Volume 35 Issue 4

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FDG-PET in breast cancer

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 Editor’s Letter 3 – Issue N°4 – Sept. 2009

Bariatric surgery: the solution to the obesity epidemic?

The dramatic incr­ to precisely which surgical procedures studies showed improvements as great what is after all a condition that could
ease in the average were the best. Likewise the real ques­ as 40% in long-term mortality in otherwise be solved by dietary self-
life expectancy of tion, namely do the clinical outcomes patients undergoing bariatric surgery. control and life-style changes. Given
the Western popula­ justify the risk, was not addressed by It is tempting to combine the separate the huge costs incurred by not treat­
tion over the last few the trial. Other data do exist however safety and outcome studies to come ing obesity, the real question should be
decades is generally which suggest that remarkable long- up with the conclusion that bariatric can we afford not to extend bariatric
attributed to the pro­ term improvements can be achieved surgery should be actively encouraged surgery, the one approach that seems
vision of basic infrastructure features with bariatric surgery, e.g. the Swed­ and perhaps extended to slightly less to be effective?
such as clean water and efficient drains ish Obese Subject (SOS) study which obese patients. Already the question
as well as to steady medical and surgi­ showed a 23.7% reduction in mortal­ now being asked is whether society
cal advances in the treatment of many ity while yet other case-controlled can afford such surgical approaches for
previously fatal diseases. In the con­
text of the increase in life expectancy,
it is an all the more sobering fact that
today some obese young adults will
lose up to 20 years of life expectancy
if they don’t drastically reduce their
weight. Despite the huge press atten­
tion that is directed to healthy living
and the desirability of maintaining
a reasonable weight, the facts show
that, especially in certain lower socio-
economic classes, there is a stubborn
increase in the rates of obesity. It
seems that voluntary efforts to modify
diets and lifestyle have very little effect
on what can now best be described as
an “obesity epidemic”. All this is part
of the background to the dramatic
increase in the numbers of bariatric PRIMEDIC™ EXTERNal DEFIBRIllaTOR
surgical interventions that are now
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outdated bariatric surgical procedures
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and safer laparoscopic procedures. Of
course even such improved techniques
are not risk-free; the question is what is
the exact level of risk. The precise level
of short-term safety associated with the
various generally used bariatric surgi­
cal procedures has been addressed by
a recently published study, namely the
Longitudinal Assessment of Bariatric
Surgery, LABS, (New England Journal
of Medicine July 2009; 361;5: 520).
The overall death rate in patients under­
going bariatric surgery was found to be
0.3%, and 4.1% of patients had major
complications. These data are very sim­
ilar to those seen in other major opera­
tions. Unfortunately, designed as it was
for the study of short-term safety, the
www.primedic.de
trial did not allow hard conclusions as
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 – Issue N°4 – Sept. 2009
A systematic review of the use of
FDG-PET in breast cancer
This review provides an up-to-date summary of the results obtained through the use
of the technique of fluorodeoxyglucose positron emission tomography (FDG-PET)
for the diagnosis of breast cancer. The article focusses on the use of the technique
in, respectively, the detection of primary breast tumours, the staging of axillary
lymph nodes, the detection of metastases and recurrent disease and the assessment
of response to therapy.
by Dr Sofía Escalona López
Worldwide, breast cancer is the most common
malignant neoplasm in woman, with its high inci­
dence and associated mortality making the disease
a correspondingly important public health prob­
lem. According to the GLOBOCAN database of
the International Agency for Research in Cancer
(IARC) data, the global incidence of breast cancer in
2002 was as high as 1,151,298 cases with the disease
being responsible for as many as 410, 712 deaths .
Positron emission tomography (PET) is one of
the techniques used in the diagnosis of breast
cancer. This relatively non-invasive, exploratory
technique provides physiological information
on the uptake of glucose and its metabolism. The
technique involves the injection of a radioactive
tracer, usually fluorodeoxyglucose (FDG), that
emits positrons. Although in itself not a new tech­
nique, PET is of growing interest as a means of
oncological imaging.
Diagnosis of primary tumours
The ability of FDG-PET to diagnosis primary
tumours in women suspected of having breast can­
cer appears to vary widely, with sensitivities ranging
from 48% to 95.7%. The sensitivity of the technique
appears to be lower when the tumours are small (<10
mm) and the uptake of FDG is correspondingly
reduced. Some authors report that false negative
results are significantly more likely when tumours
are small (≤10 mm) or when their histological grade
is moderate-low. Likewise, it has been found that
the sensitivity of the technique is greater with stage
III and IV than with stage I and II tumours (83.3%
compared to 90.5%) [1, 2]. Several studies have com­
pared the results of FDG-PET to conventional tech­
niques such as mammography, physical examina­
tion or ultrasonography. In all cases the diagnostic
efficacy of FDG-PET was superior [3]. In studies in
which the relevant data were published, the reported
tumour size was between 0.3 cm to 12 cm. It has
therefore been concluded that the capacity of FDG-
PET to detect small tumours is limited. In addition,
it has been reported that different histopathological
types of breast cancer are associated with a varying
6 Nuclear Medicine
degree of FDG uptake. Depending on tumour stage,
diagnostic sensitivity varied (47.7% in pT1 stage
and 80.6% in pT2) [4]. In ductal carcinoma in situ
(DCIS) there was a diffuse uptake with FDG-PET
and a higher number of false negatives [5].
Axillary lymph node staging
The diagnostic accuracy of FDG-PET in the stag­
ing of axillary lymph nodes is directly related to
the size of the metastases and the number of lymph
nodes involved. The detection of micrometastases
FDG-PET may not be able to
rule out small tumours and the
technique cannot replace sentinel
lymph node biopsy in axillary
lymph node staging. However,
it may be accurate enough
in the detection of metastases
and recurrent disease.
in these lymph nodes is limited by the spatial reso­
lution of FDG-PET and the sensitivity of the tech­
nique in this application is very low with a fairly
high rate of false negative results [6, 7], which are
usually associated with micrometastases in a sin­
gle lymph node [8, 9]. FDG-PET is limited in its
ability to detect metastases in single rather than in
multiple axillary lymph nodes. In comparisons of
the use of sentinel lymph node biopsy with FDG-
PET, some authors have reported that FDG-PET
is not as effective for detecting occult axillary
metastases or micrometastases as the sentinel
lymph node biopsy approach [10, 11]. However,
the specificity and predictive value of FDG-PET
in axillary lymph node staging are relatively high:
74-100% and 75-100% respectively [10, 12]. A
positive FDG-PET result might therefore indicate
resection of the axillary lymph nodes, obviating
the need for sentinel lymph node biopsy.
Detection of metastases
and recurrent disease
In the detection of metastases and recurrent dis­
ease, FDG-PET has usually been compared with
conventional imaging techniques, such as mam­
mography, ultrasonography, CT, MRI, X-rays,
and bone scintigraphy, which are generally used
following treatment for a primary tumour. In a
comparison of FDG-PET with bone scintigra­
phy, it was found that FDG-PET detected more
osteolytic-type bone lesions while scintigraphy
detected more osteoblastic lesions [13]. FDG-
PET appears to be more specific than scintigra­
phy, although no significant differences in sensi­
tivity were reported with respect to the detection
of bone metastases using radiography, CT, MRI or
bone biopsy [13,14]. The sensitivity of the tech­
nique was reported to range from 92% [15] to
96% [16] for the detection of recurrent disease.
When FDG-PET was compared with MRI for the
detection of local or regional recurrent disease or
contralateral disease, it was found that there were
no statistically significant differences in the sensi­
tivity and specificity of both techniques although
FDG-PET did detect additional metastases out­
side the MRI field. In eight patients examined,
FDG-PET was able to detect recurrence in six
patients. Combining MRI with FDG-PET when
the results indicated a suspected recurrence led
to an increase in sensitivity and specificity [17].
FDG-PET also detected unsuspected metastatic
or recurrent disease, leading to changes in patient
management; results suggested that between 10%
and 48% of patients needed their treatment to be
modified [18,19].
Assessment of response to therapy
When assessing the results of chemotherapy in the
treatment of breast cancer, a reduction in FDG
uptake is reported to be a potentially better indicator
of therapeutic efficacy than the change in tumour
dimensions as shown by mammography. (P<0.001
compared to P=0.005). The maximum tumour
uptake of FDG decreased promptly with treatment
to 78±9.2% of the basal value on day 8 (P<0.003),
68.1±7.5% on day 21 (P<0.025), 60±5.1% on day 42,
(P<0.001), and 52.4±4.4% on day 63 (P<0.0001). In
a study involving the comparison of the basal level
of FDG uptake with that at 63 day post treatment in
three non-responding patients, no statistically sig­
nificant reduction was found in the tumour uptake
of FDG (81 ±12% of basal diameter) [20].

The regional uptake of FDG has been reported to be
reduced in tumours that respond to the first cycle of
chemotherapy, and to become significantly reduced
after the second cycle (P<0.05). The histopathological
response predicted by FDG-PET after the first chem­
otherapeutic cycle showed a diagnostic accuracy of
88% (when the threshold fall in the Standardised
Uptake Value (SUV) was set to 55% of the baseline
value for optimal differentiation between respond­
ers and non-responders). However, the technique
appears to be unable to distinguish between patients
with small amounts of residual tumour and those
showing a complete pathological response [21].
As concerns the assessment of the response to
tamoxifen therapy, two studies have been carried out
with the aim of investigating whether the increased
tumour uptake of FDG after tamoxifen therapy pre­
dicted a hormonally responsive breast cancer [22,
23]. These two studies found that an increase in FDG
uptake after tamoxifen treatment was consistent with
the metabolic increase. In the first study, there was an
increase in the SUV of FDG of 1.4 ± 0.7 after treat­
ment in responder patients; in non-responders the
change in FDG SUV could barely be detected (-0.01
± 0.4; p = 0.008). In the second study an increase
was also observed (28.4 % ± 23.3 %) in responding
patients whereas there was no significant change in
non-responders. With regard to the basal value there
was a significant difference between non-responders
and responders (p=0.0002).
Conclusion
The studies described above suggest that FDG-
PET is more reliable than conventional techniques
such as mammography, ultrasonography or physi­
cal examination for the diagnosis of primary breast
tumours; the values of diagnostic efficacy for these
latter techniques were generally lower than that of
FDG-PET.
The sensitivity of FDG-PET was found to be low, as
was its negative predictive power, with respect to pri­
mary tumour detection. The resolution possible with
the technology means that it has certain limitations
in the detection of small tumours (<1 cm). On its
own, FDG-PET does not therefore appear to be reli­
able enough to allow the possibility of the presence of
a tumour to be excluded; a negative result cannot be
trusted to rule out the presence of a small tumour.
Studies that compared FDG-PET with other tech­
niques with regard to the staging of lymph nodes
also showed that the sensitivity of the FDG-PET was
very low. FDG-PET thus appears to be insufficiently
exact to enable negative results to rule out affected
lymph nodes.
However, FDG-PET may have an important role
to play in the detection of metastases and locally
recurrent breast cancer, in which situations the
technique appears to have a greater diagnostic effi­
cacy than either mammography or ultrasonogra­
phy. The results obtained are comparable to those
7 – Issue N°4 – Sept. 2009
obtained with CT, FDG-PET/CT or MRI. In addi­
tion, if unsuspected metastases are detected by
FDG-PET, this strongly suggest that the manage­
ment of the patient should be changed. Sensitivity
in the detection of metastases and local and regional
disease recurrence is improved when FDG-PET is
combined with MRI.
The diagnostic efficacy of FDG-PET in the detection
of bone metastases can be improved by combining
the technique with SPECT or bone scintigraphy.
Given the limitations of FDG-PET in the detec­
tion of osteoblastic lesions, the technique should
however not be used on its own .
The studies that assessed the efficacy of FDG-PET
in the monitoring of treatment for breast cancer
were heterogeneous in terms of the treatments pre­
scribed, the interpretation of FDG-PET results, and
the variables analysed so no reliable conclusions
can be drawn regarding the performance of FDG-
PET for the evaluation of the response to treatment.
Likewise, a possible role of FDG-PET in the predic­
tion of the response to neoadjuvant chemotherapy is
unclear. Long-term studies with more patients with
different sizes of tumour are needed for conclusions
to be drawn.
Based on our review of the literature, we thus
conclude that FDG-PET is insufficient to rule out
the presence of small tumours and that the tech­
nique cannot replace sentinel lymph node biopsy
in axillary lymph node staging. It may however be
accurate enough in the detection of metastases and
recurrent disease.
References
1. Kumar R et al. Clinicopathologic factors associated with
false negative FDG-PET in primary breast cancer. Breast
Cancer Res Treat 2006; (98): 267-74.
2. Danforth DN Jr et al. The role of 18F-FDG-PET in the
local/regional evaluation of women with breast cancer.
Breast Cancer Res Treat 2002; 75(2): 135-46.
3. Schirrmeister H et al. Fluorine-18 2-deoxy-2-fluoro-D-
glucose FDG-PET in the preoperative staging of breast
cancer: Comparison with the standard staging proce­
dures. Eur J Nucl Med 2001; 28 (3): 351-8.
4. Avril N et al. Breast imaging with positron emission
tomography and fluorine-18 fluorodeoxyglucose: Use
and limitations. J Clin Oncol 2000; 18(20): 3495-502.
5. Walter W et al. Clinical and diagnostic value of preop­
erative MR mammography and FDG-PET in suspicious
breast lesions. Eur Radiol 2003; 13(7):1651-6.
6. Guller U et al. Selective axillary surgery in breast cancer
patients based on positron emission tomography with
18F-F-fluoro-2.deoxy-D-glucose: Not yet! Breast Can­
cer Res Treat 2002; 71(2): 171-3.
7. W ahl R et al. Prospective multicenter study of axillary
nodal staging by positron emission tomography in breast
cancer: A report of the staging of breast cancer with FDG-
PET study group. J Clin Oncol 2004; 22(2): 277-85.
8. van der Hoeven JJ et al. Determinants of diagnostic per­
formance of [F-18]fluorodeoxyglucose positron emis­
sion tomography for axillary staging in breast cancer.
Ann Surg 2002; 236(5):619-24.
9. Zornoza G et al. 18F-FDG FDG-PET complemented
with sentinel lymph node biopsy in the detection of
axillary involvement in breast cancer. Eur J Surg Oncol
2004; 30(1):15-9.
10. Barranger E et al. Evaluation of fluorodeoxyglucose
positron emission tomography in the detection of axil­
lary lymph node metastases in patients with early-stage
breast cancer. Ann Surg Oncol 2003; 10(6):622-7.
11. Kelemen PR, Lowe V, Phillips N. Positron emission
tomography and sentinel lymph node dissection in
breast cancer. Clin Breast Cancer 2002; 3(1):73-7.
12. Kumar R, Zhuang H, Schnall MD. FDG PET posi­
tive lymph nodes are highly predictive of metastasis in
breast cancer. Nucl Med Commun 2006; 27(3):231-6.
13. Abe K et al. Comparison of 18FDG-PET with 99mTc-
HMDP scintigraphy for the detection of bone metas­
tases in patients with breast cancer. Ann Nucl Med
2005; 19(7):573-9.
14. R aileanu I et al. Comparison of [18F]-fluorodeoxyglu­
cose positron emission tomography and technetium
bisphosphonate bone scintigraphy to detect bone
metastases in patients with breast cancer. [French].
Medecine Nucleaire 2004; 28(7): 297-303.
15. L iu C-S et al. Clinical impact of [18F]FDG-PET in
patients with suspected recurrent breast cancer based on
asymptomatically elevated tumor marker serum levels: A
preliminary report. Jpn J Clin Oncol 2002; 32(7):244-7.
16. K amel EM et al. [18F]-fluorodeoxyglucose positron
emission tomography in patients with suspected recur­
rence of breast cancer. J Cancer Res Clin Oncol 2003;
129(3):147-53.
17. Kim TS et al. Fluorodeoxyglucose positron emission
tomography for detection of recurrent or metastatic
breast cancer. World J Surg 2001; 25(7):829-34.
18. Landheer ML et al. Value of fluorodeoxyglucose posi­
tron emission tomography in women with breast can­
cer. Br J Surg 2005; 92(11):1363-7.
19. Santiago JF et al. A retrospective analysis of the impact
of 18F-FDG PET scans on clinical management of 133
breast cancer patients. Q J Nucl Med Mol Imaging
2006; 50(1):61-7.
20. Wahl RL et al. Metabolic monitoring of breast can­
cer chemohormonotherapy using positron emission
tomography: Initial evaluation. J Clin Oncol 1993;
11(11):2101-11.
21. S chelling M et al. Positron emission tomography using
[18F]fluorodeoxyglucose for monitoring primary
chemotherapy in breast cancer. J Clin Oncol 2000;
18(8):1689-95.
22. D ehdashti F et al. Positron emission tomographic
assessment of ‘metabolic flare’ to predict response of
metastatic breast cancer to antiestrogen therapy. Eur J
Nucl Med 1999; 26(1):51-6.
23. M ortimer JE et al. Metabolic flare: indicator of hor­
mone responsiveness in advanced breast cancer. J Clin
Oncol 2001; 19(11):2797-803.
The author
Dr Sofía Escalona López
Unidad de Evaluación de Tecnologías Sanitarias.
Agencia Lain Entralgo Consejería de Sanidad
C/ Gran Vía, 27. 7ª planta. • 8013-Madrid, Spain
sofia.escalona@salud.madrid.org
 – Issue N°4 – Sept. 2009
8 Literature review
Point-of-care testing
Reflecting the importance of the subject
and the interest in it, the number of peer-
reviewed papers covering point-of-care
testing is huge, to such an extent that it
is frequently difficult for healthcare pro-
fessionals to keep up with the literature.
As a special service to our readers, IHE
presents a selection of literature abstracts,
chosen by our editorial board as being
particularly worthy of attention.
Use of saliva-based nano-biochip tests
for acute myocardial infarction at the
point of care: a feasibility study.
Floriano PN et al.
Clin Chem 2009; 55(8): 1530-8.
This paper investigated the feasibility and util­
ity of saliva as an alternative diagnostic fluid for
identifying biomarkers of acute myocardial inf­
arction (AMI). Luminex and lab-on-a-chip meth­
ods were used to assay 21 proteins in serum and
unstimulated whole saliva obtained from 41 AMI
patients within 48 hours of chest pain onset and
from 43 apparently healthy controls. Data were
analysed to evaluate the diagnostic utility of each
biomarker, or combinations of biomarkers, for
AMI screening.
Both established and novel cardiac biomarkers
demonstrated significant differences in concen­
trations between patients with AMI and controls
without AMI. The saliva-based biomarker panel
of C-reactive protein, myoglobin and myeloper­
oxidase exhibited significant diagnostic capability
and, in conjunction with ECG, enabled effective
screening for AMI comparable to that of the panel
(brain natriuretic peptide, troponin-I, creatine
kinase-MB, myoglobin), far exceeding the screen­
ing capacity of ECG alone. These whole saliva
tests were adapted to a novel lab-on-a-chip plat­
form for proof-of-principle screens for AMI. The
authors conclude that as a complement to ECG,
saliva-based tests within lab-on-a-chip systems
may provide a convenient and rapid screening
method for cardiac events in prehospital stages
for AMI patients.
Prediction and management of
bleeding in cardiac surgery.
Despotis G et al.
J Thromb Haemost 2009; 7 Suppl 1: 111-7.
Excessive bleeding after cardiac surgery can result
in increased morbidity and mortality related to
transfusion- and hypoperfusion-related injuries
to critical organ systems. The objective of this
study was to review mechanisms that result in
bleeding after cardiac surgery as well as current
and emerging interventions to reduce bleeding
and transfusion. The authors demonstrated that
point-of-care tests of haemostatic function can
facilitate the optimal management of excessive
bleeding and reduce transfusion by facilitating
administration of specific pharmacological or
transfusion-based therapy and by allowing phy­
sicians to better differentiate between microvas­
cular bleeding and surgical bleeding. The authors
consider that while emerging interventions such
as recombinant FVIIa have the potential to reduce
bleeding and transfusion-related sequelae and
may be life-saving, nevertheless randomised, con­
trolled trials are needed to confirm safety before
they can be used as either first-line therapies for
bleeding or bleeding prophylaxis. Careful investi­
gation of the role of new interventions is essential
since the ability to reduce use of blood products,
to decrease operative time and/or re-explora­
tion rates has important implications for overall
patient safety and healthcare costs.
Point-of-care assessment of antiplatelet
agents in the perioperative period:
a review.
Gibbs NM.
Anaesth Intensive Care 2009; 37(3): 354-69.
The aim of this paper was to review the strengths
and limitations of current ‘point-of-care’ tech­
niques for the detection of antiplatelet drug effects.
The review was based on a Medline search for arti­
cles with key words related to “platelet function
tests”, “point-of-care”, and “anaesthesia”, published
in English between January 1996 and September
2008.The authors found that global assessments of
‘haemostasis’ are not specific for platelet function
and are essentially insensitive to cyclooxygenase
inhibitors and P2Y12 antagonists. Global assess­
ments of ‘platelet function’ are more specific for
platelet function, but also have limited sensitivity
for cyclooxygenase inhibitors and P2Y12 antago­
nists. The newer devices developed specifically for
the assessment of antiplatelet drugs, such as Platelet
Mapping, the Impact Cone and Platelet Analyser
and the VerifyNow, are more promising, but are
not as sensitive as laboratory platelet aggregom­
etry. All three categories of devices detect G(p)
II(b)/III(a) antagonist activity, but not all provide
quantitative assessments for monitoring therapy.
The limitations appeared to be related to the com­
plexity of platelet function, the multiple pathways
of platelet activation, the wide interpatient variabil­
ity in platelet responses and the interdependence
between platelets and other aspects of coagulation.
The authors conclude that the strengths and
limitations of point-of-care devices should be
appreciated before they are used to assist clinical
decision-making in the perioperative period.
The limitations of point-of-care
testing for pandemic influenza:
what clinicians and public health
professionals need to know.
Hatchette TF et al.
Can J Public Health. 2009; 100(3): 204-7
Many governments have made significant funding
commitments to influenza vaccine development
and antiviral stockpiling. The authors consider that
while these are essential components of a response
to pandemics, rapid and accurate diagnostic testing
remains an often neglected cornerstone of pandemic
influenza preparedness. The benefits and drawbacks
of different influenza tests in both seasonal and
pandemic settings need to be understood. Culture
has been the traditional gold standard for influenza
diagnosis but requires from 1-10 days to generate a
positive result, compared to nucleic acid detection
methods such as real time reverse transcriptase
polymerase chain reaction (RT-PCR). Although the
currently available rapid antigen detection kits can
generate results in less than 30 minutes, their sensi­
tivity is suboptimal and they are not recommended
for the detection of novel influenza viruses. The
authors conclude that until point-of-care (POC)
tests are improved, the best option for pandemic
influenza preparation is the enhancement of nucleic
acid-based testing capabilities.
Point-of-care testing in microbiology:
the advantages and disadvantages of
immunochromatographic test strips.
Stürenburg E, Junker R.
Dtsch Arztebl Int. 2009; 106(4): 48-54.
This study describes the current technical status
of Point-of-Care Testing (POCT), giving some
examples, and summarises the specific advan­
tages and disadvantages of the POCT approach
in microbiology. The conclusions are that the
test systems available today are technically
mature and offer good to very good perform­
ance. For HIV, malaria, group A streptococci,
and legionellae, POCT, when indicated, is on a
par with conventional procedures. The infor­
mation yielded by rapid tests for pneumococci
and for influenza tends to be supplementary in
nature. The rapid test for group B streptococci
is unsuitable for routine use because its sensi­
tivity is still too low compared with bacterial
culture. POCT can be successful only if the tests
are performed correctly by trained personnel,
quality management procedures are followed,
and the severity of illness and the epidemiolog­
ical circumstances are taken into account when
interpreting the results.
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Figure (a): Glucose 54 mg/dL Figure (b): Glucose 247 mg/dL
StatStrip
Mean glucose difference mg/dL (mmol/L)

15 10
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10 PCx
0

Mean glucose difference (%)

(.56) SureStep

5
(.28) -10
Glucose Error

Glucose Error
0
(0)
-20
-5
(-.28)
-30
StatStrip
-10
(-.56) Accu-Chek
-40 PCx
-15
(-.83) SureStep
-20 -50
(-1.11)
20 30 40 50 60 70 20 30 40 50 60 70

Hematocrit (%) Hematocrit (%)

Figure (c): Glucose 483 mg/dL

Figures:
10 (a) Mean glucose difference (meter glucose minus reference
glucose) and (b) and (c) mean glucose percent difference
0 [(meter glucose minus reference glucose)/reference glucose
Mean glucose difference (%)

x 100)] as a function of hematocrit at glucose concentrations

of (a) 54 mg/dL, (b) 247 mg/dL, and (c) 483 mg/dL. Each
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point represents the mean ± standard deviation of the mean
Glucose Error

glucose difference or mean glucose percent difference (n=6).

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 Point-of-care: news in brief
Point-of-care test for long term
prognosis of patients with chronic
liver disease
Researchers at the Hadassah Hebrew University
Medical Centre in Israel have developed an effec­
tive new tool for assessing the prognosis of patients
with chronic liver disease, which could have impor­
tant implications in determining which patients
are the most appropriate candidates for liver trans­
plantation. Previously, prognosis in patients with
chronic liver disease has been determined by using
a combination of blood tests.
Studying 575 patients with varying types and
degrees of liver disease, the investigators showed
that a rapid, non-invasive 13C-Methacetin breath
test could predict which patients would develop
complications that would affect their prognosis.
The test can also be used in acute liver disease
to determine liver function on a daily basis and
determine how well therapy is working.
Researchers believe that the accuracy of the test,
and its capacity to assess liver function, makes the
breath test a potentially powerful new tool in pre­
dicting prognosis of liver related complications,
prioritising patients for organ transplantation and
predicting their ability to survive surgery.
www.hadassah.org.il/english
Point-of-care tests and training in
communication skills can help cut
over-prescribing of antibiotics
In a major new clinical trial, published in the
British Medical Journal, a team of researchers
from Cardiff University’s School of Medicine,
together with researchers from the Maastricht
University Medical Centre in the Netherlands,
found that those General Practitioners in pri­
mary care who made use of a simple point-
of-care blood test, and those who underwent
training in advanced communications skills,
prescribed fewer antibiotics for lower respira­
tory tract infections, which frequently do not
respond to antibiotics.
11 – Issue N°4 – Sept. 2009
As the problem of bacteria resistant to antibiotic
treatment grows, researchers are seeking ways
to improve the quality of antibiotic prescribing.
Prescribing antibiotics only when patients will
clearly benefit reduces the pressure that drives
antibiotic resistance. The clinical trial therefore
sought to evaluate ways that antibiotic prescrib­
ing could be reduced without adversely affecting
patient recovery or satisfaction with care. The trial
evaluated an ‘illness focussed’ approach, where
clinicians seek to better understand the patient’s
illness experience and communicate more effec­
tively about management, and a ‘disease focussed’ be displayed on an built-in screen, giving patients
approach, where clinicians focus on diagnosis, in access to clear, immediate advice. For example,
this case, a simple point-of-care test for C reac­ they could be told that their condition remains
tive protein (NycoCard II Reader; Axis-Shield, stable if levels of virus do not change, or they
Norway). A result can be available within three could be told to make an appointment to see their
minutes, using a drop of blood obtained by fin­ doctor if the virus begins to flare up. The project
ger prick. The value of C reactive protein in ruling will be carried out over the next three years, with
out serious bacterial infection was emphasised. the promise of additional funding.
The trial randomised 20 general practices in the www3.imperial.ac.uk
Netherlands, where 40 GPs managed 431 patients
with lower respiratory tract infection.
The results showed that 54% of GPs practising
according to usual care prescribed antibiotics, OPTI™ CCA-TS
whereas 27% of those who had been trained in the Portable Blood Gas Analyzer
advanced communication and 31% of the GPs who
used the point-of-care blood test methods did so.
Only 23% of GPs who were trained in the advanced OPTI Is The Heartbeat
communication skills and who used the blood test Of Perfusion.
prescribed antibiotics. Importantly, the results also
showed that prescribing fewer antibiotics did not
mean that patients were unwell for longer. Patient
recovery and satisfaction with care were not
compromised by GPs not prescribing antibiotics.
www.cardiff.ac.uk
Point-of-care nanosensors for HIV
diagnosis and monitoring to be
developed
The London Centre for Nanotechnology will
develop a new device to enable people living with
HIV to monitor their own health and the effec­ • Complete Blood Gas Panel
tiveness of their treatments, thanks to a £2 mil­ • Ionized Calcium & Glucose
lion EPSRC (Engineering and Physical Sciences • Low Maintenance
• No Stand-by Costs
Research Council) grant. The device will will act
as an early warning system to alert patients of the
need to seek medical help if the virus is resisting
anti-retroviral treatments. It could also be of real
benefit to doctors in developing countries who
urgently need rapid and affordable ways to diag­
nose and monitor their patients.
Researchers from the London Centre for Nanote­
chnology, a joint venture between UCL (University
College London) and Imperial College London,
and their research partners have been awarded
the Nanotechnology for Healthcare grant from
the EPSRC’s Grand Challenge Competition. The
research will bring biomedical engineers, physi­ www.optimedical.com
cists, chemists, virologists and clinicians together Visit us at Medica Hall 2 C38
to create the device, which will use nano-canti­
lever arrays to measure HIV and other protein
markers that can indicate a rise in the level of the
virus and the body’s response to it. Messages will
www.ihe-online.com & search 45313
Cardiology Special
Selection of peer-reviewed
cardiology literature
Several of the latest crop of recently-
published peer-reviewed articles in the
scientific and medical literature related
to cardiology seem likely to be of par-
ticular importance. In this regular liter-
ature abstracting service, IHE provides
summaries of selected key papers in
the field.
Relation between modifiable
lifestyle factors and lifetime risk
of heart failure.
by Djoussé L et al.
JAMA 2009; 302(4): 394 - 400
Heart failure is now recognised as the leading cause
of acute hospital admission and the most prevalent
chronic cardiovascular condition. What’s worse,
mortality rates after the onset of heart failure remain
high, ranging from 20-50 per cent, despite improve­
ments in medical and surgical management. In the
context of this bleak situation the recent results of a
huge long-running prospective cohort study (1982-
2008) involving no fewer than 20,900 men are very
encouraging in that the results show that adoption
of healthy life style factors can significantly reduce
the risk of heart failure. Carried out by a group from
the Brigham and Women’s Hospital, Harvard Medi­
cal School, the study assessed six modifiable lifestyle
factors: body weight, smoking, exercise, alcohol
intake, consumption of breakfast cereals and con­
sumption of fruits and vegetables on the lifetime risk
of heart failure. It was found that men who exercised
regularly, drank moderately, did not smoke, were
not overweight, and had a diet that included cereal,
fruits and vegetables had a highly significant lower
lifetime risk of heart failure.
SEPTEMBER
High heart rate as predictor of
essential hypertension. 2009
by Tjugen TB et al.
Prog Cardiovasc Dis 2009; 52(1): 20-5.
High heart rate has proven to be a strong pre­
dictor for cardiovascular disease and a predictor
Cardiology
of the development of essential hypertension.
Because heart rate is highly influenced by many
factors such as anxiety and physical activity,
Special
it is sometimes difficult to interpret the value
of heart rate measurement in individual per­
sons. This article from a team at the Cardiology
Department, Oslo University Hospital reviews
the debate as to whether heart rate itself is a risk
factor for development of hypertension or just A novel cardiac
a marker for sympathetic overactivation. What­
ever the answer, the presence of elevated heart PET imaging agent
rate in both hyperkinetic and hypertensive sub­
jects makes it an interesting and easy measurable
Dr M. Yu &
prognostic marker. Dr S.P. Robinson
Dual antiplatelet therapy and Page 14
antithrombotic treatment:
recommendations and controversies.
by Bryniarski L, et al. The assessment of
Cardiol J 2009; 16(2): 179-89. healthcare performance
Dual antiplatelet therapy is currently recom­ in CVD prevention
mended for all patients with acute coronary
syndromes, independently of whether they are Dr A. Lazzini &
receiving pharmacological treatment or under­
going percutaneous coronary intervention. Dr S. Lazzini
Antiplatelet agents are the cornerstone of phar­
macological treatment in interventional cardi­
Page 16
ology. However, there is a clear need for ran­
domised trials to assess the treatment strategy
of dual antiplatelet therapy in patients who also Management of rate
need long-term antithrombotic treatment (such
as those with atrial fibrillation, prosthetic heart control in chronic
valve, mitral valve regurgitation or stenosis,
deep vein thrombosis, pulmonary embolism,
atrial fibrillation
or pulmonary hypertension). In this paper the Dr T. Nikolaidou &
authors discuss trials and analyses on the use of
dual antiplatelet treatment in combination with Prof. K.S.Channer
antithrombotic therapy in particular diseases,
with a focus on the risk of haemorrhagic events Page 20
connected with this treatment, as well as recent
guidelines of the European Society of Cardiol­
ogy, the American College of Cardiology, and
the American Heart Association.
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 – Issue N°4 – Sept. 2009 14
A novel cardiac PET imaging agent
Fluordeoxyglucose (FDG) is a well-established PET imaging agent used in cardiol-
ogy to assess evaluation of myocardial metabolism and viability. However food
intake and anesthetics used have been shown to affect the uptake by the the heart
of FDG. A novel cardiac PET imaging agent (BMS747158) is being developed to
assess myocardial perfusion in diagnosis and prognosis of coronary heart disease.
The new imaging agent has been shown to have a better imaging profile than the
currently available SPECT agents. Unlike FDG, the image quality is not affected by
food intake and use of anaesthetics.
by Dr Ming Yu and Dr Simon P. Robinson
Cardiac imaging procedures such as echocardi­
ography, computer tomography (CT), magnetic
resonance imaging (MRI) and nuclear imaging
are non-invasive and readily accepted by patients.
Imaging with CT and MRI provides excellent ana­
tomical information. However, nuclear imaging
presents an opportunity to examine changes at
the molecular, cellular and organ levels, including
perfusion, metabolism and viability in the heart.
Nuclear imaging can be used to detect cardiac
changes allowing early diagnosis before clinical
symptoms are evident, to evaluate the effectiveness
of treatment and to predict disease progression.
Nuclear myocardial
perfusion imaging
Nuclear myocardial perfusion imaging (MPI)
is carried out to assess alterations in perfusion
associated with coronary heart disease such as
myocardial infarction (non-reversible perfusion
defect) and ischaemia (reversible perfusion
defect). MPI under rest and stress conditions has
been increasingly utilised over the past decade [1,
2]. Currently, it is dominated by three MPI agents:
99m
Tc-sestamibi, 99mTc-tetrofosmin and 201Thallium
(201Tl), used with single photon emission com­
puted tomography (SPECT). Although the value
of perfusion imaging with these agents to guide
clinical decisions has been proven, some limita­
tions exist. These include lack of accurate attenu­
ation correction, poor image quality in obese
patients, and, in the case of 201Tl, redistribution.
Most importantly, the myocardial uptake of these
SPECT agents is proportional to regional blood
flow under resting condition. However under
stress conditions, the uptake plateaus at regional
myocardial blood flow above 2 mL/min/g. Thus,
SPECT imaging with these perfusion agents has
the potential to underestimate myocardial blood
flow under stress conditions (the “roll-off ” phe­
nomenon). This underestimation compromises
the capability of these agents to detect mild
coronary artery stenosis.
MPI with positron emission tomography (PET)
has emerged as an accurate alternative to SPECT.
cardiology
PET has several significant advantages over
SPECT, including higher spatial resolution, accu­
rate attenuation correction and the capability to
quantify myocardial perfusion into mL/min/g
tissue. However, the current PET MPI tracers
(82rubidium chloride, 13nitrogen ammonia and
15
oxygen water) all have a short isotopic half-
life requiring on-site production (cyclotron or
3 MPI agents.
BMS747158
201Thallium
99mTc-sestamibi
Heart Uptake
2
1 Fluorodeoxyglucose (FDG) is an 18F labelled
0 imaging to assess myocardial metabolism and
0 1 2 3 4 5
Flow (ml/min/g left ventricule)
Figure 1. Upper panel: representative cardiac
tomographic images of BMS747158 in control rats
and rats with coronary ligation and in a nonhuman
primate. Images are presented in cardiac short-axis
(doughnut shaped) and long-axis (horse shoe shaped)
views. The myocardium is clear in the rats and the
primate and there is easy identification of perfusion
deficit areas in rats with coronary ligation.
Lower panel: heart uptake of BMS747158 com-
pared to the currently available perfusion imaging
agents 201Thalium and 99mTc-sestamibi, following
increasing coronary perfusion low rates in an isolated
rabbit heart preparation. It can be seen that the
correlation with perfusion flow of the heart uptake of
BMS747158 is better than with the other two agents.
generator), thus limiting the duration of dynamic
imaging and/or causing a low signal to noise ratio
(particularly with 82Rubidium, whose half-life is
1.3 min). Thus, an ideal MPI agent should have
myocardial uptake that is proportional to blood
flow, even at high flow rates under stress condi­
tions, and be a PET emitter with a half-life that
allows central unit dose distribution.
A novel myocardial perfusion
imaging agent
Developed as a PET-based MPI agent, BMS747158
is an 18F labelled 2,5 disubstituted pyridazinone
that binds the highly abundant mitochondrial
complex I of the myocardium. It has been [3].
With a half-life of 110 minutes this 18F labelled
agent can be radiosynthesised centrally and deliv­
ered to hospitals. Cardiac imaging in rats, rabbits,
pigs, nonhuman primates and human subjects
with this agent shows high myocardium uptake
and allows accurate identification of the perfusion
deficit area [3, 4, 5]. More importantly, in an iso­
lated heart preparation, the myocardial extrac­
tion of the new agent is higher and correlates bet­
ter with flow at a wide range of flow rates than
currently available SPECT MPI agents, such as
99m
Tc-sestamibi and 201thallium [Figure 1].
In a recent study in pigs, the myocardial perfusion
measured by PET imaging with BMS747158 cor­
related well with flow as quantified by the micro­
sphere technique, the gold standard for flow quan­
tification, both at rest and stress conditions [4].
These findings suggest that this agent possesses
an improved chemical profile with less “roll-
off ” than is observed with the current SPECT
Cardiac imaging with
BMS747158 and FDG under
various experimental conditions
glucose analogue that is a substrate for glucose
transporters. It has been used with cardiac PET
6
tissue viability. Cardiac images of FDG have
been used in conjunction with perfusion agent
images to identify viable tissue in myocardial
perfusion deficit regions (mismatch) [6]. The
mismatch is helpful in predicting the beneficial
effect of surgical revascularisation in patients
with myocardial perfusion defect.
In a recently published study [7], the impacts
of feeding state and anaesthetic use on cardiac
imaging and uptake of BMS747158 and FDG
were compared in rats. Rats were either fed
with a normal diet (control group) or were food
deprived for 20 hours (fasted group) and were
anaesthetised either with sodium pentobarbital

Figure 2. Representative cardiac short-axis images
of BMS747158 in comparison with FDG in rats
under control and food deprived (fasted) conditions.
Cardiac images of FDG were clear in the control rat,
but barely visible in the food deprived rat. In contrast,
the myocardium is well defined when imaged with
BMS747158 under both conditions.
(control group) or ketamine and xylazine (xyla­
zine group). Blood glucose levels were 122±10
mg/dL in the control group and about 25% lower
in the food-deprived group. Anaesthesia with
pentobarbital did not change the blood glucose
levels; however, ketamine and xylazine markedly
increased the levels by 215% at 60 minutes after
injection. Cardiac imaging with FDG showed
clear myocardium in the control rats, but the
heart was barely visible in the fasted rats [Fig­
ure 2]. The heart uptake of FDG was also mark­
edly lower in the rats anaesthetised with keta­
mine and xylazine. In contrast, imaging with
BMS747158 demonstrated a well defined myo­
cardium with minimal background interference
under all experimental conditions.
FDG transport into cardiac myocytes, like glu­
cose, is regulated by the transmembrane glucose
gradient and the insulin-regulated glucose trans­
porter on cell membranes. The apparently para­
doxical finding of low FDG heart uptake at both
low (fasted group) and high (xylazine group)
blood glucose levels (i.e. low and high transmem­
brane glucose gradient) could be the consequence
of insulin. Food deprivation lowers plasma glu­
cose and insulin levels, and consequently the
insulin regulated transporter function in the
myocardium is decreased. In contrast, xylazine
has been reported to act as an α2 agonist and
inhibit the secretion of insulin from the pancreas
[8]. This results in reduced insulin levels and low
insulin-regulated glucose transporter function,
which causes a decreased FDG heart uptake
and elevated blood glucose levels. However, the
consistent uptake of BMS747158 independent
of feeding status and anaesthesia use in rats sug­
gests this perfusion agent will not be influenced
clinically by these physiological alterations.
Under ischaemic conditions, the heart uptake of
glucose increases in anaerobic regions that are
15 – Issue N°4 – Sept. 2009
viable, not necrotic, [9]. The mismatch of dam­ comparison to 13N-ammonia and validation with
aged areas detected by cardiac imaging with a microspheres in a pig model. Circulation 2009;
perfusion agent like 99mTc-sestamibi and FDG 119(17): 2333-2342.
has been used to identify viable tissue in the 5. Maddahi J, Schiepers C, Czernin J et al. Frist
perfusion deficit area. Identification of viable human study of BMS747158, a novel F-18 labelled
tissue is critical for determination of a revas­ tracer for myocardial perfusion imaging. J Nucl
cularisation procedure in patient care. With Med 2008; 49(Supplement 1): 70P.
enhanced spatial resolution and quantification 6. B eller GA. Assessment of myocardial perfusion
capability of PET, imaging with BMS747158 and metabolism for assessment of myocardial via­
and FDG should provide greater accuracy than bility. Q J Nucl Med 1996; 40(1): 55-67.
the current SPECT agents for the determination 7. Yu M, Guaraldi MT, Bozek J et al. Effects of food
of tissue viability in ischaemic regions. intake and anesthetic on cardiac imaging and
uptake of BMS747158-02 in comparison with
Prospect and conclusion FDG. J Nucl Cardiol 2009.
BMS747158 is currently in phase II clinical 8. Abdel el Motal SM, Sharp GW. Inhibition of glu­
trial as a PET based MPI. As compared to cur­ cose-induced insulin release by xylazine. Endo­
rently available SPECT agents, heart uptake of crinology 1985; 116(6): 2337-2340.
the new agent correlates better with perfusion 9. S chwaiger M, Neese RA, Araujo L et al. Sustained
flow at cardiac stress conditions, which may nonoxidative glucose utilization and depletion of
enable better detection of mild coronary ste­ glycogen in reperfused canine myocardium. J Am
nosis. Moreover, the agent exploits the advan­ Coll Cardiol 1989; 13(3): 745-754.
tage of PET technology over SPECT. With PET
perfusion quantification, the new agent may The authors
allow diagnosis of “balanced 3-vessel disease” Ming Yu, MD PhD and Simon P. Robinson, PhD
in the heart which has been a limitation for Discovery Research
SPECT imaging. With PET attenuation correc­ Lantheus Medical Imaging
tion, the agent may also permit more accurate 331 Treble Cove Rd
determination of perfusion defects with mini­ N. Billerica, MA 01862, USA
mal interference of attenuation artifacts. With e-mail: ming.yu@lantheus.com
the enhanced image quality shown in pre- and Tel: 1-978-671-8142
clinical studies, the agent may enable better e-mail: simon.robinson@lantheus.com
delineation of the left ventricular wall to facili­ www.ihe-online.com & search 45317
tate generation of anatomical and functional
information. Indeed, functional information,
like the ejection fraction measured by nuclear
MPI has been shown to correlate closely with
that measured by cardiac MRI.
jet ventilation
the new generation
In summary, FDG has been used with PET from intubation
imaging to assess myocardial metabolism and to longterm
tissue viability. Feeding status and anaesthesia ventilation
have been demonstrated to influence the heart
uptake of FDG. BMS747158 is a new genera­
tion of MPI agent for PET imaging. In con­
trast to FDG, the physiological changes do not
influence heart uptake. Due to the improved
imaging profile, clinical use of this MPI agent
in the near future should provide better diag­
nostic and prognostic information for heart
disease stratification.
References > Integrated heating and
1. Clark AN, Beller GA. The present role of nuclear humidification system
cardiology in clinical practice. Q J Nucl Med Mol > Default settings
Imaging 2005; 49(1): 43-58. > Optional: Double Jet,
2. B eller GA, Bergmann SR. Myocardial perfusion EtCO2, Video Camera
imaging agents: SPECT and PET. J Nucl Cardiol > 9“ Color Touch Screen
2004; 11(1): 71-86. > Special parameters for
3. Yu M, Guaraldi MT, Mistry M et al. BMS-747158- superimposed jet
02: a novel PET myocardial perfusion imaging ventilation
agent. J Nucl Cardiol 2007; 14(6): 789-798.
4. Nekolla SG, Reder S, Saraste A et al. Evaluation acutronic-medical.ch
of the novel myocardial perfusion positron- for more info see editorial
emission tomography tracer 18F-BMS-747158-02:
www.ihe-online.com & search 45278
 – Issue N°4 – Sept. 2009 16 cardiology

Towards the assessment of healthcare

performance: CVD prevention
Currently, interest in the prevention of cardiovascular diseases (CVD) and the developed for formulating guidelines to identify
attention paid to this hugely important subject by researchers, physicians, policy- the most suitable tools and measures to evaluate
makers and health organisations is increasing exponentially. In many countries healthcare performance [8, 9]. Such a task is not
easy, since methodologically it is difficult to estab­
there is also a worrying increase in healthcare expenditure related to CVD. In Tus-
lish a precise economic evaluation of the finan­
cany, Italy pilot projects have been developed aimed at preventing and treatment cial burden on the community that is caused by
cardiovascular diseases. chronic diseases such as CVDs.

Starting from the well-known structure-process-

by Dr A. Lazzini and Dr S. Lazzini outcome model [10], we agree with the sugges­
tion from several authors of the need to widen
the concept of the “disease cure” process. Thus,
In recent years interest in and the attention given Gross Domestic Product (GDP). In addition, the concept should not be limited to the cure
to the prevention of cardiovascular diseases have healthcare related expenditure is increasing at of acute diseases and to secondary prevention
increased exponentially. This is of course due not a worrying rate [Figure 1]. The financial impact activities, but should also include primary pre­
only to the direct relevance and effect of cardio­ of all this highlights the importance of the need vention and health promotion activities in the
vascular disease on the health and well-being of to manage healthcare and healthcare resources community [11, 12]. While the concepts of health
individuals but also to the significant effects that using established management criteria, including and healthcare are separated from a semantic
CVD has on the global economy [1, 2]. the introduction of performance measurements. and pragmatic point of view, they are of course
Concepts such as efficiency, effectiveness, equity strictly interrelated, with one of the major points
Research and studies carried out by the World and quality have become familiar in healthcare of contact between the two concepts being pri­
Health Organisation (WHO), show that CVD is organisations and those who work for them. The mary disease prevention activities developed in
currently one of the major causes of death and importance of these concepts is set to increase in an attempt to modify behaviours and lifestyles.
disability throughout the world. It has been esti­ the near future. Several frameworks have been Many healthcare system providers believe that
mated that between 2006 and 2015, deaths due to
cardiovascular diseases are expected to increase
by 8,5%; this is in stark contrast to the predicted 17%
trend over the same period for deaths from other
pathologies such as infectious diseases, nutri­ 15%
tional deficiencies, and maternal and perinatal
conditions, which are estimated to decline by 3%.
13%
Data in the scientific literature show clearly that,
when present in the same subject, the combination
11%
of most of the individual risk factors results in a
multiplicative increase in the overall risk associ­
ated with cardiovascular disease (CVR) [3, 4, 5]. 9%
Research has also established that risk-reduction
programmes are effective if individuals adhere
7%
to the recommended or prescribed regimes [6].
Unfortunately, however there is a frequent lack of
compliance with such risk-reduction programmes. 5%
1980 1990 2000 2001 2002 2003 2004 2005 2006
Burke et al [7] estimated that 50% of individuals
withdraw from cardiac rehabilitation programmes Belgium 8% 8% 9% 10% 10% 10% 10%
within the first year, and that 50% of hyperten­ France 7% 8% 10% 10% 11% 11% 11% 11% 11%
sion patients discontinue their medication within Germany 8% 8% 10% 10% 11% 11% 11% 11% 11%
the first year of treatment. There is also a signifi­ Italy 8% 8% 8% 8% 8% 9% 9% 9%
catively high rate of relapse in smoking cessation Japan 7% 6% 8% 8% 8% 8% 8% 8% 8%
programmes: about 79% of participants abandon
Spain 5% 7% 7% 7% 7% 8% 8% 8% 8%
the programmes in the first six months.
United Kingdom 5,6% 6,0% 7,2% 7,5% 7,6% 7,7% 8,0% 8,2% 8,4%

Efficiency, effectiveness and quality: United States 8,7% 11,9% 13,2% 13,9% 14,7% 15,1% 15,2% 15,2% 15,3%

the main goals of a well-structured OECD average 6,6% 6,9% 7,8% 8,1% 8,4% 8,7% 8,8% 8,9% 9,0%
therapy process
In most Western countries expenditure on health Figure 1. Total expenditure on health as a percentage of GDP. in selected countries.
care amounts to a large percentage of national Source: OECD Fact book 2009

the most cost-effective approach in the long run
lies in such prevention activities with the inevita­
ble associated consequence of the need to adjust
health-related behaviours.
One innovative model is the Chronic Care Model
(CCM), which describes some of the changes
in the structure and process that are needed to
improve the outcome in patients with chronic
disease [13, 14]. The basic idea is that healthcare
systems can reach objectives in terms of:
a) effectiveness if they support the development
of getting patients better informed and more
interested (self-management support);
b) efficiency if they have proactive healthcare
teams (delivery system design);
c) quality if they favour interactions between the
various parties (decision support and clinical
information systems);
d) equity resulting from the previous three
objectives.
From an organisational point of view, increases
in the efficiency of the system can be achieved
by changing from a reactive approach, based on
the treatment and resolution of acute events,
to a proactive approach, based on prevention
strategies aimed at completely avoiding disease
or delaying its progression. This means that the
global assessment of CVR, influenced as it is by
the simultaneous actions of many factors, will
replace the consideration of single risk factors.
In this context the general practitioner should
therefore focus on carrying out primary preven­
tive actions aimed at reducing overall CVR. It is
evident that such an approach necessitates the
informing patients so as to create self awareness
of the health risks incurred by dangerous behav­
iours and life styles, thus enabling patients to
more effectively control their own health or ill­
ness (self-management support). Such an activ­
ity is not always easy, because patients sometimes
do not accept suggestions about their behaviour
and lifestyles; in some cases communication
between the general practitioner and the patient
may cease altogether.
The Chronic Care Model implies an approach
centred on patients but moving from a tradi­
tional functional approach based on specialisa­
tion and separation, to a perspective based on
systems in which general practitioners, special­
ists and paramedical personnel work together
as a unique team, with the common aim of
guaranteeing a more efficient and efficacious
health service.
In the practical implementation phase of such a
model in the real world, information and com­
munication technologies (ICTs) play a vital role
since by using ICT it is possible to assess the
overall CVR associated with each patient. The
17 – Issue N°4 – Sept. 2009
work-load of each of the teams involved could in lifestyle would cause a significant reduction
be eased through the creation of a medical card in the probability of incurring CVD. The under­
for each patient on a health platform, with the lying objective is to modify dangerous behav­
possibility of it being shared on the web. The iours and lifestyles, consequently reducing
overall process could thus be simplified and the risk of CVDs.
costs reduced by eliminating duplicated activi­
ties and organising patient history and medical At the individual level the policy is instead
chronology. Healthcare teams with access to the aimed at identifying subjects who have a higher
database could also contact patients with specific probability of CVD, and thereby organis­
needs, deliver a planned therapy to them, receive ing a preventive approach aimed at averting
feedback on the performance and exploit patient the disease.
reminder systems. Integrated management is the
vital platform needed to improve the efficiency, As far as the assessment of individual risk is
effectiveness and quality of the cure process in concerned, Tuscany is widely recognised for
patients with CVDs. its achievement in the integrated assessment
of CVR using a pilot project called VIRC. This
An integrated approach to was set up at the Institute of Clinical Physiol­
cardiovascular disease: ogy of Pisa and was based on the establishment
the pilot projects of the Tuscany of a clinical database that was accessible on the
regional health system web enabling the medical data relevant to the
The current Italian projects for the prevention management of patients in the field of multi­
and cure of CVD are centred on changes in the disciplinary prevention of CVD to be viewed
concept of health assistance from a traditional and assessed.
disease cure-based model, which is physician
centred and focused on acute therapy and is The calculation of CVR takes into considera­
characterised by a reactive approach to an tion a number of variables, which, as well as the
innovative model. This is chronic cure-based, usual risk factors related to lifestyle, include
patient centred, and the treatment is delivered a series of other linked factors. The variables
by a healthcare team. This model requires a net­ considered include social-economical factors,
work approach, where the different parts of the physiological anamnesis; basic clinical indica­
system connect through mechanisms enabling tors, psychosocial factors, family anamnesis
knowledge and information sharing. and a complete report of past diseases.
In most Italian regions, the prevention and
treatment of CVD are still divided among sev­
eral players with different competences and
operative responsibilities in different organisa­
tional structures [15, 16]. A distinctive feature
of the Tuscany healthcare system is the atten­
tion given to the prevention and cure of CVD,
with the relevant activities being considered as
a unique and integrated process.
The 2008-2010 Tuscan strategic health plan is
based on the awareness that, while the roles and
functions of different personnel are observed
and recognised, the mutuality and interde­
pendence of all relevant personnel is necessary
in order to achieve the final results.
The main lines of action adopted by Tuscany to
manage CVDs in an integrated way are based
on two strictly correlated activities:
a) the assessment of CVR
b) the development of new organisational mod­
els based on a network approach.
The strategies for lowering the risk factors are
focused on i) the population level and ii) the
individual level.
At the population level, the lines of action are
based on the assumption that because a large
part of the population is exposed to a moderate
level of CV global risk, an overall improvement
www.ihe-online.com & search 45274
 – Issue N°4 – Sept. 2009 18
With regard to CVD, Tuscany has also encour­
aged projects which bring about a deeper inte­
gration between the different parties involved
in the process of prevention and cure [17, 18].
The major innovation related to the applica­
tion of the CCM in Italy is the new and central
role played by primary prevention in the cure
of some chronic diseases. Cardiac decompen­
sation has been considered of importance in
CVR, and a series of standard processes has
been proposed, based on homogeneous char­
acteristics that follow the NYHA classifica­
tion of such pathology. The horizontal model
specifies six major parties: the patient, the gen­
eral practitioner, the cardiologist, the hospital
attendants, the dietician and the medical dis­
trict. Within the model, the different parties are
linked transversally, and attention is paid to the
different contributions they offer to the patient.
The result is that the approach is matrix-based,
with the tasks and functions assigned to the
different parties changing on the basis of the
patient’s decompensation class. The various
roles played can be increased or reduced based
on a standardised therapy process.
For each therapy process, a patient-driven
perspective is adopted, from which the
responsibilities of the different parties are
established In this perspective is the single
clinical demand: to require activities and
resources. Particular attention is given to
treatment traceability, which can be achieved
by the electronic clinical medical card shared
between the parties, or by simplification of
the process of admission to therapy.
Conclusions
This paper has analysed the role played by car­
diovascular prevention activities starting from
the consideration that the healthcare expenditure
has been increasing dramatically in most of the
industrialised countries.
The most consistent margins of action appear to
be linked to a reorganisation of prevention sys­
tems [19]. Most of the healthcare systems opted
for a preventive-welfare model based on the spe­
cialisation of their operators; this empowered the
systems, which could then achieve a precise artic­
ulation of competencies and responsibilities. This
kind of model presupposes a vertical approach,
while the future trends related to the adoption of
the CCM involve a horizontal perspective [20].
References
1. World Health Organization, Preventing Chronic Dis­
eases: A Vital Investment, Geneva, Switzerland, 2005
2. Sassi F, Hurst J. The prevention of lifestyle-related
chronic diseases: an economic framework, OECD
Health Working Papers, N.32, 2008
3. Grundy SM, Pasternak R, Greenland P, Smith S,
Fuster V. Assessment of Cardiovascular Risk by Use
of Multiple-Risk-Factor Assessment Equations.
cardiology
Circulation 1999; 100(13): 1481-92.
4. Wood D, De Backer G, Faergeman O, Graham I,
Mancia G, Pyörälä K. Prevention of coronary heart
disease in clinical practice: Recommendations of
the Second Joint Task Force of European and other
Societies on Coronary Prevention. Atherosclerosis
1998; 140(2): 199-270.
5. Blane D et al. Association of Cardiovascular Dis­
ease Risk Factors with Socioeconomic Position
During Childhood and During Adulthood. British
Medical Journal 1996; 313(7070):1434-8.
6. Burke LE, Dunbar-Jacob J. Adherence to medica­
tion, diet, and activity recommendations: From
assessment to maintenance. Journal of Cardiovas­
cular Nursing 1995; 9(2): 62-79.
7. Burke LE, Dunbar-Jacob JM, Hill MN. Compliance
with cardiovascular disease prevention strategies:
A review of the research. Annals of Behavioral
Medicine 1997; 19(3): 239-263.
8. WHO, Primary Health Care: a framework for
future strategic directions, Geneva: WHO, 2003.
9. Sibthorpe B. A proposed conceptual framework
for performance assessment in primary health
care, Canberra: Australian Primary Health Care
Research Institute, 2004.
10. Donabedian A. The quality of medical care.
Science 1978;200:856–64.
11. Gakidou EE, Murray CJ, Frenk J. Defining and
Measuring Health Inequality: an Approach Based
on the Distribution of Health Expectancy. Bul­
letin of the World Health Organization 2000;
78(1):42-54.
12. Hofmarcher M, Oxley H, Rusticelli E. Improved
health system performance through better care
coordination OECD Health Working Papers,
N.30, 2007
13. Wagner EH, Davis C, Schaefer J et al. A survey of
leading chronic disease management programs: are
they consistent with the literature? Managing Care
Quarterly 1999; 7: 56-66.
14. Wagner EH. Chronic Disease Management: What
will it take to improve care for chronic illness?
Effective Clinical Practice 1998; 1(1): 2-4.
15. Del Bene L. Criteri e strumenti per il controllo
Book review
Surgery of the Esophagus: Textbook
and Atlas of Surgical Practice
Ed. by JR Izbicki, AF
Chernousov, DC Broer-
ing, YL Gallinger, EF
Yekebas, PM Bogopolski,
A Kutup and
N Soehendra
Pub. by Springer, 2009,
388 pp, e149,95
This atlas provides
a thorough over­
view on current
surgical strategies in the treatment of oesopha­
geal diseases. The first part of the atlas is
gestionale nelle aziende sanitarie, 2000, Milan,
Giuffrè.
16. Del Vecchio M. Le aziende sanitarie tra specializ­
zazione organizzativa, deintegrazione istituzionale e
relazioni di rete pubblica, in Anessi Pessina, Cantù
eds. L’aziendalizzazione della sanità in Italia - OASI
Report 2003, Milan, Egea.
17. Marinò L. Dinamiche competitive ed equilibrio
economico nelle aziende sanitarie, 2001, Milan,
Giuffrè.
18. Grandori A. Knowledge governance mechanisms
and the theory of the firms. Working paper 2003,
University of Modena e Reggio Emilia.
19. Porter ME. A strategy for health Care Reform –
Toward a value-based System, The New England
Journal of Medicine 2009; 10: 1056. Massachusetts
medical society.
20. Anselmi L. Il processo di trasformazione della pub­
blica amministrazione, Il percorso aziendale 1995,
Torin, Giappichelli.
The authors
Arianna Lazzini, PhD,
Researcher, Department of Social,
Cognitive and Quantitative Sciences,
University of Modena and Reggio Emilia,
Viale Allegri 9,
Reggio Emilia 42100,
Italy
e-mail: arianna.lazzini@unimore.it
Simone Lazzini, PhD,
Researcher, Department of Business
Administration “E. Giannessi” ,
Via C. Ridolfi 10,
Pisa 56124,
Italy
e-mail: s.lazzini@ec.unipi.it
Comments on this article?
Feel free to post them at
www.ihe-online.com/comment/CCM
focused on basic diagnostic tools, indications
and preoperative work up. The second part
gives detailed instructions for current surgical
procedures illustrated with precise drawings
and operation note style text to enable the nov­
ice surgeon as well as the experienced surgeon
to perform even the most complex operations.
The basic principles of oesophageal surgery as
well as conventional surgery, endoscopic and
minimal invasive techniques are vividly pre­
sented in response to the advances achieved in
oesophageal surgery.
Springer
Heidelberg, Germany
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 – Issue N°4 – Sept. 2009 20
Management of rate control in chronic
atrial fibrillation
Atrial fibrillation is the most commonly encountered arrhythmia in cardiology.
Recent guidelines have recommended that instead of digoxin, monotherapy with
β -blockers or rate-limiting calcium antagonists should be first-line treatment for rate
control in chronic atrial fibrillation. We have reviewed the evidence and found that
combination treatment of digoxin with a β -blocker or calcium antagonist is more
effective and safer.
by Dr T. Nikolaidou and Prof. K. S. Channer
Recent guidelines in rate control
management
Atrial fibrillation (AF) is the commonest cardiac
arrhythmia and its incidence increases with age.
Considering that the population is ageing it is
important that treatment be safe and effective in
the elderly. Guidelines are usually based on clinical
trial evidence derived from younger and healthier
participants. This evidence is not always directly
transferable to elderly patients. In this age group
the most common therapeutic strategy for AF is
rate control in combination with anticoagulation.
In June 2006, the UK National Institute of Clinical
Excellence (NICE) published new guidelines for
heart rate control in patients with chronic AF [1].
These guidelines depart from historical practice
by recommending that, instead of digoxin the pre­
ferred initial monotherapy in all patients, except
in predominantly sedentary patients, should be
β-adrenoceptor blockers or rate-limiting cal­
cium antagonists. Similarly, the revised 2006
joint American College of Cardiology/American
Heart Association/European Society of Cardiol­
ogy (ACC/AHA/ESC) guidelines recommend the
use of β-blockers or calcium antagonists alone to
control heart rate [2]. Digoxin is recommended
in patients with heart failure, left ventricular
dysfunction or for sedentary individuals.
We have reviewed the clinical trial evidence and
challenge the safety of recent guidelines.
Treatment aims of rate control in
chronic AF
Optimal rate control in AF is difficult to define.
It is aimed at reducing heart rate (HR) at rest and
exercise in order to prevent tachycardia-induced
cardiomyopathy. It also aims to control heart rate
variability throughout the day (maximum minus
minimum HR) without causing excessive brady­
cardia or pauses. From a clinical perspective,
treatment aims are to improve survival, symp­
toms, exercise tolerance and quality of life. Side-
effects of medication need to be weighed against
cardiology
their benefits. Co-morbidities, such as hyperten­
sion, heart failure, ischaemic heart disease, val­
vular heart disease and peripheral vascular dis­
ease, are also taken into account when selecting
appropriate rate-limiting therapies.
Systematic review of the evidence in
rate control management
We have systematically reviewed the literature for
trials of digoxin, β-blockers or calcium antago­
nists alone or in combination for managing rate
control in chronic AF [3]. Forty-six trials met
eligibility criteria, of which 36 were randomised
controlled trials, one a cross-over non-ran­
domised study, one a case control study and eight
were observational trials. The published studies
are small, with the largest one recruiting 136 par­
ticipants. They are also heterogeneous in protocol
design and drug dosages. Some studies employ
24-hour HR recordings while others utilise exer­
cise testing. Side effects and symptom control are
not consistently reported. The mean age across
studies ranges from 48-74 years. We performed a
qualitative analysis describing the evidence avail­
able for β-blockers and calcium antagonists first
as monotherapy and then as combination therapy
with digoxin.
Digoxin
Digoxin has traditionally been used for rate con­
trol in AF. It acts primarily by exerting a vago­
mimetic influence on the atrio-ventricular (AV)
node and has a positive inotropic effect, which is
beneficial in patients with heart failure. It has few
side effects and a long half-life, allowing once daily
dosing. However, digoxin has a flat dose-response
curve and a narrow therapeutic index often lead­
ing to the use of sub-therapeutic doses. It is less
effective at controlling heart rate during exercise
and in states of increased sympathetic activation
[4]. Channer et al found that doubling serum
digoxin concentration improved HR control
but not HR variability, and daytime pauses were
significantly prolonged [5].
β -blockers alone and in combination
with digoxin
β-blockers have heterogeneous effects on HR con­
trol depending on their specificity for the β recep­
tor and concomitant β-agonist activity. Ten studies
assessed β-blockers as monotherapy in control­
ling HR in chronic AF. Only one study found that
β-blockers improved resting HR compared to dig­
oxin, while four studies found improved exercise
HR. Two studies report improvement in exercise
tolerance with β-blockers alone while six found no
change. Nineteen studies tried the combination of
β-blocker with digoxin. Combination treatment
resulted in improved HR control at rest and exer­
cise. However, the effect on exercise tolerance was
inconsistent with five studies reporting deteriora­
tion in exercise capacity, three reporting improve­
ment and ten reporting no change. Khand et al
reported on the use of carvedilol in 47 patients
with AF and heart failure [6]. When used alone
carvedilol did not improve HR or exercise toler­
ance compared to digoxin. Withdrawal of digoxin
in these patients resulted in worsening heart fail­
ure with deleterious effects. In the same study the
combination of digoxin with carvedilol improved
HR as well as left ventricular ejection fraction.
Side effects of β-blockers reported in these stud­
ies include heart failure, intermittent claudica­
tion, arrhythmia, postural dizziness and bron­
chospasm. Two studies reported worsening heart
failure on withdrawal of digoxin [6, 7].
Diltiazem and verapamil alone and
in combination with digoxin
Five studies evaluated diltiazem as monotherapy
in HR control. When compared to digoxin
diltiazem was better at controlling exercise HR,
but exercise capacity was not improved. Combi­
nation of diltiazem with digoxin improved resting
and exercise HR, as well as 24-hour HR control.
Exercise tolerance was shown to improve in two of
eight studies. Maragno et al found that the com­
bination of diltiazem with digoxin provided bet­
ter mean 24-hour HR control compared to either
drug alone [8]. In two studies, HR control at rest
and exercise, as well as exercise tolerance, were all
improved when the combination of digoxin and
diltiazem was compared to digoxin alone [9, 10].
Seven studies examined monotherapy with
verapamil and three found improved exercise
HR compared to digoxin. In two studies there
was improvement in exercise tolerance [11, 12].
When the combination of verapamil with digoxin
was assessed most trials found improvement in
 21 – Issue N°4 – Sept. 2009

resting and exercise HR compared to digoxin.
Three studies also found improvement in exercise
capacity, while four showed no change.
Diltiazem and verapamil have negative inotropic
effects and are also associated with significant side-
effects. Verapamil also reduces the clearance of dig­
oxin resulting in higher digoxin concentrations. In
a study by Roth et al, 75% of participants showed
at least one adverse reaction to diltiazem [13]. In
the same study one patient with mild heart failure
developed worsening heart failure after discontinu­
ation of digoxin while receiving diltiazem 360mg/
day. Side-effects of verapamil in the studies included
bradycardia, deranged liver function tests, impo­
tence, peripheral oedema, arrhythmia and heart fail­
ure. In a study by Schwartz et al, two patients with
a previous history of heart failure decompensated
after commencing verapamil treatment [14].
Conclusions
Digoxin has been the mainstay of treatment for
many years in patients with chronic AF, and new
treatment recommendations should be safe and
evidence-based. The evidence on managing rate
control comes from small studies with varied
methodologies. A review of the literature shows
that the combination of digoxin with a β-blocker
improves HR control at rest and exercise
compared to digoxin alone.
However, there is also evidence that β-blockers
may worsen exercise capacity and need to be used
cautiously. The combination of digoxin with a
non-dihydropyridine calcium antagonist results in
improved HR at rest, exercise and over 24 hours
compared to digoxin. It may also improve exercise
capacity. Side-effects of β-blockers and calcium
antagonists are dose-related. Combining these
drugs with digoxin has a synergistic effect on rate
control and allows smaller doses to be used. Large
randomised trials directly comparing treatment
options with an emphasis on symptom control, exer­
cise capacity and quality of life are needed to inform
future practice. We recommend that combination
treatment with digoxin and a β-blocker or calcium
antagonist should be first line management.
References
1. National Collaboration Centre for Chronic Conditions.
Atrial fibrillation: national clinical guideline for man­
agement in primary and secondary care. London: Royal
College of Physicians, 2006.
2. Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB,
Ellenbogen KA, et al. ACC/AHA/ESC 2006 guidelines
for the management of patients with atrial fibrillation-
-executive summary: a report of the American College
of Cardiology/American Heart Association Task Force
on Practice Guidelines and the European Society of
Cardiology Committee for Practice Guidelines (Writing
Committee to Revise the 2001 Guidelines for the Man­
agement of Patients With Atrial Fibrillation). J Am Coll
Cardiol 2006;48(4):854-906.
3. Nikolaidou T, Channer KS. Chronic atrial fibrillation: a
systematic review of medical heart rate control manage­
ment. Postgrad Med J 2009;85(1004):303-12.
4. Koh KK, Kwon KS, Park HB, Baik SH, Park SJ, Lee KH,
et al. Efficacy and safety of digoxin alone and in combi­
nation with low-dose diltiazem or betaxolol to control
ventricular rate in chronic atrial fibrillation. Am J Car­
diol 1995;75(1):88-90.
5. Channer KS, Papouchado M, James MA, Pitcher DW,
Rees JR. Towards improved control of atrial fibrillation.
Eur Heart J 1987;8(2):141-7.
6. K
 hand AU, Rankin AC, Martin W, Taylor J, Gemmell I,
Cleland JG. Carvedilol alone or in combination with dig­
oxin for the management of atrial fibrillation in patients
with heart failure? J Am Coll Cardiol 2003;42(11):1944-51.
7. Lawson-Matthew PJ, McLean KA, Dent M, Austin
CA, Channer KS. Xamoterol improves the control of
chronic atrial fibrillation in elderly patients. Age Ageing
1995;24(4):321-5.
8. Maragno I, Santostasi G, Gaion RM, Trento M, Grion
AM, Miraglia G, et al. Low- and medium-dose diltiazem
in chronic atrial fibrillation: comparison with digoxin
and correlation with drug plasma levels. Am Heart J
1988;116(2 Pt 1):385-92.
9. Koh KK, Song JH, Kwon KS, Park HB, Baik SH, Park
YS, et al. Comparative study of efficacy and safety of
low-dose diltiazem or betaxolol in combination with
digoxin to control ventricular rate in chronic atrial
fibrillation: randomized crossover study. Int J Cardiol
1995;52(2):167-74.
10. Lundstrom T, Ryden L. Ventricular rate control and
exercise performance in chronic atrial fibrillation:
effects of diltiazem and verapamil. J Am Coll Cardiol
1990;16(1):86-90.
11. Tsuneda T, Yamashita T, Fukunami M, Kumagai K,
Niwano S, Okumura K, et al. Rate control and quality
of life in patients with permanent atrial fibrillation: the
Quality of Life and Atrial Fibrillation (QOLAF) Study.
Circ J 2006;70(8):965-70.
12. P  omfret SM, Beasley CR, Challenor V, Holgate ST. Rela­
tive efficacy of oral verapamil and digoxin alone and in
combination for the treatment of patients with chronic
atrial fibrillation. Clin Sci (Lond) 1988;74(4):351-7.
13. Roth A, Harrison E, Mitani G, Cohen J, Rahimtoola
SH, Elkayam U. Efficacy and safety of medium- and
high-dose diltiazem alone and in combination with
digoxin for control of heart rate at rest and during exer­
cise in patients with chronic atrial fibrillation. Circula­
tion 1986;73(2):316-24.
14. Schwartz JB, Keefe D, Kates RE, Kirsten E, Harrison
DC. Acute and chronic pharmacodynamic interaction
of verapamil and digoxin in atrial fibrillation. Circula­
tion 1982;65(6):1163-70.
The authors
Dr Theodora Nikolaidou MRCP(UK) MBChB
(corresponding author)
Research Fellow
Royal Hallamshire Hospital
Glossop Road, Sheffield S10 2JF
UK
Professor Kevin S Channer MD FRCP
Consultant Cardiologist and Physician
Royal Hallamshire Hospital
Glossop Road, Sheffield S10 2JF
UK

New web-based cardiology PACS

Most current cardiology
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treatment. To address such issues, Carestream Health has launched a new web-
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ability to continuously check the progress and results of an operation may
prevent the need for a second surgical intervention. Cappa C-Nav is opti­
mally tailored for the mobile C-arm Arcadis Orbic 3D and, if needed, can
be retrofitted for these systems.
Siemens AG
Erlangen, Germany
www.ihe-online.com & search 45326
Point-of-care ultrasound system
A versatile tool for vascular and endovascular
surgeons, the M-Turbo point-of-care ultrasound
system offers high quality rapid imaging for both
clinical assessments and ultrasound guided pro­
cedures. The system allows abdominal, nerve,
vascular, cardiac, venous access, pelvic and
superficial imaging. Excellent image quality is
obtained with sharp contrast resolution and
clear tissue delineation. With SonoHD imaging
technology, enhanced colour flow and soon an
optional new SonoRemote control, the M-Turbo
has 16 times the processing power of the compa­
ny’s previous generation model and still weighs just around 3 kg. The system
boots in seconds from a cold start and has been drop-tested from a metre.
It is simple to use and clean, as a sealed, fluid-resistant interface allows
thorough disinfection.
SonoSite Ltd
Hitchin, Herts, UK
www.ihe-online.com & search 45328
23 – Issue N°4 – Sept. 2009
Multi-beam OCT scanner
Using the high resolution capability
of Michelson Diagnostic’s proprietary
technology, the VivoSight multi-beam
OCT scanner provides state-of-the
art images of skin and other surface
tissue through the use of a compact,
ergonomically designed hand-held
probe. The probe is designed for use
on external tissue, such as for imaging
skin microstructure, with an isotropic resolution of better than 10 µm to a
depth of up to 2 mm. Scan rates vary from 6.5 fps to 35 fps depending on the
scan width, which, in turn, can be varied up to 5 mm. The probe has full x-y
scanning capability enabling rapid capture of 3D TIFF format image stacks
up to 5 mm x 5 mm, with a pixel size of 4 µm. A specially designed adjusta­
ble stand-off enables image capture from awkward locations without subject
discomfort. The software is designed to be quick and easy to understand and
use, and does not require an in-depth understanding of OCT.
Michelson Diagnostics Ltd
Orpington, Kent, UK
www.ihe-online.com & search 45327
Wireless technology platform
With the introduction of Mortara Instrument’s Wireless Acquisition Module
(WAM) for resting ECG, a new go wireless technology platform is avail­
able. The platform is comprised of Mortara’s proprietary technology that is
specifically designed to offer an equivalent or lower cost alternative to wired
designs in ECG applications. The technology is optimised for diagnostic
ECG acquisition with simple configuration, long battery life and robust
transmission protocols to be integrated into a wide array of ECG acquisi­
tion products. The WAM is the first go wireless product for resting ECG
acquisition to be introduced, and is a high-fidelity diagnostic ECG acquisi­
tion module with integrated go wireless capabilities enabling transmission
to Mortara ELI electrocardiographs. At the touch of a button an ECG can
be acquired or rhythm strip initiated. The wireless capability eliminates the
traditional expensive and bulky ECG cable and allows caregivers greater
freedom of movement while acquiring electrocardiograms. The WAM
is targeted to simply replace traditional patient cable designs.
Mortara Instrument, Inc.
Milwaukee, WI, USA
www.ihe-online.com & search 45329
www.ihe-online.com & search 45302
 – Issue N°4 – Sept. 2009
24
Small but powerful patient monitor
The new LifeWindow Lite monitor from Digicare
Biomedical Technology is small in size but big in
performance. Designed with only world class vital
signs modules, the new system delivers unprec­
edented performance and reliability. Several
options of measurement modules are available;
these configurable, upgradable, additional mod­
ules can be installed at any time. The operation
of the monitor by touch screen is intuitive and all
monitored vital signs are stored and can be trans­
ferred to clinical information systems. Connec­
tion to the company’s central monitoring station
is totally wireless for up to 16 bedside monitors.
Remote viewing and control is possible.
Digicare Biomedical
Technology, Inc.
Boynton Beach, FL, USA
www.ihe-online.com & search 45318
Improved nuclear cardiology
performance
GE Healthcare’s recently launched nuclear car­
diology platform based on Alcyone technol­
ogy combines cadmium zinc telluride (CZT)
detectors, focused pin-hole collimation, 3D
reconstruction and stationary data acquisi­
tion, to improve workflow, dose management,
and overall image quality.  The new Alcyone
technology will be available on GE Healthcare’s
www.ihe-online.com & search 45141
PRODUCT NEWS
Discovery NM 530c and Discovery NM/CT
570c systems. Alcyone’s heightened sensitiv­
ity and zero equipment motion improves both
image quality and energy resolution, ena­
bling the potential for new clinical applica­
tions including 3D dynamic acquisitions and
simultaneous dual isotope imaging.
With conventional nuclear cardiac imaging,
patients must hold their arms above their head
for two scans that take between 15-20 minutes
each. With the Discovery NM 530c, the scan­
ning time is reduced to 3-5 minutes for each
scan. This reduction in time can mean less
pain for the patients caused by the uncomfort­
able position, and can also reduce the likeli­
hood of any patient movement caused by such
pain, which can result in artifacts in the scan.  Offering a new imaging and intervention
 The Discovery NM/CT 570c can perform a
complete cardiac scan in less than five minutes
including myocardial perfusion imaging (MPI),
Computed Tomographic Angiography (CTA),
and calcium scoring (CaSC).
GE Healthcare
Chalfont St Giles, UK
www.ihe-online.com & search 45320
Demand-compatible resuscitator
The proven COM­
BIBAG resuscita­
tor from Wein­
mann can now
be used with a
demand valve.
Patients can now
receive 100% oxy­
gen via the resus­
citator. Tried-and-
tested over the
years, the COM­
BIBAG features practical recessed grips for use
in paediatrics. The smaller volumes are appro­
priate for the ventilation of small children.Use
of the same resuscitator for adults and children
saves space in the emergency case or backpack.
Weinmann
Hamburg, Germany
www.ihe-online.com & search 45319
FRONT COVER PRODUCT
Complete MR-based prostate
package
option for patients with elevated and/or
rising PSA levels, the first complete MR-
based solution for the analysis, planning
and interventional biopsy of prostate cases
has been introduced to the market by the US
company Invivo. The new system has been
developed over the past five years through
close collaboration between the company
and selected prestigious clinical centres
throughout the world. Extensive evaluation
of the software, with its comprehensive set
of advanced prostate image visualisation
tools for performing real-time image analy­
sis and interventional procedure planning
was carried out during this collaboration.
Based on the well-established DynaCAD
advanced visualisation system for viewing
and analysing MR images, which is used
clinically for MR image analysis and breast
biopsy interventional planning, the new
DynaCAD for Prostate provides increased
operational efficiency and enables the radi­
ologist to rapidly interpret the 3,000 images
that constitute a dynamic contrast-enhanced
prostate MRI.
In situations where the urologist faces the
dilemma of patients with elevated and/or
rising PSA levels and negative TRUS-guided
biopsy results, the new complete clinical
MR prostate solution offers an alternative
to keeping patients in an uncertain state.
The new DynaTRIM, a device for the first
MR-guided intervention application, ena­
bles the physician to conduct targeted MRI-
guided interventions of the prostate gland
so reducing the number of cores acquired
during biopsy. This is especially useful for
patients that have had several sessions of
biopsies with negative results. Such patients
only need a maximum of four MR-guided
biopsies; the detection rate is 59%.
Invivo
Orlando, FL, USA
www.ihe-online.com & search 45321
 PRODUCT NEWS 25 – Issue N°4 – Sept. 2009

Microbial sealant recommended for
reducing surgical contamination
InteguSeal, the microbial sealant from Kim­
berly-Clark Health Care, is a barrier intended
to prevent intraoperative contamination of sur­
gical incisions. Following skin disinfection, it is
applied as a liquid; it then seals the skin around
the operative site, preventing wound contamina­
tion from the surrounding skin microflora whilst
allowing normal transpiration of water vapour.
Clinical studies have shown that InteguSeal
reduces surgical wound bacterial contamination when used in conjunction with
standard skin preparation, and that its use in surgery can significantly reduce
the rates of surgical site infection (SSI). The product has been given a ‘recom­
mendation 1’ by the UK Department of Health’s Rapid Review Panel (RRP),
which announced that the basic research and development behind the product,
its validation and recent in-use evaluations have shown benefits that mean that
the product should be included as appropriate in protocols for cleaning hygiene
or infection control.
Kimberly-Clark Healthcare
Zaventem, Belgium
www.ihe-online.com & search 45324
Calibrating pneumatic equipment
It is vital that pneumatic equipment be
checked for for reliability and precision
using an absolutely dependable testing
device. Designed to meet such require­
ments, the FlowAnalyser bi-directionally
measures with the highest precision and
reliability the flow, pressure, temperature,
humidity and O2 concentrations from
pneumatic equipment. The unique adult,
paediatric and high frequency ventilation measurement modes make the system
the ideal calibration tool for the verification of all ventilator, spirometers and
anaesthesia machines. The FlowAnalyser is now equipped with many new fea­
tures such as a simulation of the RT-200 operating mode through the provision
of an RS-232 interface communication capability, thus providing an up-to-date
replacement for the discontinued RT-200 system. The system software enables
easy viewing on the computer monitor of flow, pressure and volume measure­
ments while simultaneously saving respiratory parameters. Measurement results
can be presented either graphically in real-time curves or numerically. Trending
reports of up to 100 hours can be generated to verify long-term ventilator func­
tionality. To facilitate device management, test reports can also be created and
saved electronically or printed.
imtmedical ag
Buchs, Switzerland
www.ihe-online.com & search 45323
slot design which provides a positive grip on the suture, allowing the band
to be pulled into position with the minimum of inconvenience. Another
unique feature of LogiFlex is the availability of individual patented tip options,
providing a bespoke solution to every manufacturer of gastric bands.
Surgical Innovations
Leeds, Yorks, UK
www.ihe-online.com & search 45325
FRONT COVER PRODUCT
Advanced jet ventilator system
Equipped with all features
needed for jet ventilation in
every possible clinical set­
ting, the new MONSOON
3 jet ventilator from Acu­
tronic is the most advanced
apparatus of its kind. The
double jet outlet enables the application of superimposed jet ventila­
tion with separate high and low frequency gas outlets. Another strik­
ing feature is the high performance jet gas conditioning system, which
automatically warms and humidifies the entire delivered jet gas — this
was a much appreciated feature of the preceding model in the MON­
SOON series, but is now even more impressive, thanks to a completely
redesigned conditioning unit. Likewise, the cumbersome distilled
water tubing system in earlier models is no longer necessary. All that
is needed now is to connect the infusion system to the luer-lock water
inlet and to put a drop counting sensor in place. This enables continu­
ous jet ventilation of any duration, from minutes to weeks, without any
risk of mucosal damage due to dry and cold gases or over-hydration by
an uncontrolled water supply. Many default and customisable settings
facilitate the use of the system in various operating room environments
as well as in intensive therapy. A large bright colour display unit can be
rotated in all directions and even placed distant from the main instru­
ment. The system is controlled via a comprehensive software menu with
a logical architecture, which allows very easy and intuitive operation.
Acutronic
Hirzel, Switzerland
www.ihe-online.com & search 45322
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Flexible laparoscope for bariatric surgery

The Endoflex range of laparoscopic
instruments from the UK com­
pany Surgical Innovations has been
extended with the introduction of
the Logiflex device, made from both EPG6view
single-use and reusable components 6Ch ECG
to enhance performance and cost-
Medical Equipment Solutions
effectiveness. The device’s sterile insert provides a solution to gastric banding,
with the flexible tip featuring a ‘cut down’ profile allowing for easy insertion of www.progettimedical.com
the instrument through the retro-gastric tunnel. It also incorporates a unique
www.ihe-online.com & search 44949
 – Issue N°4 – Sept. 2009
The China Medical Equipment Fair spring 2009
Founded in 1979, the China International
Medical Equipment Fair (CMEF), is held twice
a year, in the spring and autumn. After 30 years
of continuous innovation and self-improve­
ment, CMEF has become the largest exhibition
of medical equipment, related products and
services in the Asia-Pacific region. The exhi­
bition is a wide coverage of over ten thousand
products in fields including medical imaging,
in vitro diagnostics, electronics, optics, first aid,
rehabilitation nursing, medical information
technology and outsourcing services. The 61st
international China Medical Equipment Fair
(CMEF) held at Shenzhen, China from April
18-21 was another successful addition to this
series of expos.
The 61st CMEF show, spread across an area of
110,000 square metres, attracted 2,179 exhibi­
tors from 21 different countries, who were
Calendar of events
October 1-3, 2009
ESMRMB 2009
Antalya, Turkey
Tel: +43 1 535 13 06
Fax +43 1 535 70 41
e-mail: office@esmrmb.org
www.esmrmb.org
October 11-14, 2009
ESICM 2009
22nd Annual Congress of the European
Society of Intensive Care Medicine
Vienna, Austria
Tel. +32 2 559 03 55
Fax +32 2 527 00 62
e-mail: Vienna2009@esicm.org
www.esicm.org
October 20 – 23, 2009
Medical Fair Brno Central Europe 2009
Brno Exhibition Centre, Czech Republic
Tel. +420 541 152 818
Fax +420 541 153 063
e-mail: medicalfair@bvv.cz
www.bvv.cz/medicalfair-gb
October 28-31, 2009
62nd CMEF Autumn 2009
New International Convention & Exposition Center,
Chengdu, China
Tel. +86 10 6202 8899 ext 3825
Fax +86 20 6235 9314
26 Show report
eager to promote their corporate image, main­
tain close communication with clients, look for
buyers or distributers and learn about innova­
tions and advances. Over 57,000 visitors visit
the show, nearly four thousand of whom were
from countries other than China, including
other Asian countries, Europe, America and
Africa. The event featured companies from all
over the world with products and services for
the entire medical supply chain, from concept
and design to manufacturing and distribution.
imaging, diagnostics, critical patient care, elec­
tronics or other healthcare products and serv­
“CMEF really lives up to its ices for hospital and medical institutes, it was all
available under one roof enabling efficient and
reputation of being Asia’s most effective interactions between medical device
manufacturers and service providers.
established and largest event
for the medical equipment In addition, this year’s CMEF had a special focus
on IT. The whole development process of hospi­
sector.” Mr S. W. Nixon, tal information management, as well as the lat­
est technologies were exhibited. Another speci­
Director of Viamed Ltd., UK ality segment was ‘Medisoft’ which focused on
the registration, logistics, and services involved
in the medical devices industry.
Many Chinese exhibitors said that they were
aggressively targeting Arab, Asian, European, The next CMEF in Autumn 2009 will take
Eastern European, and North and South Amer­ place from 28-31 October, 2009, in the New
ican as well as local markets. Several exhibitors International Convention & Exposition Cen­
noted a big spike in the number of international tre, Chengdu, China. The event is expected
attendees compared to the past. to attract a large number of high-quality
exhibitors and professional visitors, and
The event was an excellent platform for any­ make a significant contribution to the further
one interested in the medical industry. Be it development of Chinese emergency medicine.
e-mail: jin.liu2@ReedSinopharm.com January 25-28, 2010 March 9-12, 2010
http://en.cmef.com.cn Arab Health 30th international Symposium on Intensive Care and
Dubai, United Arab Emirates Emergency Medicine (ISICEM)
October 28-31, 2009 Tel. +971 4 3365161 Brussels, Belgium
Salon de la Santé 09 - North Africa’s Premier Fax +971 4 3364021 Tel. +32 2 555 3631
International Health Care Trade Fair www.arabhealthonline.com Fax +32 2 555 4555
Casablanca, Morocco e-mail: avl@intensive.be
Tel. +49 6221 4565 0 February 25-28, 2010 www.intensive.org
Fax +49 6221 4565 25 Early Disease Detection and Prevention
e-mail: info@fairtrade-messe.de (EDDP) conference 2010 March 15-18, 2010
www.salonsante.info/2564.html Munich, Germany World of Health IT Conference & Exhibition
Tel. +41 22 5330 948 Barcelona, Spain
November 18-21, 2009 Fax +41 22 5802 953 www.worldofhealthit.org
MEDICA 2009 e-mail: eddp2010@paragon-conventions.com
Düsseldorf, Germany www.paragon-conventions.com/eddp2010/ June 16-19, 2010
e-mail: info@medica.de World Congress of Cardiology Scientific
www.medica.de February 26-28, 2010 Sessions 2010
2010 First International Meeting on Featuring the 3rd International Conference on Women,
November 29 – December 4, 2009 Cardiac Problems in Pregnancy (CPP) Heart Disease and Stroke
RSNA 2009 Valencia, Spain Beijing, China
Chicago, IL, USA Tel. +41 22 5330948 e-mail: congress@worldheart.org
http://rsna2009.rsna.org e-mail: secretariat@cpp2010.com www.worldcardiocongress.org
www.CPP2010.com
December 11-13, 2009
Medifest’09 March 4-8, 2010 For more events see
Pragati Maidan, New Delhi, India ECR 2010 www.ihe-online.com/events/
Tel. +91 11 3058 0444 / 3058 0777 Vienna, Austria
Fax +91 11 3058 1000 Tel. +43 1 533 40 64 - 0 Dates and descriptions of future events have
e-mail: info@vantagetradefairs.com Fax +43 1 533 40 64 - 448 been obtained from usually reliable official
www.vantagemedifest.com/medifest_india e-mail: communications@myESR.org industrial sources. IHE cannot be held respon-
http://myESR.org sible for errors, changes or cancellations.
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