiography kits.

After the RSNA, Bracco announced a sole-source agreement with AmericanPhysician Partners, Inc. (APPM) to provide radiographic contrast media. APPM, amerger of seven radiology groups in New York, Maryland, Kansas, Texas, andCalifornia, was formed in 1996. The group operates 65 diagnostic imagingcenters and maintains 45 hospital relationships.

Nonionic contrast medium from Cook

Cook Imaging (Bloomington, IN), a manufacturer of interventional radiologydevices, recently introduced a new nonionic contrast medium, ioxilan(Oxilan®), indicated for cerebral arteriography, coronary arteriography,left ventriculography, visceral angiography, aortography, peripheralarteriography, excretory urography, and CT imaging of the head and body.Ioxilan is a low-osmolality, low-viscosity agent. Clinical trials showed nosignificant clinical difference between ioxilan and iohexol (Omnipaque®,Nycomed), the comparator agent.

News from the RSNA 1997 will be covered in future Technology & Industrycolumns. Our next installment, for example, will focus on advances inultrasound.