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Screening Mammography Guidelines
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Reducing risks in mechanical ventilation
Optimising shock wave lithotripsy outcomes

Self-treatment for women Compact colour Intraoperative

after pelvic radiotherapy ultrasound system radiotherapy system
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 editor’s letter 3 – Issue N°7 – Dec. 2009/Jan 2010

A glimpse of the future of cancer medicine

It seems like only addition to the drivers, there are also were identified, (corresponding targetting the specific mutated genes
yesterday but actu- “passenger” mutations, which do not on average to approximately one and which patients would benefit
ally it is now nearly actually contribute to the neoplasm mutation per 15 cigarettes smoked!). from such treatment. Already the
10 years since the but can serve as a molecular record Study of these mutations showed Wellcome team are working to corre-
ground-breaking of each cancer’s evolutionary past, that many occurred long before the late the genetic changes with response
feat of the first reflecting mutagenic exposures and tumour actually became apparent to cancer treatments. The road ahead
sequence of the eventual defects of DNA repair. In and also showed how the cells have is still long,
human genome was announced, the melanoma cancer, a total of more attempted (frequently unsuccess- but at least it
amid hype and (perhaps exagger- than 30000 passenger and driver fully) to repair the damage. The hope seems to be
ated) optimism. The hope then was mutations were found, whereas in is that this information will now in the right
that the knowledge of the sequence lung cancer nearly 23000 mutations allow the development of new drugs direction.
of the human genome would not
only give a deeper understanding
of basic biology, but that this could
be leveraged into improved under-
standing of the many pathologies
affecting humans and thus allow
a concomitant improvement in
their prevention and/or treatment.
Although genomics is of course
only one aspect of the complex bio-
logical systems that make up living
organisms, it was felt ten years ago
that the central role of genes meant
that a knowledge of their sequence
(or even existence) would be of huge
help in reaching the holy grail of
medicine, namely personalised pre-
vention or treatment, on the basis
of the patient’s genomic character-
istics, of the killer diseases such as
cancer. Although there have been
some successes in the development
of anti-cancer drugs based on a
deeper understanding of the under-
lying biological processes (e.g. ther-
apeutic monoclonals for HER2/neu
breast cancers and small molecule
inhibitors for BCRI/ABL chronic
myeloid leukaemia and for EGFR
mutations in lung cancer) the out-
standing challenges are huge. Cur-
rently deaths from cancer are nearly
8 million per year worldwide and,
worse, the incidence is increasing
dramatically. It is against this som-
bre background that the recent news
of the first comprehensive analysis
of cancer genomes (Pleasance et
al, Nature 2009 Dec 16th) is par-
ticularly important. Using advanced
sequencing techniques teams from
the Wellcome Trust Sanger insti-
tute have identified all of the muta-
tions in two cancers (small cell lung
cancer and melanoma). All cancers
carry somatic mutations, of which
the subset of the so-called driver
mutations in cancer genes actu-
ally cause the cancer to develop. In
[Link] & search 45401
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 – Issue N°7 – Dec. 2009/Jan. 2010 6 Coronary artery Disease

Next-generation drug eluting stents

Late stent thrombosis has emerged as a major concern in the use of drug-eluting The stent platform
stents (DES), with studies showing that late DES thrombosis delays arterial healing. In the first generation of DES (Taxus and Cypher),
To meet this challenge, the next generation of DES are being developed to increase 316L stainless steel is used as the platform and the
strut thickness ranges from 130 to 140μm. With
safety and biocompatibility by optimising the three major components of DES,
316L stainless steel, the radial strength is de-
namely the stent platform, the polymer and the drug used. pendent upon the thickness of the stent’s struts.
Newer stent designs use cobalt-chromium, which
by Dr G. Nakazawa and Dr R. Virmani has greater radial strength, radiopacity, and thus
allows thinner struts. In fact, the 2nd generation
of DES (Endeavor with zotarolimus and Xience
Polymer-based sirolimus and paclitaxel drug Miami Lakes, FL, USA and does not affect the V with everolimus-eluting stents) are constructed
eluting stents (DES) have significantly reduced paclitaxel “Taxus” stent from Boston Scientific, from cobalt-chromium and have thin stent struts
the rates of restenosis compared bare metal stents Natick, MA, USA. Most hypersensitivity reactions (80-90μm) that result in a decrease in neointimal
(BMS) and have quickly become the standard of are observed after one year or more. The problem response and more rapid re-endothelialisation.
care for coronary artery disease. However, late is thus most probably related to the polymer rather Preclinical data have demonstrated that stents
stent thrombosis (LST) has emerged as a major than the drug, as the drug should be completely with thinner struts have greater endothelialisa-
safety concern, especially in patients who receive eluted by this time. The Cypher non-erodable tion compared to those with thicker struts [7].
“off-label use” such as bifurcation, long lesions polymer consists of polyethylene-co-vinyl acetate The distance that endothelial cells have to migrate
(>30mm), saphenous vein bypass graft, use in (PEVA) and poly n-butyl methacrylate (PBMA), is less in stents with thinner struts than thicker
the left main coronary artery, chronic total oc- and both have been associated with hypersen- struts, so it is not surprising that stents with
clusion, renal failure and acute myocardial infarc- sitivity reactions in humans and animals when thinner struts re-endothelialise faster.
tion (AMI). Pathology studies of patients dying used in non-vascular locations [5,6]. On the other
from late DES thrombosis show delayed arterial hand, extensive fibrin deposition is observed with Polymers
healing characterised by persistent fibrin deposi- the Taxus stent, with or without stent malapposi- In First Generation DES, non-erodable poly-
tion and poor endothelialisation as the primary tion. It is unclear how the Taxus polymer SIBBS mers were used in both the Cypher and Taxus
substrate [1]. Thus there is still lots of room to [poly(styrene-b-isobutylene-b-styrene)] con- stents (Cypher: polyethylene-co-vinyl acetate
improve DES technology. tributes to these observations, since these reac- (PEVA) and poly n-butyl methacrylate (PBMA)
tions are drug dose-dependent; this reaction is and Taxus: SIBBS [poly(styrene-b-isobutylene-b-
Findings at autopsy – probably related to the cytotoxicity of paclitaxel. styrene)]). However, as mentioned above, these
currently used first generation DES polymers are likely to provoke an inflammatory
In 2006, we reported that, compared to BMS im- Components of Drug Eluting Stents reaction [4,8]. This may be the result of poor in-
planted for a similar duration, there was delayed DES consists of three major components: 1) the tegrity of the polymer on the underlying metal
arterial healing in DES, as evidenced by the persis- stent platform to scaffold the vessel; 2) the poly- surface; uneven application, webbing of polymers
tence of fibrin, incomplete re-endothelialisation, mer to allow controlled release of the drug; and 3) or surface debris. Once the inflammation process
and sparse smooth muscle cell coverage [1]. Later, the drug to inhibit neointimal growth. is triggered, the reaction may persist for a long
using the data from a larger number of autopsy
cases, we showed that a lack of endothelial strut
coverage was the single factor that best correlated
with late stent thrombosis [2]. The arterial heal-
ing in DES lesions was heterogeneous, especially
in thrombosed cases, suggesting that the under-
lying lesion morphologies also contribute to the
rate of healing. For example, we have observed a
significantly higher incidence of late stent throm-
bosis in patients treated with DES for AMI com-
pared to those treated for stable lesions [3]. In
these AMI patients, heterogeneity of healing and
delay of healing was observed at culprit sites in
contrast to non-culprit sites.

However, it is not only factors concerning the

underlying patient and the lesion that affect vas-
cular healing — it is also the devices themselves.
Hypersensitivity reaction is one of the compli-
cations that has been reported following DES
The Cypher drug-eluting stent (DES) contains polymer-based sirolimus on a stainless steel structure. These three
implantation [4]. Our observations revealed that components —the underlying scaffold structure, the polymer coating of the scaffold and the drug itself which is
this phenomenon is limited to the polymer-based eluted form the polymer — are essential for the overall performance of a DES. Active R&D in all three compo-
sirolimus “Cypher” stent from Cordis Corp., nents seems set to result in new stents, with not only higher efficacy but an improved safety profile.
 7 – Issue N°7 – Dec. 2009/Jan 2010

period because the polymers are non-erodable. mer, promoting tubulin polymerisation and cell
For this reason, the use of biodegradable poly- cycle arrest [13].
mers for drug delivery is now being investigated. It is not fully understood how both of the DES
The earliest, and most commonly used, biode- devices continue to function long-term after the
gradable polymers are polyesters which include drug is completely eluted. However, proliferation
PLA (poly[lactide]), PGA (poly[glycolide]) and of smooth muscle cells following stent implanta-
PLGA (poly[glycolic-co-lactic acid]). As de- tion peaks early (seven days in a porcine coro-
scribed by Middleton [9] the properties of an ideal nary artery model [14]), so if DES can inhibit
biodegradable polymer are: smooth muscle cell proliferation during this pe-
1) i t should not evoke an inflammatory/toxic re- riod, the DES may remain effective for a long
sponse, time. However, there is some doubt that DES
2) i t should be metabolised in the body after ful- can be effective permanently, since clinical stud-
filling its purpose, ies using intravascular ultrasound have shown a
3) i t should be easily processed into the final slight increase in the target revascularisation rate
product form, [15] or neointimal volume over four years [16].
4) it should have acceptable shelf life, While both drugs reduce neointimal growth by
5) it should be easily sterilisable. disrupting smooth muscle cell proliferation, re-
The speed of degradation of the polymer is con- endothelialisation is also impaired [1]. However,
trolled by many factors, such as hydrophilicity of it is not only the extent of endothelialisation that Protect your patient’s eyes
the monomer, pH, number of reactive hydrolytic is important but also the structural integrity and during general anesthesia
groups in the backbone, crystallinity, or polymer anti-thrombotic function in late stent throm-
size [9]. The numbetr of these factors means that bosis (LST). Recent clinical studies suggest that
against corneal abrasion,
the development of biodegradable polymers for DES also impairs endothelial responses to ace- See us at Medica
use in DES technology remains challenging. If tylcholine and exercise-mediated vasodilation in Hall 16 Stand E06
the drug is eluted faster than the rate at which the humans [17,18]. Thus, both drugs lead to sup-
polymer degrades it is possible that the resulting pressed endothelial function as well as inhibition
inflammation will nullify the advantages con- of endothelial cell proliferation and migration. U.S.A. 813-889-9614 • Fax 813-886-2701
ferred by using biodegradable polymers. An op- It is likely that newer analogues of rapamycin,
timal elution and degradation profile should be such as zotarolimus and everolimus used in 2nd
aimed for to avoid such mismatches. generation DES (Endeavor and Xience V), have
Our experience shows that it is possible to achieve similar biological effects. However, the Xience V
this balance, and it is thus probable that the ben- stent uses a lower concentration of everolimus [Link] & search 45469
efits of biodegradable polymer can be obtained than in 1st generation DES, and Endeavor has
without any significant resultant inflammation. a higher dose of drug (zotarolimus) than other
We believe that overall biodegradable polymers 1st and 2nd generation DES. It also has the fastest
are likely to be safer than non-erodable polymers release kinetics among currently available DES,
since, as the polymer degrades the inflamma- and therefore the concentration in the arterial
tion will eventually subside and the bare metal wall tissue is likely to be less. Recent preclinical
stent-surface will remain. studies, which compared the various DES in a
rabbit model, show better endothelialisation in
Drugs 2nd generation DES compared to 1st generation
The use of anti-proliferative agents such as si- DES [19]. Other drugs being tested in DES in-
rolimus and paclitaxel given locally at high con- clude biolimus A9, tacrolimus, and pimecroli-
centration has proved to be very successfully in mus. Biolimus A9 is another rapamycin analogue
reducing neointimal formation in animal models with high lipophilicity, but results in a suppres-
[10,11]. Following encouraging results in preclin- sion of smooth muscle cells similar to siroli-
ical studies, clinical studies were conducted and it mus and its other analogues. The biolimus A9
was found that, compared with BMS, there were eluting stent has recently received the CE mark
dramatic reductions in restenosis rates. This has and has shown efficacy in both animals and
lead to the generalised use of DES in patients with humans [20-22].
coronary artery disease. Pimecrolimus and tacrolimus act through the
Ca++/ calmodulin-dependent protein phosphatase
The methods of action of sirolimus and pacli- calcineurin pathway [23]. Inhibition of calcineu-
taxel have been extensively studied. Sirolimus rin results in the suppression of transcription
binds to the FK-binding protein 12 (FKBP-12) factors, such as the nuclear factor of activated T
and subsequently inhibits the mammalian target cells (NFAT). This causes the downregulation of
of rapamycin (mTOR), which prevents the deg- several cytokine genes, including ILs, IFN-g and
radation of p27kip1, a cyclin-dependent kinase TNF-a, which leads to suppression of the inflam-
inhibitor that plays an important role in regulat- matory response, but the ability of these drugs
ing vascular smooth muscle cell migration and to suppress smooth muscle cell proliferation is
proliferation [12]. Paclitaxel is a lipophilic diter- questionable. In fact this class of drugs failed to
penoid, known to suppress smooth muscle and show clinical efficacy, suggesting that calcineurin
endothelial cell proliferation and migration by blockage may not be effective, at least in humans
binding to the b-subunit of the tubulin heterodi- at the concentration used in DES [24,25].
[Link] & search 45342
 – Issue N°7 – Dec. 2009/Jan. 2010 8 Coronary artery Disease

EyeGard™ is the Next generation of DES Targets 2003;3:193-203.

safe, effective way In addition to the improvements that have been

made in 2nd generation DES, there are currently
14. C arter AJ et al. J Am Coll Cardiol 1994;24:
1398-405.
to protect the eyes newer approaches being tested such as biodegrad- 15. Morice MC et al. J Am Coll Cardiol 2007;50:1299-304.
during surgery. able polymers, polymer free drug delivery, the pro-
healing approach, and fully biodegradable stents.
16. Aoki J et al. J Am Coll Cardiol 2005;46:1670-6.
17. Hofma SH et al. Eur Heart J 2006;27:166-70.
These approaches are being vigorously pursued 18. Togni M et al. J Am Coll Cardiol 2005;46:231-6.
and will probably be available in the near future. 19. J oner M et al. J Am Coll Cardiol 2008;52:333-42.
Importantly, these technologies focus not only on 20. Ostojic M et al. Eurointervention 2008;3:574-579.
the efficacy, but also on the safety aspects of the de- 21. Grube E, Buellesfeld L. Expert Rev Med Devices
vice. The FDA guidelines recently stated that “for 2006;3:731-41.
any given drug devices combination, the potential 22. Grube E et al. Eurointervention 2005;1:53-57.
efficacy observed in animal studies should be bal- 23. Donners MM et al. Ann Med 2003;35:523-31.
anced by any potential safety concerns” [26]. It is 24. Onuma Y et al. Eur Heart J 2009;30:1477-85.
likely that the next generation of DES will be safer 25. Verheye S et al. JACC Cardiovasc Interv 2009;2:
with better stent design, greater biocompatibility, 205-14.
• Latex free, hypo-allergenic material and appropriate drug dose and release kinetics. 26. Administration FaD. Guidance for Industry - Coro-
nary Drug-Eluting Stents, [Link]
• Reduces lash removals
References ode/guidance/[Link]. 2008.
• Faster and easier than tape 1. Joner M et al. J Am Coll Cardiol 2006;48:193-202.
• Adult and pediatric sizes 2. Finn AV et al. Circulation 2007;115:2435-41. The authors
• Gentler adhesive also available 3. Nakazawa G et al. Circulation 2008;118:1138-45. Gaku Nakazawa, MD and Renu Virmani, MD
See us at Medica 4. Virmani R et al. Circulation 2004;109:701-5. CVPath Institute, Inc.,
Hall 16 Stand E06 5. Ahmed DD, Sobczak SC, Yunginger JW. Immunol Gaithersburg, Maryland, USA
Allergy Clin North Am 2003;23:205-19. Correspondance:
6. Leggat PA, Kedjarune U. Int Dent J 2003;53:126-31. Renu Virmani, MD
U.S.A. 813-889-9614 • Fax 813-886-2701 7. Joner M et al. J Am Coll Cardiol 2008;In press. CVPath Institute, Inc.,
8. Finn AV et al. Arterioscler Thromb Vasc Biol 19 Firstfield Road,
2007;27:1500-10. Gaithersburg, MD 20878, USA
9. Middleton JC, Tipton AJ. Biomaterials 2000;21: e-mail: rvirmani@[Link]
2335-46.
[Link] & search 45470 10.Gallo R et al. Circulation 1999;99:2164-70.
11. Suzuki T et al. Circulation 2001;104:1188-93.
Comments on this article?
Feel free to post them at
Medcorp International
12. Sun J et al. Circulation 2001;103:2967-72.
[Link]/comment/DES
13. Abal M, Andreu JM, Barasoain I. Curr Cancer Drug

New computer model could lead to safer stents

MIT scientists have developed computer models to predict physiologically realistic drug delivery
patterns from stents in branched arterial vessels. They simulated several arterial settings to show
that drug distribution in these situations is determined by a complex calculation of the stent’s posi-
tion relative to arterial branches and constant blood flow changes caused by the branching.
Distributors Wanted Drug-eluting stents are now widely used all over the world to treat obstructive arterial disease, yet
some patients with the stents have suffered life-threatening side effects: an increase risk of blood
Little Sucker has become the product clotting and heart attacks. Several important questions remain unanswered — in particular, the
of choice with nurses, respiratory mechanisms that govern drug delivery to specific lesion sites are poorly defined and pose chal-
therapists, and in many hospitals in the lenges for stent designers, physicians and regulatory agencies that must evaluate stents’ safety and
U.S. Little Suckers replace up to three efficacy.
products with just one Little Sucker. Predicting drug distribution is complicated by the branching of arteries into two or more vessels,
which establishes alterations in flow, wall shear stress and geometries. All of those can be modelled
Our three sizes, Preemie, Standard,
and defined mathematically, however, the variations cannot be captured across the full spectrum
and Nasal Tip, are ideal for oral and
nasal suctioning in the nursery (labor of perturbations and combinations in animal systems or in the lab, let alone the human. Computa-
and delivery), neonatal intensive care, tional models are therefore required.
pediatric intensive care, and emergency The computer model was generated by combining principles of digital image processing and para-
departments. Please contact us for metric computer-aided geometry design with computational fluid dynamics and mass transport.
samples and pricing. A video link showing how these geometry models are created can be found on the journal website.
Dave Berberian
The authors believe this modelling technique can be extended to simulate several settings with
Medcorp International, Dept. CN various stent designs as well as complex arterial geometries with and without disease, altered flow
25612 Stratford Place
Laguna Hills, CA 92653 USA environments and other boundary conditions.
MED

12179
TEL: 949-582-0313
FAX: 949-582-3747 Kolachalama V, Levine E, Edelman E. Luminal flow amplifies stent-based drug deposition in arterial
Medcorpint@[Link]
www. [Link]
bifurcations. PLoS ONE 2009; Dec. 2 issue.

[Link] & search 45155

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 – Issue N°7 – Dec. 2009/Jan. 2010 10 Pulmonary Medicine

Long-term follow-up of ARDS patients after Extracorporeal

Membrane Oxygenation (ECMO) treatment
Treatment using extracorporeal membrane oxygenation (ECMO) can result in a high
rate of survival in patients with severe acute respiratory distress syndrome (ARDS).
Both the ECMO technique and its cost are controversial. It is therefore important
to evaluate the long-term results of ECMO treatment of severe ARDS, particularly in
relation to pulmonary morphology, function and Quality of Life (QoL). However are
only a few such follow-up studies have been published. This article describes the
long-term follow-up of ARDS patients treated with ECMO in the specialised ECMO
unit at Karolinska Hospital, Stockholm

by Dr V. Lindén

Figure 1. Chest X-ray of an adult patient with ARDS

ARDS is a life-threatening complication of vari- oxygenation and carbon dioxide removal without
and ”white lungs” on ECMO. White arrows =
ous types of lung injury. It is defined as an acute- interfering with the lungs. This enables less aggres- ECMO cannulas in v cava sup- right
in onset condition characterized by arterial hy- sive ventilation during recovery of the lungs, which atrium and arcus aortae.
poxaemia that is resistant to oxygen therapy alone; may avoid ventilator-associated damage and thus
diffuse radiological infiltrates are seen in the ab- protect the lungs [2]. pneumonia, aspiration and near drowning.
sence ARDS is the secondary manifestation of a During recent months a number of patients in
large number of primary processes of pulmonary ECMO: past and present Stockholm, Sweden with life-threatening
origin, such as pneumonia, contusion, aspiration, Extracorporeal circulation procedures were influenza N1H1 pneumonia have also been
or of extrapulmonary origin such as sepsis [1]. first used in humans in 1953 when an atrial successfully treated with ECMO.
Treatment of ARDS requires aggressive support- septum defect was successfully repaired on
ive care that include positive pressure ventilation cardiopulmonary bypass; this opened up a Although mortality in ARDS is still high, there
and increased oxygen concentration, but such new method for open heart surgery. Twenty is an increasing number of patients who have
treatment risks barotrauma and oxygen toxic- years later, the first successful use of long term survived the condition. There is therefore a
ity, which can further aggravate the lung injury. extracorporeal pulmonary support was re- growing need to understand the long-term ef-
There are a number of adjuvant treatment strat- ported, followed by many others, notably from fects of ARDS and its treatment by ECMO. The
egies, such as protective ventilator techniques, Professor R Bartlett’s group in Ann Arbor, ECMO procedure is advanced, invasive and ex-
ventilation in prone position, permissive hyper- Michigan, USA [3]. Today, ECMO is a well ac- pensive; follow-up studies in patients after se-
carbia, nitric oxide and use of ECMO that may cepted therapy for acute, severe, reversible vere ARDS and ECMO are few in number, and
reduce ventilator-induced lung injury and mor- pulmonary insufficiency in neonates e.g., as a little is known of residual changes and symp-
tality. ECMO involves gas exchange through result of meconium aspiration. In paediatric toms that may occur a long time after the ECMO
an extracorporeal oxygenator, and provides and adult patients the fields of application are treatment itself [5]].
 11 – Issue N°7 – Dec. 2009/Jan 2010

A long term study of represent fibrosis, in a majority of Lung function tests ment of pulmonary function was
post-ECMO, post-ARDS our patients. However, the extent of Pulmonary function tests per- radiospirometry. All patients had
patients morphological abnormalities was formed in patients some time after prolonged wash out durations,
During a five year period, 37 adults limited, and the predominance of ARDS point to a variable degree of which were 50% longer compared
with severe ARDS were treated by anterior parenchymal pathology persistent lung function impair- with healthy individuals (p<0.05),
ECMO at the ECMO department, previously described in convention- ment, including obstructive and/or consistent with subclinical obstruc-
Karolinska University Hospital, ally treated ARDS patients was not restrictive ventilatory defects, bron- tion. Radiospirometry reflects the
Stockholm, Sweden [4]. All patients observed. One reason for this might chial hyperreactivity and impaired trapping of air in the peripheral
had had good pulmonary function be that ECMO treatment, with gen- oxygen transfer. In our patient airways, which is thought to be one
pre-ARDS. tle ventilation, protects the lungs study group we found that most of the most important reasons for
from ventilator-associated dam- lung function values had normal- permanent and unspecific
Standard ECMO procedures were age. The extent of HRCT changes ized, with mean values for all lung pulmonary symptoms after ARDS.
carried out in all patients. The ven- suggestive of fibrosis was corre- spirometry tests in the lower inter-
tilator settings were reduced within lated with the duration of ECMO val of normal. The most sensitive Exercise tests have rarely been
three hours of starting ECMO in (p < 0.01). test in our study for residual impair- used in follow-up studies of ARDS
order to prevent further ventilator-
associated lung injury, and these
lower settings were maintained dur-
ing lung recovery until the end of
ECMO. The patients remained on
“gentle” conventional ventilation
until they breathed spontaneously.

Twenty-six patients (70%) survived

to discharge and, of these, 21 pa-
tients agreed to participate in the
long-term study. Mean time from
discharge to the follow-up study was
26 months. The pulmonary follow-
up evaluation consisted of a physical
examination, computed tomography
(HRCT), extensive pulmonary func-
tion tests including scintigraphy and
QoL, and assessment of impaired PRIMEDIC™ EXTERNAL DEFIBRILLATOR
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Related Quality of Life (HRQoL)
after 12 months. Severe disease and
prolonged mechanical ventilation
are high risk factors for persistent
abnormalities. Patients who require
ECMO probably have a more se-
vere ARDS, which theoretically may
result in more serious long-term
respiratory sequelae. However, the
gentle ventilation strategy that is
currently enabled by ECMO may
in fact help minimise ventilator-
induced lung injury and shorten the
recovery phase.

Lung
parenchymal abnormalities
High resolution CT (HRCT) showed
some degree of reticular pattern and
[Link]
ground-glass opacity, presumed to
[Link] & search 45189
 – Issue N°7 – Dec. 2009/Jan. 2010 12 Pulmonary Medicine

patients. Our study demonstrated test

values in the lower normal interval for
two-thirds of the patients. The exercise
tests were interrupted due to leg fatigue
(75% of patients) and dyspnea. After a
long period of time ECMO was signifi-
cantly associated with more extensive CT
changes, restrictive pulmonary function
and impaired lung diffusion (p<0.05).
This might be explained by a more severe
underlying disease in patients requiring
longer periods of ECMO.

Reduced HRQoL
Several investigations have measured the
overall Health-Related QoL (HRQoL) in
patients a long time after conventional
treatment for ARDS; HRQoL is an im- Figure 2. A patient with ARDS and the ECMO equipment
shown with a white/red arrow (oxygenator, pump, heat-
Monitor Your Costs While portant secondary outcome for both exchanger and tubings), CRRT (continous renal replacement
You Monitor Temperature physical and mental health. All studies
showed that there was some residual im-
therapy) shown with a white/black arrow and ventilator
(white/green arrow). The patient survived and is included in
with Crystaline® II pairment in QoL due to breathing prob- the ARDS and ECMO follow-up study.
See us at Medica lems. Pulmonary symptoms as measured
Hall 16 Stand E06 by the St George’s Respiratory Questionnaire ECMO centres in follow-up studies after ARDS
(SGRQ) are included in only a few follow-up is most desirable.
studies. The SGRQ questionnaire measures QoL In conclusion, lung parenchymal changes on
U.S.A. 813-889-9614 • Fax 813-886-2701 and impairment of health in airway disease, di- HRCT suggestive of fibrosis and minor pulmo-
vided into three domains - symptoms, restricted nary function abnormalities remain common
activity and impact on daily life. and can be detected more than one year after
ECMO-treated severe ARDS. Furthermore, these
Our post-ARDS and post-ECMO patients had patients experience a reduction in HRQoL due to
[Link] & search 45471 mean scores in the SGRQ which were higher the pulmonary sequelae.
than normal values in all domains, indicat- However such impairments are usually mild and
ing subjective respiratory problems with an the majority of adult ARDS and ECMO survi-
impact on daily life. The problems were most vors are in good physical condition and are active
often described as ‘shortness of breath’ even socially and professionally.
during light exercise. However, our patients
had an overall tendency to score lower than References
conventionally treated ARDS patients. The older 1. W  are L, Matthay M. The acute respiratory distress
patients had significantly higher SGRQ scores syndrome. Review article. N Engl J Med 2000; 342:
overall (p<0.05), which might reflect the more 1334–49.
difficult recovery from severe injuries in elderly 2. Lindén V et al. High survival in adult patients with
patients. None of our patients was in ARDS treated by extracorporeal membrane oxy-
need of extra oxygen, and they all re- genation, minimal sedation and pressure support
turned home after discharge from hospi- ventilation. Intensive Care Med 2000; 26: 1630–7.
tal. The majority (76%) returned to their 3. Bartlett R et al. Extracorporeal life support. The
former occupations after ECMO-treated ARDS. University of Michigan experience. J Am Med
May 25 - 28 2010
São Paulo - BRAZIL These findings are important from a socioeco- Assoc 2000; 283: 904–8.
nomic point of view, all the more so since two 4. Lindén VB et al. Extracorporeal membrane oxy-
17th International Fair of Products, Equipment, Services
and Technology for Hospitals, Laboratories, earlier studies found that the majority of long- genation in ARDS: a long-term follow-up study
Pharmacies, Health Clinics and Medical Offices
time survivors of ARDS and ECMO therapy regarding pulmonary function and health-related
were in good physical condition and were active quality of life. Acta Anaesthesiol Scand 2008; 53:
The most important both socially and professionally . 489–495.
healthcare fair for 5. S chelling G et al. Pulmonary function and heal-
Brazil and Latin America Our recommendation is that, in adult sur- threlated quality of life in a sample of long-
vivors of ECMO-treated ARDS, a follow-up term survivors of the acute respiratory distress
programme be carried out 12 months after syndrome. Int Care Med 2000; 26: 1304–11.
Organized by In Cooperation with Filiated to
discharge from hospital. The follow-up should
include HRCT of the lungs, exercise tests, diffu- The author
sion capacity tests, radiospirometry and SGRQ. Viveka Lindén, MD, Assoc Professor
[Link] There are only around 30 adult survivors of Pediatric Intensive Care Unit
Tel.: (5511) 3897-6199
e-mail: international@[Link]
ARDS and ECMO reported annually to the Astrid Lindgren Children`s Hospital
worldwide Extracorporeal Life support Organi- Karolinska University Hospital,Stockholm, Sweden
zation (ELSO); future collaboration between all [Link]@[Link]
GE Healthcare

Evolving care starts with evolving

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© 2009 General Electric Company - All rights reserved

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[Link] & search 45465

 – Issue N°7 – Dec. 2009/Jan. 2010 14 Pulmonary Medicine

Risk reduction in mechanical ventilation

Mechanical ventilation, whilst lifesaving, can be a risky procedure. This article Oral care practices in the critically ill vary sig-
discusses how the risks associated with airway management, pneumonia and nificantly, and although oral care protocols
sedation in mechanically ventilation patients can be reduced. have been introduced widely in critical care
settings, the evidence base for these protocols
including care frequency, products and meth-
by Dr M. J. Grap and Dr C. L. Munro ods of oral care remains limited [15]. Dental
plaque increases over time in the critically ill,
and appears to be worse at ICU admission in
Approximately one fourth to one half of criti- infections in this patient population, greatly those subsequently infected with respiratory
cally ill patients require mechanical ventilation. adding to ICU and hospital length of stay and pathogens [16].
Although lifesaving, mechanical ventilation can mortality [8].
present a variety of significant risks including Compared to usual care, the use of chlorhexi-
those related to airway management practices, Backrest elevation of 300 to 450 has been shown dine gluconate (CHX), a broad spectrum anti-
development of ventilator associated pneumonia to reduce aspiration and ventilator-associated bacterial agent, has been shown to reduce respi-
and complications from sedation. pneumonia (VAP). Aspiration occurs frequently ratory tract infection rates including VAP after
and can even occur around an inflated endotra- elective cardiac surgery. Recent meta-analyses
Airway management practices cheal tube cuff [9]. ICU mortality rate, pneu- of CHX use in critically ill adults have been
Mechanically ventilated patients require fre- monia rate and aspiration risk are all greater complicated by the variety of populations stud-
quent suctioning to keep the endotracheal tube for supine patients than for semirecumbent ied, the different formulations and dosages of
(ETT) clear, but suctioning can predispose to patients. Supine head positioning during the CHX used, and intervening variables. Because
hypoxaemia. Guidelines for the prevention of first 24 hours of mechanical ventilation was one CHX is an inexpensive intervention with low
hypoxaemia during ETT include hyperoxy- of four VAP risk factors (which also included potential for adverse effects (other than tem-
genation using 100% oxygen, either through a organ system failure, age greater than 60 years, porary tooth staining with long term use), it
manual resuscitation bag (MRB) or the ventila- and prior antibiotic use). has gained wide acceptance despite conflicting
tor [1]. Hyperinflation to greater than the venti- evidence of its effectiveness in VAP reduction.
lated volume has been shown to be detrimental A longitudinal study to describe the relation- Tooth-brushing is also a common oral care
and is recommended only when really needed ship between backrest elevation and develop- intervention, but two recent randomised con-
[2]. In the United States, the majority (60%- ment of VAP showed that subjects spent the trolled trials found no benefit in VAP reduc-
80%) of endotracheal tube (ETT) suctioning majority of the time at backrest elevations of tion from tooth-brushing alone or from the
occurs using closed suctioning systems (i.e. us- less than 30º, but that the combination of early, addition of tooth-brushing to CHX use.
ing an in-line suction catheter) [3]; worldwide, low backrest elevation and greater severity of
open suctioning systems (i.e, using an MRB) to illness increased the incidence of VAP. Unfor- Sedation and
provide hyperoxygenation are still common [4]. tunately, use of low backrest positions is com- mechanical ventilation
However MRB FiO2 (the proportion of inspired mon, despite there often being no clear indi- Mechanically ventilated patients require se-
oxygen in a gas mixture) delivery varies widely cation for that position [10, 11]. Compliance dation to help attenuate the anxiety, pain
(0.24 to 0.97) [5]. MRB oxygen delivery to the with backrest elevation for VAP reduction is a and agitation associated with this interven-
patient is directly related to oxygen flow to the national health care focus. Presently the United tion, and although 85% of intensive care unit
MRB, which should always be set at a minimum States National Quality Forum (NQF)recom- (ICU) patients receive sedation, risks associ-
of 15L/min [6]. mends the use of a “ventilator bundle”, a group ated with sedation in this population are sig-
of interventions to reduce VAP, which includes nificant. The overall goals of sedation in the
Although closed suctioning systems protect backrest elevation of 30 to 450 [12]. Qual- critical care setting are to provide physiologi-
healthcare providers from potentially contami- ity improvement projects have illustrated that cal stability, ventilator synchrony and patient
nated secretions and have not been shown to in- implementation of higher backrest positions, comfort. However, inappropriately high levels
crease pulmonary infection rates, their use may often in combination with other VAP preven- of sedation lead to alterations of respiratory
result in a buildup of secretions with the ETT in- tion strategies (ventilator bundle), reduce the drive, inability to maintain and protect the
creasing over time, a narrowing of the tube lumen incidence of VAP. airway, and cardiovascular instability [17] as
and increases in the patient’s effort in breathing well as a prolonged duration of mechanical
[7]. In addition, suctioning may cause trauma to Colonisation of the oropharynx with potential ventilation, and ventilator associated pneu-
the airway, therefore use of the lowest possible VAP pathogens is another risk factor for VAP monia [18]. Conversely, inadequate levels of
continuous pressure is also recommended. ETT [13]. The majority of organisms that are asso- sedation may result in agitation, placing the
suctioning is a necessary intervention for the ciated with VAP have been found to colonise intubated patient at risk for self-extubation,
mechanically ventilated patient and although it the oral pharynx of the critically ill patient haemodynamic instability and physical harm
presents significant risks, these can be reduced prior to the VAP diagnosis, and they are prob- or injury.
through the use of a proper technique. ably transferred from the oropharynx to the
trachea during intubation [14]. After intuba- To improve patient outcomes, levels of seda-
Ventilator Associated tion, the endotracheal tube provides a pathway tion and agitation must be measured appro-
Pneumonia (VAP) for direct entry of bacteria from the orophar- priately. Although sedation - agitation tools
Pneumonia occurs in 25% of ventilated pa- ynx through the open glottis to the lower are used to measure the effectiveness of se-
tients, and is responsible for 90% of nosocomial respiratory tract. dation in ICU patients, many have not been
 15 – Issue N°7 – Dec. 2009/Jan 2010

well tested and do not provide a continuous measure of sedation or 18. Rello J et al. Am J Respir Crit Care Med 1999;159:1742-1746.
agitation. Continuous measures that are readily available, such as blood 19. Esteban A et al. Am J Respir Crit Care Med 1994;106:1188-1193.
pressure or heart rate mesurement, may reflect patient status, e.g. higher 20. Ely EW et al. N Engl J Med 1996;335:1864-1869.
BP or HR often accompanies increased activity or agitation, although these 21. Kollef MH et al. New Horiz 1998;6:52-60.
measures are non-specific. 22. MacIntyre NR et al. Am J Respir Crit Care Med 2001;120:375S-395S.
23. Chase JG et al. Comput Methods Programs Biomed 2004;76:131-141.
In addition, continuous use of sedation is often associated with prolonged
weaning processes, with 41% of mechanical ventilation time spent wean- The authors
ing patients [19]. The use of multidisciplinary weaning protocols has been Professor Mary Jo Grap, RN, PhD, ACNP, FAAN
shown to significantly reduce the duration of mechanical ventilation [20]. and
The key to successful weaning may be that a protocol is used, rather than Professor Cindy L. Munro, RN, PhD, ANP, FAAN
specifically how it is constructed or what method of weaning is used [21].
Interestingly, independent clinical judgment or experience about readi- Adult Health and Nursing Systems Department, School of Nursing
ness to wean is a relatively poor predictor of weaning success. Clinical as- Virginia Commonwealth University, Richmond, VA, USA
sessments (respiratory pattern, cardiovascular response, comfort/anxiety,
oxygenation) are better predictors of success rather than more complex Correspondence to
weaning parameters. Daily spontaneous breathing trials (SBT) are supe- Mary Jo Grap, School of Nursing,
rior to gradual ventilator reduction strategies, and these should include Virginia Commonwealth University , PO Box 980567
an objective measurement of sedation. It is also clear that nurses and re- 1100 East Leigh St., Richmond, VA 23219, USA
spiratory therapists can effectively achieve weaning goals based on the use Tel +1 804-828-0723
of protocols. Importantly, implementation of weaning protocols requires e-mail: mjgrap@[Link]
a consistent team effort that may be difficult to sustain in the complex
critical care environment.

Reducing risks of mechanical ventilation is an active area of research.

Several modifications of ETT design have been proposed to reduce VAP
risk, including tubes which enable continuous aspiration of subglottic
secretions (CASS), tubes with silver (antimicrobial) coating, and “mucus
shaver” tubes which reduce biofilm accumulation. In addition, continuous
instillation of antibiotic into the subglottic space above the ETT cuff is be-
ing investigated to reduce VAP. Newer technologies to continuously evalu-
ate agitation are based on sensing patient motion using digital video im-
age processing, and classify levels of motion that correlate with observed
patient agitation [23]. Objective measures of sedation, such as processed
electroencephalography signals, also hold promise, but have not achieved
widespread implementation.

In summary, reducing the risks associated with airway management,

pneumonia and sedation in the mechanically ventilation patients is essential
to improve outcomes in the critically ill.
However, reducing the risks associated with mechanical ventilation in the
critically ill is a vast, complex and interdisciplinary process.

References
1. Grap MJ et al. Am J Crit Care 1996;5:192-197.
2. Pedersen CM et al. Intensive Crit Care Nurs 2009;25:21-30.
3. Sole ML Am J Crit Care 2003;12:220-230.
4. Kelleher S, Andrews T. J Clin Nurs 2008;17:360-369.
5. Glass C et al. Heart Lung 1993;22:158-165.
6. Corley M et al. [Link] 19[1], 45-49. 1993.
7. Glass C, Grap MJ, Sessler CN. American Journal of Critical Care (AM J CRIT
CARE) 1999 Mar ; 8 (2 ): 93 100 (21 ref ). 1999;8:93.
8. Alvarez-lerma F et al. Clinical Intensive Care 1997;8:164-170.
9. Huxley EJ et al. Am J Med 1978;64:564-568.
10. Grap MJ et al. Intensive Crit Care Nurs 2003;19:68-74.
11. Grap MJ et al. Am J Crit Care 1999;8:475-480.
12. Roadmap for safety: National Quality Forum officially releases 30 safe
practices for better healthcare. Qual Lett Healthc Lead 2003;15:12-4, 1.
13. Fourrier F et al. Crit Care Med 1998;26:301-308.
14. Cardenosa Cendrero JA et al. Am J Respir Crit Care Med 1999;116:
462-470.
15. Grap MJ et al. Am J Crit Care 2003;12:113-118.
16. Munro CL et al. Am J Crit Care 2006;15:453-460.
17. Barr J, Donner A. Crit Care Clinics 1995;11:827-847.
[Link] & search 45395
 – Issue N°7 – Dec. 2009/Jan. 2010 16 Women’s health

Breast cancer screening with breast self

examination: not yet a dinosaur
Worldwide, breast cancer is one of the most prevalent cancers and is responsible to end the fight against breast cancer. With over
for nearly half a million deaths per year, although encouragingly the mortality from 1.5 billion dollars raised, this organization has
the disease, in developed countries at least, has gradually been decreasing. This provided unending support for research to find a
cure, educational opportunities to those recently
decrease is partly due to improvement in therapy, but screening programs also
diagnosed as well as a common bond for all breast
play a vital role. Recent US recommendations on breast cancer screening have cancer survivors. The Susan G. Komen and Avon
been controversial, particularly with regard to the frequency of mammography and Foundation host an annual walk for survivors
the role of breast self examination (BSE). This article makes a plea for the continua- and activists to convey their continued support to
tion of BSE as the only non-invasive, low cost tool for women, particularly those at find a cure. Other programs such as The National
high risk of developing the malignancy and as a synergistic adjunct to imaging. Breast Cancer Foundation chose to increase aware-
ness by promoting early detection and providing
free mammogram screening to underserved com-
by Dr L. G. Wilke and J. Gallagher munities. Since the installation of countless breast
cancer foundations, public awareness of the breast
and its associated diseases has increased as a result
As long ago as 1947 the American Cancer Society stage. Unfortunately, a mere 25% of the enrolled of the vast array of educational materials available
(ACS) initiated a public education campaign on patients actually performed BSE on a regular on the internet [11-16].
“Cancer’s Danger Signals”. One of the seven origi- basis. However, those who did perform BSE had
nal signals of cancer was described as a “lump or an earlier clinical stage as well as a decrease in The result of the past 30 years of “breast aware-
thickening in the breast or elsewhere” [1]. Ever axillary node metastasis [5]. Another study pub- ness” has led to the question of whether monthly
since that time just after World War II, when the lished in the New England Journal of Medicine breast self examinations should continue to be a
focus was turning from public safety to public analysed mortality rates when using both breast “strong” recommendation from the medical com-
health, there has been an active interest in iden- self exams and clinical exam (CBE) techniques. munity. The breast is no longer a “hidden organ”
tifying the most effective means for early identifi- The analysis suggested that mortality rates would and empowered women are now acting as their
cation of breast cancers. The importance of early decrease by 18.8% and 24.4% with regular breast own advocates by performing breast exams or per-
identification cannot be understated as breast self exams and clinical breast exams, respectively haps becoming more “aware” of breast changes that
cancer remains a prevalent disease internationally. [6]. Support for the increased awareness of breast occur over time. Recently the United States Pre-
cancers and the potential importance of BSE ventive Services Task force (USPSTF), established
Worldwide, more than 1.3 million women were came from the work of Cady documenting the in 1984 to prevent premature death in citizens
diagnosed with breast cancer in 2007, with more decrease in size of presenting breast cancers over below the age of 65, has issued its current recom-
than 400,000 dying of the disease in that year [2]. 60 years in a single Boston hospital. Between 1949 mendations on breast cancer screening [17]. This
In the United States alone, an estimated 192,000 and 1984, the mean tumour diameter of a breast group has performed an extensive meta-analysis of
cases of invasive breast cancer per year are diag- cancer decreased from 3.4 to 2.3, this occurring national and international trials on screening tech-
nosed with another 62,000 cases of in situ or Stage prior to the mass introduction and availability of niques. Mammography, despite its false positive rate
0 cancer undergoing treatment. The most notable screening mammography [7]. and increased radiation risk with additional films,
risk factor for breast cancer remains age. Between remains a key screening methodology for women
the years of 2002 and 2006, women under the age Screening tools: mammography aged 40 to 69 and continues to show effectiveness
of 24 had the lowest incidence of breast cancer in In both the United States and Western Europe, in reducing mortality from breast cancer.
the United States (1.4 per 100,000), while women screening mammography or plain film evaluation
aged 75-79 years had the highest incidence of of the tissues and structures of the breast became Breast Self Examination, however, has been
breast cancer (441 per 100,000) [3]. Additional risk much more prevalent in the 1980s. Since that time removed from both the ACS and USPSTF
factors include early age at menarche, late age at multiple randomized clinical trials and observa-
menopause, nulliparity or late age at first birth, and tional studies have validated the importance of
a family history of breast cancer [4]. The majority of this screening tool in identifying breast cancer at
women with breast cancer however have minimal earlier stages and in reducing the mortality from
risk factors for the disease and therefore national this disease [8,9]. Variability exists in the cur-
and international efforts to identify the most effec- rent utilization of screening mammography in
tive screening tool for breast cancer remain at the the United States but it is estimated that between
forefront of public health efforts. 40 and 75% of women over age 40 undergo this
yearly exam[10].
Screening tools: BSE
One such screening tool that came into promi- With these two screening tests, namely BSE and
nence in the 1970s was Breast Self Examina- Mammography supported by the American Can-
tion (BSE). The literature at that time included cer Society, multiple nonprofit entities moved for-
a study by Foster et al in Vermont, USA, who ward or were established to support the impor-
published an observational trial of 335 patients tance of early detection of breast cancer. The
with breast cancer to assess the relationship Susan G. Komen organization was established
between breast self exams and clinical cancer in 1982 as a heartfelt promise to a lost loved one
 17 – Issue N°7 – Dec. 2009/Jan 2010

screening recommendations and history of premalignant breast detected 43% of the new cancers. “find” their cancers in a not insignif-
is now an optional tool in surveil- lesions, family history or genetic The 6 breast cancers detected by icant number of cases. As we move
lance. The evidence supporting mutations, we prospectively tested breast MRI were not detectable by towards a better understanding of
this change comes primarily from whether BSE should still be recom- BSE, CBE, or screening mammog- breast cancers and its heterogeneity
three international clinical studies mended for breast cancer surveil- raphy. These findings demonstrated and the need for individualizing care,
of BSE, as well as a meta-analysis lance in patients undergoing yearly the potential synergy of combined BSE remains the only noninvasive,
of observational and clinical trials breast MRI and mammography. We BSE and imaging in screening high- low cost tool for women, especially
of BSE [18-21]. The largest of the found that BSE detected 6 new inva- risk women. Notably, a recent study those at high risk for developing the
trials was performed with 266,000 sive breast cancers and one atypical from Harvard, found that 71% of malignancy to help in the identifica-
women from Shanghai, China; the lesion, representing 46.6% of the women diagnosed with breast can- tion of their cancers. As technology
trial randomized women aged 31-64 abnormalities detected in the 3 year cer at age 40 or younger discovered improves, perhaps a more specific
to a program of BSE instruction and time period. During the same time their breast cancers by BSE [26]. and sensitive test will emerge that
competency versus a control arm. interval, mammography identified Most physicians involved in the can replace BSE, CBE and mammog-
After 11 years of follow-up the study 14% of the malignancies
IHEurJunPage:DI and breast
Europe routine
10/12/09 care Page
14:25 of women
1 with breast raphy, but until that time these tools
found no significant difference in Magnetic Resonance Imaging (MRI) cancer will report that women do will remain in the armamentarium
the mortality rate of women in the
BSE and control groups [18]. One of
the primary criticisms of the Shang-
hai trial is that BSE was used as the
only tool for breast cancer screen-
ing; mammography, either screen-
ing or diagnostic, was not available
to this population of women from
China [22]. In the United States the
mortality rate from breast cancer
has been decreasing 2.3% per year
from 1990 to 2001. Though this is
in part due to improved, individual-
ized therapies and a maximal level
of resources, screening programs are
also believed to play a role in this
mortality reduction [23]. Screen-
ing for breast cancer in the United
States since the late 1980s has not
included BSE in isolation; rather it
has been performed in conjunction

Mark the course

with imaging modalities and clini-
cal breast examination (CBE). The
Breast Health Global Initiative 2005
Guidelines report that in a devel-
SEE US AT ECR 2010 FOR HANDS ON MAMMOGRAPHY EXPERIENCE
oped society such as the US, popu-
lation based mammograms remain Try your hand at reading and manipulating digital mammography cases at our ECR Digital
© Carestream Health, Inc. 2009. CARESTREAM is a trade mark of Carestream Health, Inc.

the primary screening method [23]. Mammography Self-Assessment Workshops.

Vetto and Kearney both indicate that The workshops will be facilitated by eminent clinicians Roland Holland, MD, PhD, from
the National Expert and Training Centre for Breast Cancer Screening, Radboud University
increased breast awareness through
Medical Centre, Nijmegen and Ulrich Bick, MD, Department of Radiology, CCM,
early support of BSE, however, led Charité-Universitätsmedizin, Berlin.
to this current societal acceptance Participants may register for up to seven one-hour sessions. Each session starts with an
of mammography and continues to introduction that includes the learning objectives, the method of reading and self-assessment.
Participants will have 45 minutes to read the cases, then assess their own number of false
highlight the co-dependance of the positives and false negatives, and discuss the cases with the medical experts. Each module
two modalities [22,23]. For exam- contains 30 selected screening mammography cases with a mix of biopsy proven positives
ple, in a retrospective cohort study and negatives. The modules are independent of each other and do not need to be
completed sequentially.
of 27,421 women from the Pacific
Participation is limited and early registration is advised.
Northwest, women who reported
more frequent BSE and perceived Visit [Link]/ecr
quality of BSE were more likely to for details of how to register on-line.
have diagnostic mammograms [24]. Let Carestream Health give you a hand at ECR.
Recently our Mulitdisciplinary
Breast Wellness group at Duke
Univeristy published our data on
BSE for patients at high risk for ECR
V EN
VI NNA
NA A
AUS
USTR
TR
TRIA C
CENTRE EXPO B

the development of breast cancer

[25]. In this study of 147 women
Comments on this article?
Feel free to post them at
at high risk for the development of
[Link]/comment/xxxxxxxxx
breast cancer based either on prior
[Link] & search 45473
 – Issue N°7 – Dec. 2009/Jan. 2010 18 Women’s health

of physicians and their patients to try and identify update for the U.S. Preventive Services Task Force.
FRONT COVER PRODUCT breast cancer at its earliest stages. Ann Intern Med. 2009;151:727-37
18. Thomas DB et al. Randomized trial of breast self-
Effective and gentle self-treatment for References examination in Shanghai: final results. J Natl Cancer
women following pelvic radiotherapy 1. [Link] Inst. 2002;94:1445-1457.
Around 40% of acs_history.asp 19. UK Trial of Early Detection of Breast Cancer Group.
women diagnosed 2. [Link] 16-year mortality from breast cancer in the UK trial
with a gynaecologi- Facts_and_Figures_2007_rev2.pd of early detection of breast cancer. Lancet. 1999; 353:
cal malignancy will 3. Horner MJ et al. eds. SEER Cancer Statistics Review, 1909-14
receive radiation as 1975-2006. National Cancer Institute. Bethesda, MD, 20. Semiglazov VF et al. Interim results of a prospec-
part of their treat- posted on [Link] tive randomized study of self-examination for early
ment. One effect of 4. Tchou J and Morrow M. Available Models for Breast detection of breast cancer (Russia/St. Petersburg/
this treatment can Cancer Risk Assessment: How Accurate Are They? WHO). Voprosy-onkologii. 1999; 545: 265-71.
be altered sexual JACS 2003; 197: 1029-1035. 21. Hackshaw AK, Paul EA. Breast Self-examination
functioning and 5. Foster RS et al. Breast self-examination practices and and death from breast cancer: a meta-analysis. Br J
partner relations. breast-cancer stages. N Engl J Med, 1978; 299: 265- of Cancer. 2003; 88: 1047-53.
It is common for 270. 22. Kearney AJ, Murray M. Evidence Against Breast Self
women to experience some adhesions to the 6. Greenwald P et al. Estimated effect of breast self- Examination is not Conclusive: What policymakers
treated area after radiotherapy, which can make examination and routine physician examinations and Health Professionals Need to Know. J of Public
the vagina narrower, drier and less elastic. Pre- on breast-cancer mortality. N Engl J Med, 1978; 299: Health Policy. 2006; 27: 282-94.
venting the formation of scar tissue within the 271-273. 23. Vetto JT. Teaching Breast Self-Examination: A Tale
vagina helps ensure that it remains supple so 7. Cady B, Stone MD, Wayne J. New Therapeutic Possi- of Two Cities. J Cancer Educ 2006; 21: 115-116.
that coitus and medical vaginal examinations bilities for Primary Invasive Breast Cancer. Ann Surg 24. Tu S et al. Breast Self-Examination: Self-Reported
are not painful. 1993; 218: 338-349 Frequency, Quality, and Associated Outcomes. J
Designed in conjunction with the UK National 8. Tabar L et al. Mammography service screening and Cancer Educ. 2006; 21: 175-181.
Forum of Gynaecological Oncology Nurses mortality in breast cancer patients: 20-year follow-up 25. Wilke LG et al. Breast self-examination: defining a
(NFGON), Amielle Care vaginal dilators help before and after introduction of screening. Lancet. cohort still in need. Am J Surg 2009; 198: 575-579.
women take an active role in their recovery Apr 2003; 361:1405-1410 26. Srila Samphao et al. Diagnosis of breast cancer in
following radiotherapy to the vagina, cervix or 9. Duffy SWet al. The impact of organized mammog- women age 40 and younger: delays in diagnosis
pelvis. By using Amielle Care regularly (mini- raphy service screening on breast carcinoma mortal- result from underuse of genetic testing and breast
mum three times weekly), women themselves ity in seven Swedish counties. Cancer. Aug 2002; 95: imaging. Am J Surg. 2009 Oct;198:538-43.
can gradually help reduce the risk of scarring 458-469
by keeping the vaginal wall supple, and can be 10. Behavioral Risk Factor Surveillance System Public The authors
confident about recommencing sexual rela- Use Data 2006, National Center for Chronic Disease Lee Gravatt Wilke, MD FACS
tions. The device consists of four graduated Prevention and Health Promotion, Centers for Dis- Associate Professor of Surgery
cones with universal handle and a water-based ease Control and Prevention, 2007. Duke University Medical School
lubricant, all of which are presented in a dis- 11. [Link] and Health System
creet bag. 12. [Link] Durham, NC USA
13. [Link]
Owen Mumford Ltd 14. [Link] Jennifer Gallagher
Woodstock, Oxon, UK 15. [Link] Research Associate
[Link] & search 45502 16. [Link] Duke University Health System
17. Nelson HD et al. Screening for breast cancer: an Durham, NC, USA

Comments on this article?

Feel free to post them at
[Link]/comment/xxxxxxxxx
 women’s health 19 – Issue N°7 – Dec. 2009/Jan 2010

Changing the guidelines on

mammography screening
One of the main talking points at the recent annual meeting
Breast Cancer
of the RSNA held in Chicago at the beginning of December Mammography Screening
was the recent publication from the U.S. Preventive Services
New USPTF conclusions
Task Force (USPSTF) of revised screening mammography
guidelines, proposing that mammography screening should • Screening recommended to begin at age 50 for most women.
be carried out less often and starting at a later age. At one •Thereafter screening only every two years.

level, this is an affair that seems to affect only the United States • No screening after age 75
• No benefit shown for clinical breast examination or breast self-examination.
since, in Europe, the situation regarding recommendations • False positive results and need for additional imaging are common
on mammography screening is much more disparate than in
America. In Europe, different countries have different guidelines, Table 2. The recently published guidelines for US mammography screening [1].

recommendations and re-imbursement policies. However, the biopsy. Biopsy techniques vary in the health policy and public health. The
fact is that any conclusions drawn about the pros and cons of level of invasiveness and amount of necessary qualifications for serv-
mammography screening based on the vast US database have tissue acquired, which affects yield ing on the USPSTF are a knowl-
direct relevance to Europe. We report here on the background and patient experience. edge and experience in the critical
to the controversy and on the reaction of a select RSNA panel evaluation of research published
The USPSTF in peer-reviewed literature and in
of experts in mammography who did not hide their negative
The United States Preventive Serv- the methods of evidence review.
response to the proposed new guidelines. ices Task Force (USPSTF) is a panel The members should be expert in
of outside experts that is charged disease prevention and health pro-
with making evidence-based rec- motion and have clinical expertise
The clinical background and acceptable to most women. It is ommendations to both the public in the primary health care of chil-
Breast cancer is the most frequently carried out by using either plain film and the health care community dren or adults. Crucially, there is no
diagnosed noncutaneous cancer or digital technologies, although the regarding the provision of clinical breast cancer screening expert cur-
and the second leading cause of shift to digital is increasing. Con- preventive services. The mission of rently serving on the USPSTF.
cancer deaths among women. The trast-enhanced magnetic resonance the USPSTF is to produce evidence- The current USPSTF recommen-
incidence increases with age and imaging (MRI) has traditionally based recommendations on the dations for mammography screen-
the probability of a woman devel- been used to evaluate women who appropriate screening, counselling ing are shown in Table 1. The new,
oping breast cancer is 1 in 69 in her have already received a diagnosis of and provision of preventive medica- recently published guidelines [1]
40s, 1 in 38 in her 50s, and 1 in 27 breast cancer. Recommendations for tion for asymptomatic patients who are shown in Table 2.
in her 60s [1]. Data suggest that the its use in screening apply to certain are seen in the primary care setting.
incidence of breast cancer in the US high-risk groups only. If a woman There are currently 16 members on Radiologists respond.
and in the developed world has sta- has an abnormal mammographic the USPSTF, with expertise in the A panel of radiologists, expert
bilised in recent years and mortality finding on screening or a concern- fields of primary care, epidemiology, in mammography got together
has decreased since 1990 thanks to ing finding on physical examination,
many factors, including screening additional imaging and biopsy may EXPERIENCE THE SUPERIORITY
[2]. In 2005, 68% of women aged 40 be recommended. Such additional of high-performance defibrillator & monitor
to 65 years had screening mammog- imaging may consist of diagnostic
raphy within the previous 2 years in mammography or mammography
RESCUE LIFE
the United States. done with additional or special THE DEFIBRILLATOR
Breast cancer is known to have an views, targeted breast ultrasonog-
asymptomatic phase that can be raphy, or breast MRI. Additional
detected with mammography. Mam- imaging may help classify the
mography screening is sensitive lesion as a benign or suspicious
(77% to 95%), specific (94% to 97%), finding to determine the need for

Breast Cancer
Mammography Screening
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Existing US recommendations

2010 - DUBAI
• Annual screening recommended to begin at age 40 for most women, Medical Equipment Solutions ZABEEL HALL ITALIAN
with or without clinical breast examination (CBE). PAVILLON ZZ C30
• Insufficient evidence to decide for or against routine breast self-examination [Link]

Table 1. The current guidelines for US mammography screening

[Link] & search 44951
 – Issue N°7 – Dec. 2009/Jan. 2010 20 women’s health

early 1980s. Perhaps reflecting this, the number References

Statistically signifcant mortality reduction of women aged 40 and older who actually fol- 1. Nelson, HD et al Screening for breast cancer: an
from single randomised controlled trials of lowed the old recommendation on mammogra- update for the US preventive task force. Ann Intern
mammography screeing of women age phy screening has risen from 29% in 1987 to 70% Med. 2009 ;Nov 17;151(10):727-37, W237-42.
40 - 49 at entry in 2003. Several randomised trials, including 2. Edwards BK et al Annual report to the nation on
European studies [3,4] were presented as proof the status of cancer, featuring population-based
Trial Mortality of the benefits of initiating screening in women trends in cancer treatment. J Natl Cancer Inst.
reduction
between the age of 40 and 50 [Table 3]. 2005; 97:1407.

Gothenburg 45% Turning to the points raised by the USPSTF 3. Bjurstam N et al. The Gothenburg breast screen-
regarding the potential radiation risk caused by ing trial: first results on mortality, incidence, and
Malmo 36% mammography screening, the panel of mam- mode of detection for women ages 39-49 years at
mography experts quoted recent studies by randomization. Cancer 1997 Dec 1;80(11):2091-9.
the US National Council on Radiation Protec- 4. Andersson, I & Janzon L. Reduced breast cancer mor-
Table 3. Many randomised controlled trials from tion and Measurements which showed that at tality in women under age 50: updated results from
Europe, including the so-called Gothenburg [3] and
the Malmö Mammographic Screening Program.
Malmo [4] were cited as proof of the advantages
J Natl Cancer Inst Monogr 1997;(22):63-7.
in reducing breast cancer mortality by screening in “... screening mammography is 5. National Council on Radiation Protection and
women under 50 years of age.
one of the great women’s health Measurements “A guide to mammography and
at the recent RSNA meeting to refute the new other breast imaging procedures” NRCP report no
guidelines. The panel comprised: success stories of the last couple 149, 2004
• Dr Phil Evans, Director, Center for Breast Care,
University of Texas Southwestern Medical
of decades ...”
Center and President, Society of Breast Imaging
•D  r Stephen A. Feig, Professor of Radiology, Uni-
Comments on this article?
versity of California Irvine School of Medicine and Prof. D.B. Kopans, Harvard Feel free to post them at
[Link]/comment/mammo
President-Elect, American Society of Breast Disease
Medical School
• Dr Daniel B. Kopans, Senior Radiologist, Breast
Imaging Division, Massachusetts General
Hospital and Professor of Radiology, Harvard current mammography radiation doses, even a Breast PET scanner
Medical School. 1% reduction in mortality confers more benefit
than the risk of the screening procedure itself
The principal point that the panel made was that [5]. Since the actual mortality reduction is of
the new guidelines were not based on scientific the order of 40 % the benefits far outweigh the
evidence. Most importantly, according to many theoretical radiation risk. As for the psycho-
experts, the guidelines would actually cause logical stress caused to the patient as a result
unnecessary deaths. In fact the panel presented of the level of false positives which required a
screening mammography as being one of the recall for further investigation or in extreme
great women’s health success stories of the last cases, even a biopsy, the panel admitted that
couple of decades. The reduction in mortality screening mammography was not perfect but
from breast cancer in women who were screened pointed out that the real stress occurred with The MAMMI Breast PET system is a scan-
annually is actually between 40 and 50% so that women who had not had screening and who ner dedicated to the early detection of breast
today the average patient with invasive cancer is unfortunately realised that they had potentially cancer and treatment follow up. Thanks to
39% less likely to die from her disease than in the lethal breast cancer. its spatial resolution and image contrast,
the system makes it possible to visualise
breast cancer tumours at early stages. In
addition the progress of chemotherapy or
radiotherapy treatments can be followed.
The MAMMI system does not require any
breast compression as with X-ray examina-
tion. Indeed, the acquisition is carried out
in the prone position and the 3D images
are accurately quantified and with charac-
teristic PET effects corrected. The hanging
breast device makes the examination com-
fortable for the patient. The ring detector
allocates 12 modules each using a single
continuous crystals and a position sensitive
photomultiplier. Acquisition times are about
5 minutes per frame.

Oncovision Gem Imaging

Valencia, Spain
[Link] & search 45507
 women’s health 21 – Issue N°7 – Dec. 2009/Jan 2010

A selection of peer-reviewed literature on

women’s health
The number of peer-reviewed papers covering the vast field of physical activity returned to base- The “Acupuncture on Hot
women’s health is huge, to such an extent that it is frequently line levels; however, self-worth Flashes Among
difficult for healthcare professionals to keep up with the and body mass index significantly Menopausal Women”
improved. Women were more study: observational
literature. As a special service to our readers, IHE presents
knowledgeable about physical follow-up results at 6
a few key literature abstracts from the clinical and scientific activity at follow-up; however, and 12 months.
literature chosen by our editorial board as being particularly they failed to maintain physical by EK Boroud et al.
worthy of attention. activity after the intervention. To Menopause Dec 2009
enhance long-term physical activ- The previously published “Acu-
ity adherence, continued research puncture on Hot Flashes Among
Estrogen therapy and these cholinergic projections; and intervention modifications Menopausal Women” study
cognition: a review of the however, studies also suggest that are needed. compared the effectiveness of
cholinergic hypothesis. the effectiveness of estrogen ther-
by GB Gibbs apy decreases with age and time
Endocr. Review Dec 2009 after loss of ovarian function. The
Hall: Sheikh Saeed
author proposes a model in which Stand: AC15
deficits in basal forebrain cholin-
ergic function contribute to age-
related changes in the response
to estrogen therapy. Based on
this model, it is proposed that
cholinergic-enhancing drugs,
used in combination with an
appropriate estrogen-containing
The pros and cons of estrogen drug regimen, may be a viable
therapy for use in postmeno- therapeutic strategy for use in
pausal women continue to be a older postmenopausal women
major topic of debate in wom- with early evidence of mild
en’s health. Much of this debate cognitive decline.
focuses on the potential benefits
vs. the harm of estrogen therapy Women bound to be
on the brain and the risks of active: one year follow-up
cognitive impairment associated to an innovative pilot
with aging and Alzheimer’s dis- intervention to increase
ease. Many animal and human physical activity and
studies suggest that estrogens can self-worth in women.
have significant beneficial effects by JL Hubert, et al.
on brain aging and cognition and Women’s Health 2009; 49(6): 522.
reduce the risk of Alzheimer’s- The purpose
related dementia; however, others of the study
disagree. Important discoveries reported in
have been made, and hypotheses this paper
have emerged that may explain was to assess
some of the inconsistencies. This the effec-
review focuses on the cholinergic tiveness of
hypothesis, specifically on evi- a lifestyle
dence that beneficial effects of intervention
estrogens on brain aging and cog- (a women’s
nition are related to interactions book club;
with cholinergic projections ema- Women Bound to be Active) in
nating from the basal forebrain. promoting long-term physical
Evidence suggests that many of activity. Thirty-five women (26-
the effects of estrogens on neu- 70 years; mean age 50.6 years)
ronal plasticity and function and completed the 8-month inter-
cognitive performance are related vention and participated in the
to or rely upon interactions with one-year follow-up. At follow-up, [Link] & search 45277
 – Issue N°7 – Dec. 2009/Jan. 2010 22 women’s health

experiencing, on average, 12.6 hot acupuncture group and 5.8 in the

flashes per 24 h. The acupuncture control group, a nonsignificant
group received 10 individualized difference of 0.2. Differences in
acupuncture treatments during quality-of-life scores were not
12 weeks and advice on self- statistically significant at 6 and
care, whereas the control group 12 months. The statistically sig-
received only advice on self-care. nificant differences between the
Hot flash frequency and inten- study groups found at 12 weeks
sity (0-10 scale) and hours of were no longer present at 6 and
individualized acupuncture sleep per night were registered 12 months. The study showed
treatment plus self-care versus in a diary. Health-related qual- that acupuncture can contrib-
self-care alone on hot flashes ity of life was assessed by the ute to a more rapid reduction
and health-related quality of life Women’s Health Questionnaire. in vasomotor symptoms and
in postmenopausal women. This From baseline to 6 months, the increase in health-related qual- 74,942 Chinese women. A time-
paper reports on the observa- mean reduction in hot flash fre- ity of life in postmenopausal dependent interaction between
tional follow-up results at 6 and quency per 24 hours was 5.3 in women but probably has no green tea consumption and age
12 months. The study was a prag- the acupuncture group and 5.0 long-term effects. of breast cancer onset was found
matic, multicenter randomized in the control group, a nonsig- (p for interaction, 0.03). In com-
controlled trial with two paral- nificant difference of 0.3. At 12 Is green tea drinking parison with non-tea drinkers,
lel arms. The 267 participants months, the mean reduction in associated with a later women who started tea-drinking
were postmenopausal women hot flash frequency was 6.0 in the onset of breast cancer? at 25 years of age or younger had
Q Dai et al.; a hazard ratio (HR) of 0.69 to
Ann Epidemiol 2010 Jan; 20(1): 74 -81 develop premenopausal breast
Studies have found that tea cancer. On the other hand, com-
polyphenols inhibit aromatase. pared with non-tea drinkers,

The 7th Annual

Because of the substantial differ- women who started tea drink-
ence in levels of estrogens between ing at 25 years of age or younger

World Health
premenopausal and postmeno- had an increased risk of post-
pausal women, the relationship menopausal breast cancer with
between tea consumption and an HR of 1.61. Additional analy-

Care Congress
breast cancer risk may depend on ses suggest regularly drinking
menopausal status. The authors green tea may delay the onset
examined this hypothesis in the of breast cancer but that further
Shanghai Women’s Health Study, a studies are needed to confirm
April 12-14, 2010 population-based cohort study of the findings.
Gaylord National Resort and Convention Center
Washington, DC
Carestream Health Offers Free Hands On
Mammography Experience at ECR 2010
Preliminary Agenda Features
During the upcoming European Congress of Radiology (ECR 2010) to be
Emerging Themes Including: held in Vienna, Austria on March 4 - 8, Carestream Health will be running
a series of free Digital Mammography Self-Assessment Workshops to help
Employer Incentives and Prevention healthcare professionals acquaint and train themselves in digital mammog-
for Improved Productivity raphy [Link] workshops will be facilitated by the eminent clinicians
Roland Holland MD, PhD from the National Expert and Training Centre for
New Models for Health Plan, Breast Cancer Screening, Radboud University Medical Centre, Nijmegen, The
Hospital and Health System Netherlands and Ulrich Bick, MD, Department of Radiology, CCM, Charité-
Universitätsmedizin, Berlin, Germany.
Collaboration Participants may register for up to seven one-hour sessions. Each ses-
sion starts with an introduction that includes the learning objectives, the
Implications of Health Reform on All
method of reading and self-assessment. Participants will have 45 minutes
Sectors in Health Care to read the cases, then assess their own number of false positives and false
negatives, and discuss the cases with the medical experts. Each module
Meaningful Use and the Deployment
contains 30 selected screening mammography cases with a mix of biopsy
of Health IT proven positives and negatives. The modules are independent of each
other and do not need to be completed sequentially.

To register, please call 800-767-9499. To learn more, please Participation is limited and early registration is advised. Visit
visit [Link] [Link] for details of how to register on-line.

Carestream Health
Rochester, NY, USA
Women’s health: NEWS in brief 23 – Issue N°7 – Dec. 2009/Jan 2010

Protein from pregnancy hormone may prevent breast cancer undiagnosed on static MRI and at physical examination. Pelvic organ
Researchers have found prolapse is relatively common and occurs when the pelvic floor muscles
that hormones produced become weak or damaged and can no longer support the pelvic organs. If
during pregnancy induce a left untreated, living with prolapse can be a challenge, both physically and
protein that directly inhib- emotionally, as the symptoms can
its the growth of breast disrupt day-to-day life. Dynamic
cancer. This protein, alpha- MRI is carried out while the patient
fetoprotein (AFP), may performs a straining maneuver, such
serve as a viable, well-tol- as bearing down. A study performed
erated agent for the treat- at NYU Langone Medical Center in
ment and prevention of New York, USA included 84 women
breast cancer, according to with lower urinary tract symptoms
findings published in Cancer Prevention Research, a journal of the American who underwent dynamic and static
Association for Cancer Research. MRI scans for a suspected urethra
Recent studies have shown that hormones released during pregnancy, such as abnormality. Ten of the 84 patients
oestrogen, progesterone and human chorionic gonadotropin, reduce a women’s were found to have an abnormality
risk for breast cancer. AFP is a protein normally produced by the liver and yolk of the urethra. However 33 patients
sac of the foetus. A study lead by Dr Herbert Jacobson, who is a basic breast were diagnosed with pelvic organ
The image above is an example of
cancer researcher at Albany Medical College, USA sought to determine whether prolapse, of whom 29 were diagnosed dynamic MR imaging of pelvic
administering pregnancy hormones to carcinogen-exposed rats led them to exclusively
ANNONCE 101on dynamic imaging.
X 178:ECM 11/12/09 18:31 organ Pageprolapse:
1
produce AFP, which in turn produces the protective effect of pregnancy in the [Link] ( [Link]
absence of pregnancy. Results from this study showed that treatment with oes-
trogen plus progesterone, oestrogen alone or human chorionic gonadotropin
reduced the incidence of mammary cancers in rats. Furthermore, the research-
ers noted that each of these treatments elevated the serum level of AFP and Manufactured
that AFP directly inhibited the growth of breast cancer cells growing in culture, in France
by
suggesting that these hormones of pregnancy are preventing breast cancer
through their induction of AFP. Noveko International Inc.

[Link]

Study shows antibiotic unsuccessful in preventing New color doppler

preterm labour
The antibiotic azithromy-
ultrasound scanner
cin is effective in treat- • Fully digital
ing infections such as • Powerful
syphilis, Chlamydia and • Easy to use
Ureaplasma urealyticum, • Exceptional image quality
which are thought to • Post Processing
play a significant role in • 4D option
causing preterm labour.
Recent studies have also
shown that the drug is
effective in reducing the
risk of miscarriage following amniocentesis. The drug is currently used to treat
infection in patients all over the world, but has not been previously tested on
pregnant women at high risk of preterm labour. Researchers at Liverpool Uni-
[Link]

versity, UK investigated how effective the antibiotic could be in women in South-

ern Malawi, where one in five babies are born prematurely. Women living in this
ARAB HEALTH
region are also at high risk of sexually transmitted infections and other diseases, STAND ZS 11
which may have a significant impact on labour and the long-term development
of a foetus. In a study of 2,000 pregnant women, half were treated with the oral CONTACT US
antibiotic and half were treated with placebo drugs. It was found that the antibiotic FOR
made no significant difference to the outcome of the pregnancies between the two DISTRIBUTION
groups of women. The drug was effective in treating infection, but a high number
of women still went on to experience preterm labour. The findings suggest that
[Link]

infection may not be the primary cause of preterm birth and other treatments
should be investigated. A high number of women with infection still went on to
experience preterm labour. The study suggests that it is important to investigate
other factors, apart from infection to determine the cause of preterm labour.
[Link]/better-births 126, Boulevard de la République
16000 ANGOULEME - FRANCE
+33(0) [Link]
Dynamic MRI identifies pelvic organ prolapse Noveko International Inc.
E-mail : ecm@[Link]
In women with lower urinary tract symptoms, dynamic MRI allows
clinicians to diagnose pelvic organ prolapse — a condition that often goes
[Link] & search 45414
 – Issue N°7 – Dec. 2009/Jan. 2010 24 Urology

Optimising outcomes in the modern era

of shockwave lithotripsy
Shockwave lithotripsy (SWL) remains the least invasive treatment modality for of patients with renal stones respectively less
renal and ureteral stones. Other management options for renal stones include than 10mm, 11-20mm and greater than 20mm
observation (with intervention if symptoms develop), ureteroscopic stone extraction being rendered stone free. It is generally thought
that for stones less than 20mm in diameter, SWL
and percutaneous stone extraction. Management alternatives for ureteral stones
is the first line treatment option, whilst recog-
include medical expulsive therapy, ureteroscopy and, rarely, percutaneous nising that more than one SWL session may
extraction. In brief, SWL involves the production in a generator of shockwaves be required, and that it may take several weeks
which are focused on a stone within the kidney or ureter. Numerous adaptations to to pass the fragments created. Stones that are
the equipment itself, the methods of patient selection, treatment and follow-up have known to be of hard composition such as cys-
been developed since the introduction of SWL into clinical practice in the early tine, brushite and calcium oxalate monohydrate
may be best treated by another modality. It may
1980s. This article reviews the current status of SWL therapy.
be difficult to know, however, what type of stone
the patient has unless a history of cystine stones,
by Dr T. Schuler or known hard compositions from previous
stone events, can be elucidated.

Basics of shockwave lithotripsy begin with a review of absolute contraindica- Stone location deserves special mention, par-
Shockwave lithotripters serve to fragment renal tions to SWL, which include pregnancy, the ticularly stones within the lower pole of the
and ureteral stones sufficiently such that the presence of distal urinary tract obstruction and kidney. The lower pole study group compared
patient will pass the fragments spontaneously, patients who are anticoagulated or having bleed- SWL and percutaneous stone removal for lower
without the need for more invasive therapy, ren- ing diatheses. Relative contraindications include pole stones and found stone free rates of 37%
dering them stone and symptom-free. Shock- proximity of the stone to be treated to abdomi- and 95% respectively for stones measuring
waves are generated by electrohydraulic, electro- nal or renal aneurysms, morbid obesity, uncon- 11-20mm in diameter. In a follow-up study, the
magnetic or piezo-electric systems, depending trolled hypertension and patients whose body group found no difference between SWL and
on the design of the lithotripter and are propa- habitus precludes adequate positioning to target ureteroscopy with respect to stone-free rates
gated through the patient where they are focused the stone. for lower pole stones of less than 10mm. SWL
on the stone. The stones are targeted by means of was however favoured from the point of view of
fluoroscopy or ultrasonic imaging. Patient factors patient acceptance and convalescence compared
Patient factors which may contribute to poor to the more invasive ureteroscopic approach.
The origin of clinical SWL was with the Dornier outcomes with SWL include obesity and the Methods to improve fragment clearance from
HM3 lithotripter. Although very powerful, this distance of the skin to the stone. Obesity has the lower pole will be discussed in further detail
instrument was cumbersome in that patients been reported as an independent predictor of later. With respect to ureteral stones, recent
were required to be submerged in a water bath SWL failure on multivariate analysis of series. jointly developed guidelines of the EUA and
in order to couple the shockwaves to the soft tis- More recently, several authors have reported
sue of the patient and, although resulting in an skin to stone distance (SSD), measured by pre-
excellent clinical outcome, its sheer power neces- treatment non-contrast computed tomography,
sitated anaesthesia. More modern lithotripters as being predictive of SWL failure. Published
have been simplified by advances in the coupling data have reported a decrease in success rates
mechanisms that have alleviated the need for when SSD was greater than 10cm and 9cm
water submersion. In addition, they have been in [Link] data may not apply to all
essence “de-tuned” in order to improve patient lithotriptors however, given the differences in
tolerance and eliminate the need for anaesthe- focal zones between machines. Patients with
sia. Typically patients can be treated with intra- congenital renal anomalies such as a horse-
venous sedation. This has led to a reduction in shoe kidney may also have problems passing
the success rates of modern SWL series, but has fragments created by SWL.
increased patient acceptance and satisfaction so
that SWL remains as a reasonable non-invasive Stone factors
treatment option. It is well known that SWL success correlates
with stone burden. Patients with multiple stones
Methods of increasing successful should expect to undergo more than one treat-
outcomes with SWL ment to be rendered stone-free, and therefore
The success SWL can be optimised by careful may be considered for more invasive procedures
patient selection, consideration of stone charac- such as ureteroscopy or percutaneous nephro-
teristics, alteration of treatment parameters and lithotripsy should they desire to be stone free
augmenting fragment passage. with a single treatment. Stone size correlates
A discussion regarding patient selection should with success rates with 79.9%, 64.1%, and 53.7%
 25 – Issue N°7 – Dec. 2009/Jan 2010

AUA recommend SWL as being shockwave energy during treat- meta-analysis revealed a 10.2% slower rates was most significant
superior to ureteroscopy for stones ment. A small clinical study showed weighted risk difference in suc- for stones >100mm2 in a recent
less than 10mm in size within the that step-wise escalation of shock- cess rates in favour of patients study in which larger renal stones
upper ureter, with ureteroscopy wave energy resulted in a significant treated at slower rates. Tradition- treated at 60 shocks per minute
being superior for both stones improvement in overall success rate ally, patients have been treated were successfully treated in 75.7%
in the distal ureter and stones eight weeks post treatment. Addi- with 120 shocks per minute, with of cases compared with 40%
greater than 10mm in size in the tionally, the benefit of priming the recent data suggesting the addi- treated at 120 shocks per minute.
upper ureter. kidney with low energy shockwaves tional benefits of treatment rates The same group from the Uni-
may reduce renal injury induced of 60-90 shocks per minute. This versity of Toronto have recently
More recently, several authors have by shockwaves. does however increase the time published their data demonstrat-
reported on the predictive value of required for treatment, and in ing an improvement in outcomes
Hounsfield Unit (HU) attenuation The rate at which the shockwaves areas with long waiting lists for in a series of exclusively ureteral
of the stone on computed tomog- are delivered during treatment SWL it may negatively impact the stones randomised to treatment at
raphy in predicting the outcome of has also been demonstrated to access to care. Notably, the increase 60 versus 120 shocks per minute.
SWL therapy. A 100% clearance of impact on success rates. A recent in success rate for stones treated at Again the slow treatment group
stones less than 500 HU was noted
compared with 55% for stones
>1000 HU. Further to this, several
authors have reported a signifi-
cant reduction in successful treat-
ments when stone attenuation was
>900 HU.

Treatment parameters
Once the urologist and patient
have elected to proceed with SWL
as a stone management modality, it
is important to optimise the treat-
ment itself in order to achieve the
best possible outcome. As decribed
earlier, the initial method of cou-
pling the shockwaves to the patient
was with emersion in a water bath.
This has largely been abandoned
by the development of dry treat-
8th International Exhibition
ment heads, which have enclosed
on Hospital, Diagnostic,
water cushions that are positioned
against the patient’s skin. The Pharmaceutical,
patient must however be coupled Medical & Rehabilitation
to the water filled cushion. Numer- Equipment & Supplies
ous coupling agents have been
described, with the end goal being
elimination of air bubbles within
the coupling medium. It has been
suggested that optimal results are
achieved by applying 250cc of gel
directly to the treatment head and
subsequently using the inflation of
the water cushion to collapse any 15 - 17 Sept 2010
air pockets. This minimises han-
dling of the coupling medium and Suntec Singapore
the potential for introduction of
air, which scatters the shockwaves.
In order to overcome difficul-
[Link]
ties with coupling, some modern
lithotripters utilise a shallow water
bath. Once coupling is established,
it is important to try to mini- Sponsored by : Held in : Endorsed by : Supported by : For enquiries, please contact : Organized by :

mise patient movement, which

Messe Düsseldorf, organizer of Messe Düsseldorf Asia Pte Ltd
may introduce air and reduce the 3 HarbourFront Place
#09-02 HarbourFront Tower Two
efficiency of coupling. Singapore 099254
Tel : (65) 6332 9620
Fax : (65) 6337 4633 /
Little clinical data exist on the (65) 6332 9655
medicalfair-asia@[Link]
ideal way in which to increase the
[Link] & search 45406
 – Issue N°7 – Dec. 2009/Jan. 2010 26 urology

achieved a significantly higher success rate fragment passage after SWL. It included tri- be discussed with the patient and should be
of 64.9% compared with 48.8%. More stud- als with both renal and ureteral stones and a based on stone factors, patient factors and the
ies are required to determine if the effect variety of medical expulsive agents includ- patient’s expectation of treatment outcome.
of slowing shockwave delivery rates will be ing alpha blockers, calcium channel blockers Once the decision to use SWL has been made,
effective on all types of lithotripters and to and an herbal agent Phyllanthus niruri alone consideration should be given to methods
identify stone and patient characteristics or in combination with an oral corticosteroid. which optimise fragmentation of stones and
that would most benefit from reduction in The analysis revealed a weighted risk differ- their subsequent passage in order to prevent
treatment rate. ence of 17% in favour of MET in addition to the need for additional SWL or more invasive
SWL with respect to treatment success com- therapies.
Augmentation of fragment passage pared to SWL. MET was well tolerated and was
Fragment passage may be augmented by physi- most beneficial for stones greater than 10mm. Further reading
cal treatment to aid in stone passage (mechani- Subsequent this study, further trials have sug- Schuler TD, Shahani R, Honey RJ, Pace KT. Medical
cal percussion, inversion and diuresis [MPID]) as gested the benefit of tamsulosin, an alpha expulsive therapy as an adjunct to improve shock-
well as treatments with medical agents to expel adrenergic blocker, with repect to aiding in wave lithotripsy outcomes: a systematic review and
the fragments (medical expulsive therapy [MET]) fragment passage. meta-analysis. J Endourol 2009; 23: 387-393.
or medications such as postassium citrate to
dissolve fragments. The utility of potassium citrate (60mEq/day A complete bibiography is available from
in divided doses) to aid in reduction of stone the author
The first study to report on MPID was a cross- burden, post SWL has been demonstrated. In
over randomisation of 69 patients who had patients treated with potassium citrate, 44% The author
fragments in the lower pole of the kidney post- were stone free while 56% of patients had a Dr Trevor Schuler,
SWL. Patients were inverted on a treatment stable residual stone burden as opposed to the Assistant Professor , Surgery
table, treated with an intravenous diuretic and control group, of whom only 12.5% became University of Alberta
had their backs percussed with a physiotherapy stone free, 25% had a stone burden that was Off Campus
mechanical chest percussor. This resulted in unchanged and 62.5% had an increase in their Edmonton, AB,
40% of the treatment arm become stone free as stone burden during follow-up. Canada.
compared to 3% in the observation arm. e-mail: ts9@[Link]
Conclusion
The use of medical expulsive therapy to aid Shockwave lithotripsy represents the least Comments on this article?
in the passage of fragments was recently sum- invasive and most tolerable option for most Feel free to post them at
marised in a meta-analysis. This identified urinary calculi. The decision to undergo SWL [Link]/comment/SWL
four studies in which MET was used to aid in versus other stone treatment modalities must
 NEWS IN BRIEF 27 – Issue N°7 – Dec. 2009/Jan 2010

Physiologic factors linked to image people in 2008. Almost 53% of people aged 65 and
quality in MDCT over with diabetes received diabetes test strips by
2008. Sixty-three per cent of patients not receiving
insulin used blood glucose test strips in 2008. In
light of the overall costs and questionable benefits
of blood glucose self-monitoring in many patients,
more focused policy decisions regarding test strips
have been proposed in several jurisdictions accord-
ing to Muhammad Mamdani and coauthors of St.
Michael’s Hospital in Toronto in a study on options health protected. When patients are admitted for
A large multicentre international trial has found to reduce test strip usage. They project that expen- treatment for a heart attack and after being given
that the image quality of multi-detector computed ditures associated with blood glucose self-moni- as much information as reasonable to make an
tomography (MDCT) scans, used for the nonin- toring will exceed $1 billion in Canada and suggest informed decision to consent to a trial of stem
vasive detection of coronary artery disease, can be policy changes could lead to cost reductions. cells they almost always accept. However, several
significantly affected by patient characteristics such [Link] hours later, following successful treatment of the
as ethnicity, body mass index (BMI), and heart rate, heart attack when the patient is approached for
according to a study to be published in the January Poverty greater health burden than consent in full for the main part of the study, they
issue of the American Journal of Roentgenology. smoking or obesity often decline. Prof Mathur suggests that a new con-
The study included 291 patients with coronary artery The average low- tract may be needed between medicine and soci-
calcification and found that, compared with exami- income person loses ety that assumes a default position that says that
nations of white patients, studies of black patients 8.2 years of perfect everyone attending hospital should be involved in
had significantly poorer image quality. Physiologic health, smokers 6.6 medical research, unless they specifically opt out of
factors such as high heart rate, arrhythmia, obesity, years and the obese the process at the time of consent.
and high coronary calcium burden with motion lose 4.2 years, accord- [Link]
continue to limit the diagnostic accuracy of MDCT ing to researchers at
as compared with conventional invasive coronary Columbia Universi- Study shows reduction in ventilator-
angiography. The study is significant because a rel- ty’s Mailman School associated pneumonia (VAP)
evant effect of BMI, heart rate, ethnicity, and breath- of Public Health.
ing artifact on the degradation of image quality was But poverty rates are typically not seen as health
found, according to the lead author of the study, problems. A new study published in the Decem-
Dr Melvin E. Clouse. “The diagnostic ability of any ber 2009 issue of the American Journal of Public
imaging method is directly dependent on image Health, shows that poverty and school dropout
quality,” said Clouse. rates are at least as important a health problem
“With this new knowledge combined with new and as smoking. On average, poverty showed the
advanced CT scanners, we have the potential to greatest impact on health. Smoking was second,
improve image quality of coronary CT angiogra- followed by being a high school dropout, non-
phy, further making the test even more accurate and Hispanic Black, obese, a binge drinker, and unin-
independent of patient characteristics,” he said. sured. Healthy life lost combines both health and Ventilator-associated pneumonia (VAP) is one of the
[Link]/ life expectancy into a single number, sometimes top three infection concerns of clinicians today; it
known as quality-adjusted life years. To analyse may account for up to 60 percent of all deaths from
Self-monitoring of blood glucose the medical and non-medical policies that might health-care-associated infections (HAIs). Approxi-
using test strips is inefficient use of affect population health, the researchers exam- mately 8 to 28 percent of critical care patients develop
health-care resources ined such policy goals as smoking prevention, VAP, which has a mortality rate of 20 to 33 per-
increased access to medical care, poverty reduc- cent. A leading cause of VAP is micro-aspiration of
tion, and early childhood education to provide potentially infectious secretions through gaps in the
policymakers with a sense of how different policy endotracheal tube cuff. The cuff seal is the final barrier
priorities might influence population health. that protects the lungs from aspiration of potentially
[Link] infectious oropharyngeal secretions. A new study pre-
sented at the recent American Society of Critical Care
Should patients be obliged to take Anesthesiologists (ASCCA) meeting in New Orleans
part in research? showed that a significant reduction could be achieved
A leading UK heart stem cell scientist, Professor in the incidence of ventilator-associated pneumonia
Anthony Mathur argues that if people want treat- The study, supported by an educational grant from
Routine self-monitoring of blood glucose levels ment for a heart problem, they should be obliged Kimberly-Clark, was conducted at the Tampa General
by people with type 2 diabetes who are not taking to take part in the research. His experience at Barts Hospital in Tampa, Florida and showed that the use
insulin is an ineffective use of health resources as Hospital, London, UK is based on the conduct of of the Kimberly-Clark MicroCuff ET Tube, a micro-
the modest benefits are outweighed by the signifi- stem cell trials designed for patients brought in as thin cuff designed to reduce micro-aspiration, could
cant cost of test strips, suggest two recently pub- emergencies suffering a heart attack. The possibil- reduce VAP by 61 percent per patient ventilator day.
lished studies from Canada. In Ontario, blood ity of using a patient’s own stem cells to repair the There was also a decrease in the number of ICU days.
glucose test strips were the third largest cost for damage caused by their heart attack could benefit No significant differences were observed in median
the Ontario Public Drug Programs in 2007/08, the thousands of people suffering with this condi- length of hospital stay, median length of mechanical
accounting for $100 million or 3.3% of all drug tion each year. However stringent laws and regula- ventilation or mortality between baseline data and data
expenditures. Usage of test strips increased by tions are in place to ensure that trials of such new collected after use of the new cuff.
almost 250% from 76,320 people in 1997 to 263,513 therapies are carefully conducted and the patient’s [Link]/microcuff.
 – Issue N°7 – Dec. 2009/Jan. 2010
28 on show at Arab Health

Increase in productivity in MRI avoid undesired activation, both devices include a power switch at the side.
Today’s healthcare A mini-USB port allows users to transfer their data (up to 2x60 readings)
environment is increas- to a computer using supplied software.
ingly faced with fewer
staff, and less time. Beurer GmbH
With its advanced RF Ulm, Germany
solution, Siemens has Arab Health Stand ZY10
been able to focus on [Link] & search 45503
the productivity across
the entire MRI work-
flow, and as a result LED-based surgical lights
developed the Day The Dräger Polaris line of medical
optimizing throughput (Dot) engine. Dot multiplies the power of Siemens’ illumination systems represents a
Tim technology, resulting in greater image consistency, improved diagnostic union of innovation and proven
confidence, greater ease of use, and increased productivity. The new gen- technology to give a a source of
eration of Siemens’ Tim (Total imaging matrix) technology and the Dot light that is brilliant, cool, efficient
(Day optimizing throughput) engine are incorporated in the new MAGNE- and economical. High-power LEDs
TOM Skyra 3T scanner. The combination of Tim and Dot delivers patient- last up to 25 times longer than con-
centred care and significantly improves productivity across the entire MRI ventional halogen or gas discharge
workflow. Additional innovations include the Tim Dockable Table for easy lamps while consuming just a frac-
patient preparation outside the scanner room, and an all new coil architec- tion of the energy. This translates
ture incorporating DirectConnect coil design, providing cableless coils for to significant savings for both the
fast and easy set up and higher Signal-to-Noise Ratio (SNR). Consistent, hospital and the environment. The
robust images can be achieved by automating exams, as well as personal- LEDs used in the system will provide approximately 30,000 hours of quality
izing each exam for virtually every patient to better help staff to provide illumination. There are several models in the range. The Polaris 700 features 54
superb, more effective patient care. Dot proposes optimized exam strategies, precision reflectors, each holding two LEDs, to give a total of 108 LEDs. These
requiring only confirmation prior to scanning. Dot adapts to each patient’s are bundled together in 6 separate arrays that move in unison when the central
breath-hold capacity and then links to the best scanning protocol to match. handle is rotated. This reflector array design provides adequate shadow control
Personalized, high-quality exams can be easily reproduced, even when con- and depth illumination. The Polaris 500 is a good choice to expand the perform-
ditions change. Now, every patient gets the same consistent exam every time. ance of the surgical light system. Featuring a total of 60 LEDs the light head
Dot can also be customized easily to reflect the standards of care of each provides additional illumination capacity. The Polaris 500 can be used as single
individual institution. The 70 cm Open-bore design of the MAGNETOM minor surgical light as well as in several combinations. The colour temperature
Skyra can accommodate a large variety of patient sizes, shapes and condi- of both lights is 4,600 K neutral white, giving the surgeon a realistic, detailed and
tions. The super-short magnets allow many studies to be completed with undisturbed view of the operating field. The light beam projected by the LEDs
the patient’s head outside the bore while still supporting a full 50 cm FoV is inherently cool; the thermal energy produced is dissipated by the integrated
(45 cm in z-direction). thermal management system.

Siemens Healthcare Draeger

Munich, Germany Lübeck, Germany
Arab Health Stand 3B30 Arab Health Stand 3B10
[Link] & search 45504 [Link] & search 45505

Blood pressure monitors with touch screen ECG with highly visible LCD
Two new blood pressure moni- The new CardiMax FX-8222
tors have been introduced by the from Fukuda Denshi comes
Germany-based health equip- with a large LCD, which
ment specialist Beurer who has displays a clear ECG wave-
succeeded in combining two of its form. The operation of the
core competencies into one unique unit is carried out through
innovation. A leading producer of the user-friendly function
blood pressure monitors, Beurer keys or via the touch panel.
brings design to a new level with It is possible to save the data
two eye-catching medical devices, in an SD card or in a USB
the BM58 and the BC58. Their memory. Alternatively, the
striking design highlights the system can be connected to
main features while offering a high level of convenience and ease of use. a DMS (Data Management System) via either a wired or wireless network.
By employing touchscreen technology, the designers were able to avoid The system is equipped with a large 6.4 inch Color TFT (640 x 480 dots)
using buttons in favour of a large display with easily readable numbers display. The recording uses 145 mm paper.
and symbols. Thanks to a WHO indicator and an integrated arrhythmia
identification, the upper arm or wrist blood pressure monitors provide Fukuda Denshi
reliable and accurate blood pressure readouts. Both models are oper- Tokyo, Japan
ated via a generously sized touchscreen, whose touch-sensitive surface Arab Health Stand 6D10
responds accurately and provides intuitive control of every feature. To [Link] & search 45506
 on show at Arab Health 29 – Issue N°7 – Dec. 2009/Jan 2010

Advanced imaging for radiology and cardiology

With the introduction
of the Synapse 3D sys-
tem, Fujifilm is entering
the advanced visualiza-
tion field and, by build-
ing on the company’s
core strength in image
processing, is now offer-
ing its own advanced
imaging capabilities
for both general radio-
graphic and cardiovas-
cular applications. The
company has also made other significant enhancements to its Synapse PACS
including the introduction of Synapse communications and new features
to further aid the interpretation of breast imaging studies. The 3D product
offers more than a dozen clinical applications delivering both radiology- and
cardiovascular-specific applications such as 2D, 3D, 4D, virtual ultrasound,
liver analysis, lung analysis, coronary CT/MR analysis and cardiac fusion.
Developed in conjunction with radiologists, cardiologists and surgeons who
performed joint research with engineers, Synapse 3D is integrated into Fuji-
film’s Synapse PACS application – eliminating the need for a 3rd party soft-
ware. The application is enterprise capable, and is available at any workstation
where Synapse PACS is available. Powered by server-based rendering tech-
nology, Synapse 3D enables the radiologist or the technologist to perform
the renderings. Synapse has undergone significant refinements to support
THE INTERNATIONAL eHEALTH,
not only the image and information managements needs of radiology and TELEMEDICINE AND HEALTH ICT FORUM
cardiology departments, as well as other critical care departments including For Education, Networking and Business
oncology, pathology and ophthalmology. The ability to provide both stor-
age and distribution of images throughout the enterprise in both DICOM
and web formats is critical to the integrated healthcare network. Additional
features including smart forwarding and smart pre-fetching functionally
have been added to allow images to flow seamless from and to Synapse PACS
from third-party systems.

Fujifilm Medical systems

Stamford, CT, USA
Arab Health stand 2F10
[Link] & search 45497

4D Ultrasound
The release of the
CTS-8800 from SIUI
looks set to promote
Med-e-Tel is the Meeting place with a proven
the popularisation of
potential for Education, Networking and Busi-
4D ultrasound imag- ness among a global audience of medical and
ing. Through the match care professionals, healthcare institutions,
of 4D ultrasound and patient organisations, industry representatives,
B&W imaging, users researchers, educators and government agen-
cies.
of the new system can
obtain 4D ultrasound JOIN US AT THE 8TH ANNUAL MED-E-TEL IN
imaging function at LUXEMBOURG AND EXPAND YOUR GLOBAL TELE-
the price of a B&W MEDICINE AND eHEALTH NETWORK!

[Link]
ultrasound, instead of paying for an expensive high-end colour Doppler. In
contrast to the complicated operation of traditional 4D ultrasound imaging,
the CTS-8800 is simple and easy to use, so that in just a few simple steps high
quality 4D ultrasound images can be easily obtained.
Partners: Venue:

SIUI
Shantou, Guangdong, China
Arab Health stand SAJ39
[Link] & search 45496
 – Issue N°7 – Dec. 2009/Jan. 2010
30 on show at Arab Health

Portable ultrasound system exam, but allows the addition of interventional

Designed using capabilities to further extend its clinical value.
the latest tech- The Senographe Essential e has the largest active
nology suitable field of view available, enabling fast and efficient
for use in the imaging of nearly any sized woman. The ergo-
medical envi- nomic design allows fast and comfortable posi-
ronment and tioning to promote patient comfort and clinical
equipped with efficiency. As a digital system, the Senographe
a large range provides outstanding image quality with dose
of wide-band efficiency, minimizing re-takes to help promote
probes (convex, patient safety and provide a smooth workflow.
micro-convex, Bringing higher resolution at the time of acqui-
endo-cavity sition has been a key need for screening and height adjustment and the most useful combi-
and linear), the exaGo ultrasound system offers diagnostic breast imaging centres. Many tech- nations of these movements. The table can be
exceptional image quality and is suitable for all nologists currently use 1 MP monitors when instantly returned to its starting position, be
applications. Thanks to the wide-band probes, the acquiring mammography images to confirm levelled or be moved to four easily programmed
new instrument provides the benefits of variable positioning and check the images for quality memory positions. The patient anatomy can
frequency technology in optimising the details of standards before they are sent to the radiologist. be positioned relative to the C-arm with new
the tissues observed during examination. Com- The radiologist may need additional views after precision and speed. Using the innovative and
pact and powerful, the new system is easily porta- the patient has been released based on the first intuitive Palm Control system, the surgeon can
ble yet, when docked on its trolley, converts into a single-handedly control every table movement;
traditional US scanner. a lock-out function is included to prevent acci-
dental table movement. Because there are no
ECM motorized controls in the float feature of the
Angoulême France Palm Control, it is like the table top is gliding
Arab [Link] Z511 on a pristine sheet of ice.
[Link] & search 45498
Steris
Saran Cedex, France
Advanced mammography system Arab Health Stand 4D50
with 3MP monitor [Link] & search 45500
The recently introduced Senographe Essen-
tial e mammography system with its 3 Mega- set of images. The patient must return for the
pixel (MP) monitor is the latest member of the additional images. Now, centres have the option Abdominal fat analyser
Senographe Essential family of products in GE to choose a higher resolution monitor in the High levels of visceral fat and trunk fat have
Healthcare’s mammography [Link] new exam room, enabling technologists and radiolo- been scientifically proven to be linked to heart
system provides all the benefits of the Senog- gists to have a clearer vision of the breast image disease, metabolic syndrome and type 2 diabe-
raphe Essential platform for either the doctor’s at the point of acquisition. The non-diagnostic 3 tes. Until now abdominal fat has been difficult
office, screening clinic, mobile unit or hospital MP monitor helps to refine and define the breast and expensive to measure, especially in larger
and in every case always uses just the technol- tissue and can eliminate retakes. During inter- research studies or in routine clinical practice.
ogy that is needed to meet specific requirements. ventional procedures, the 3 MP monitor can also Now, the AB 140MA system from Tanita enables
For example, the new system is equipped with help radiologists better visualize faint micro- abdominal fat to be measured simply and easily.
the technology needed to conduct a screening calcifications during the procedure, promoting The system uses a specially designed electrode
better outcomes. belt placed on the bare mid-riff of the subject.
By means of dual frequency BIA technology, a
GE Healthcare measurement is taken in 30 seconds and gives
Chalfont St Giles, UK. directly both trunk and visceral fat percentages.
Arab Health Stand 4D30
[Link] & search 45501

Image-guided surgical table

The SurgiGraphic 6000 table from Steris offers
a new level of operating room performance and
control—and brings radiology-quality imaging
into the operating room. All aspects of the new
table have been designed to meet the demands
of the operating room environment—whether
for minimally-invasive vascular, orthopaedic, or
other procedures. The table delivers the patient
positioning and mobility required for most Tanita Europe
minimally invasive procedures requiring fluor- Hoofddorp, The Netherlands
oscopy; lateral and longitudinal float, Trende- Arab Health 5C50
lenburg and reverse Trendelenburg, lateral tilt, [Link] & search 45499
[Link] & search 45143
 on show at Arab Health 31 – Issue N°7 – Dec. 2009/Jan 2010

Test tools for QA of diagnostic X-ray imaging systems Automatically adaptive surgical light
The new TruLight 5520 OR light eases
the surgeon’s workload by automati-
cally adapting illumination as situations
change during surgery. It provides the
perfect lighting for each phase of a sur-
gical procedure. All the surgeon has to
do is set the ideal lighting intensity at
the beginning of the operation. Even if
the light is moved during the operation,
The TNT 12000 X-Ray Test Tools package from Fluke Biomedical is an the light maintains the illumination pre-
expanded X-ray test tool platform that includes the new DoseMate dosim- set by the surgeon. The “Adaptive Light
eter and has integrated mA/mAs measurement capability. The new range is Control plus” system thus ensures the best possible lighting conditions
the most up-to-date and most comprehensive family of instruments available during the entire operation without the surgeon or the assistant having to
for assuring the quality and safety of diagnostic X-ray imaging systems. With readjust the light settings.
its choice of all-in-one exposure solid-state detector, dosimeter, ion chambers,
optional mA/mAs invasive shunt or non-invasive clamp device, and the option Trumpf medical systems
of handheld display or laptop interfaces (both completely wireless), the range Ditzingen, Germany
of tools provide state-of-the-art solutions for all X-ray test protocols. Arab Health Stand 3A1
[Link] & search 45475
Fluke Biomedical
Everett,WA, USA
Arab Health Stand 1H19 Portable nasal wash system
[Link] & search 45485 Designed for upper airways and
nasopharynx washing using an aero-
sol with constant composition and
Syringe pump with large memory capacity properties, the Rhino Clear Mobile
Suitable for standard and intensive system has been designed to be prac-
care use as well as in anaesthesia, tical and easy to use. Being much less
the new A606 S syringe pump cumbersome than other systems it is
from CODAN ARGUS has a 32-bit easily portable and is suitable for use
controller enabling fast communi- not only with saline solutions but also
cation with other devices, such as a PDMS. It is equipped with a battery capa- with all medications commonly used
ble of nine hours autonomy and a fast recharging time of only six hours. The in aerosol therapy. The device is man-
large LCD screen shows clearly all relevant infusion parameters at a glance. ufactured from biocompatible and non-allergenic material and, in compli-
Since the recording of all user pump manipulations is important, especially for ance with EU regulations, does not contain any phthalates. Individual nasal
traceability in case of an incident, the new syringe pump has been designed adaptors are available for personal use and exist in three formats: for up to 3
to have a large memory capacity which can store up to 1000 events in its log, years of age; up to 10 years and over 10 years of age.
so that pump usage that might have been carried out even weeks or months
previously can be examined. The use of the ARGUSmedb medication library Flaem Nuova
minimises the chances of dosing errors, through the establishment of both soft Martino della Battaglia, Italy
and hard limits, which can be set individually for each medication. Arab Health Stand ZZB50
[Link] & search 45488
Codan Argus
Baar, Switzerland
Arab Health Stand 7D10
[Link] & search 45487
PRO2XY
On-site
medicinal
Multi-modality LCD display
The Modalixx LCD display provides versatil-
oxygen
ity to meet the specific demands of any medi- generator
cal institution, and is the only multi-modality
Your source of on-site oxygen :
solution on the market that autosyncs to any
• turnkey system
legacy colour or grayscale analogue modal-
• economically interesting
ity including Cath Lab, MRI, CT, RF rooms,
• complying with
C-Arm, Endoscopy/ Surgical, Portable X-Ray, ISO 10083 Standard
and Nuclear Medicine applications. The display is compatible with a range of • guaranteed flow
low line to high line video signals and can upgrade to 2 mega pixel resolution. and rate of oxygen
• output pressure 5 or 12 bar
Ampronix
Irvine, CA, USA [Link]
sales@[Link] ZABELL HALL
Arab Health 1H01
STAND ZT 10
[Link] & search 45492
[Link] & search 45339
 – Issue N°7 – Dec. 2009/Jan. 2010
32 on show at Arab Health

in the new range: GS Exam Light IV is designed for the OB/GYN office,
FRONT COVER PRODUCT whereas the GS 300 General Exam Light combines intense light output
and cool operation in a compact design for in-office procedures. The GS
Multi-performance in all Ultrasound applications 600 Minor Procedure Light features three LEDs and a wider head designed
The ProSound Alpha 6 from Aloka for minor surgical procedures and exams and finally the GS 900 Procedure
belongs to the next generation of com- Light has six LEDs, for nearly every application in any environment.
pact colour ultrasound systems. The new
system is multi-purpose fully upgrada- Welch Allyn
ble and provides unprecedented per- Skaneateles Falls, NY, USA,
formance in all ultrasound applications. Arab Health Stand 6A50
Incorporating the benefits of the high [Link] & search
end ProSound Alpha series and building
on the ProSound technology strengths, the Alpha 6 addresses all diagnostic
applications in one system, a marked difference to other ultrasound systems. Enhancing breast imaging with elastography
The system supports a full range of application-specific probes and software, Elastography is a non-
designed to target all specialist diagnostic areas in general imaging, cardio- invasive medical imaging
vascular, obstetrics & gynaecology and internal medicine. The ProSound technique that can detect
Alpha 6 high power processor allows a number of different imaging modes tumours based on their
previously seen only in high end systems, without compromise on image stiffness (elasticity) com-
quality and colour Doppler sensitivity. The compact, ergonomic design of pared to normal tissue.
the ProSound Alpha 6 features a large, programmable touch screen panel for The most common type
quick access to frequently used controls. A height adjustable operation panel of elastography uses ultra-
and swivel LCD monitor provides ease of use to the examiner. sonic imaging to compare
the shapes of the tissue
Aloka Europe, under examination before
Zug, Switzerland and after it is compressed
Arab Health Stand 2F20 slightly. Cancerous tumors tend to be many times stiffer than normal tissue,
[Link] & search which “gives” under compression. Many tumours, including breast tumours,
show up better in an elastogram than in conventional ultrasonic images. The
latest version of the iU22 ultrasound system from Philips features advanced
Range of LED surgical lamps breast imaging capabilities, including elastography, which in addition to fea-
Now available on international markets, the tures such as volume imaging, tissue aberration correction and smart exam,
Green Series of Medical Exam Lights from makes the iU22 well-suited for breast imaging., Elastography on the iU22
Welch Allyn feature energy-efficient light- system with L12-5 transducer and Advanced Breast Tissue Specific Imaging
emitting diodes (LEDs) as opposed to halogen (TSI) preset enables clinicians to differentiate the relative stiffness of tissue
lamps and so do not require bulb replacement. through sonographic examination.
Producing white, bright light with a colour
temperature of 5,500ºK, the lights provide Philips
a superior light that offers industry-leading Eindhoven, The Netherlands
lumen performance and 50,000 hours of life. Arab Health Stand 3E30
The touchless auto on/off and intensity control [Link] & search
features reduce the risk of infections due to
cross-contamination. There are several models
Whole body exercising by vibration system
Unique because of its use of sonic wave tech-
nology, a whole body vibration device has been
introduced to the market. The TurboSonic
system is a highly efficient and stable training
system which provides exercise effects for all
body parts. Using vibrations of approximately
50 Hz, it is claimed that the system stimulates
muscles, bones, nerves and the heart as well as
the hormone system. It is also claimed that the
user’s strength, flexibility, energy, endurance,
balance and coordination is improved. Pain,
stress, and fatigue are reduced. The system is
suitable for people of all ages in the areas of
sports, wellness and fitness, as it keeps the
muscles and bones in general good shape.

[Link]
Ehrighausen, Germany
Arab Health Stand ZD11
[Link] & search
[Link] & search 45305
 PRODUCT NEWS 33 – Issue N°7 – Dec. 2009/Jan 2010

Portable warmer for infusion fluids and Ireland as well as other information from [Link] guidance out-
The treatment of patients suffering from hypothermia lines the need for ICUs to focus upon strict infection control practices and
remains a real challenge for emergency health serv- planning for sufficient supplies of key drugs, equipment and staff and for
ices, particularly in countries that have severe winters. health care workers, patients and visitors to follow the appropriate infec-
This has led to several innovations being introduced so tion control precautions to minimise the possibility of health-care associ-
that IV fluids may be warmed in the field. These range ated transmission. Focusing on the control of the spread of respiratory
from simply leaving the IV fluids on the dashboard droplets as the proven route of human-to-human transmission, the guid-
of the attending vehicle with the heating set to high, ance also outlines general personal protective equipment measures in a
to car battery-powered heaters and small insulating check-list format. Concentrating specifically on mechanical ventilation,
blankets for the IV bag and tubing. In a more rigorous the document draws from key national guidelines which state that closed
approach, the FlexWarmer device from Elltech uses suctioning should be employed and that ventilation circuits should not be
a reusable chemical heating pack and a heat-transfer broken unless absolutely necessary.
case which warms a loop of the IV tubing as the fluid
flows to the patient. The system is extremely simple to Kimberly-Clark Health care
operate — all that is needed is to place the heat pack Zaventem, Belgium
in its case and the IV tubing in the warming channel, and then to activate the [Link] & search 45491
pack. The device is available in two formats, for 4 and 5mm channel standard
tube sets respectively.
Brushes for cleaning surgical instruments
Elltec The quality and integ-
Nagoya, Japan rity of surgical instru-
[Link] & search 45484 ments have an impor-
tant impact on the
quality of surgical care
Exercise stress test system — instruments will last
Comprising the cycloergometer much longer if they
CRG 200 exercise bicycle and the are cleaned with an
CardioTEST software, the com- appropriate solution
plete CardioTEST Alfa System immediately after sur-
is a professional tool specifically gery and if they are regularly sharpened, lubricated and sterilised. The new
designed for the measurement of range of “Cleanables” brushes from Sharn has been designed for the effi-
both exercise and resting ECGs. cient cleaning of all medical instruments. Brushes are available with single
Controlled by a PC running the or double ended bristles of 5mm, 8mm or 10mm bristle diameter. All the
CardioTEST software via an brushes are 63 cm in length and feature anti-microbial nylon bristles with
RS-232 interface, the exercise a large bristle area that provides up to 50% more brushing power. The shal-
bicycle incorporates the most low cannula cleaning brushes illustrated are 13 cm long and are available
modern technology and ena- with 5mm, 7mm and 10mm bristle diameter. Also new is a box lock brush
bles load adjustment within the range of 25 – 400 W. Since the load level featuring a comfortable flat white handle. It is 18 cm long with a brushing
is controlled by microprocessor, it does not depend on speed, which can be surface of 3 cm by 7 cm.
adjusted according to the patient’s individual needs. The cycloergometer is
equipped with ECG mode recording 12 standard leads. The design of the Sharn Anesthesia, Inc
bicycle not only ensures comfort and safety but also facilitates easy operation Tampa, FL, USA
and cleaning. [Link] & search 45490

Aspel
Zabierzów, Poland
[Link] & search 45486

Managing H1N1 influenza within ICUs

A booklet containing best practice
guidance and bringing together a
summary of the latest advice and
protocols for Intensive Care Units
(ICUs) preparing for the H1N1 influ-
enza virus is available from Kim-
berly-Clark Health Care via a simple
download from the company’s special
web site ([Link]). The
booklet extracts relevant information
for ICUs from documents published
by a wide range of organisations and
professional bodies including the World Health Organisation (WHO), the
national UK and Portuguese governments, clinical societies in Germany
[Link] & search 45466
 – Issue N°7 – Dec. 2009/Jan. 2010
34 PRODUCT NEWS

FRONT COVER PRODUCT Calendar of events

February 25-28, 2010 May 25-28, 2010
Intraoperative Early Disease Detection and Pre- Hospitalar 2010

radiotherapy system endobronchial tubes. The adult version has a diameter

vention (EDDP) conference 2010
Munich, Germany
São Paulo, Brazil
[Link]/ingles/
Developed after of 15 french and the paediatric version is 10 french in Tel. +41 22 5330 948
Fax +41 22 5802 953 June 1-3, 2010
a careful analy- diameter; both are 70 cm in length and have a safety e-mail: eddp2010@paragon- Hospital Build Middle East
sis of the limita- stopper. Designed for single patient use, the devices [Link] Exhibition and Congress 2010
[Link]/ Dubai, United Arab Emirates
tions of current are latex-free and sterile packed. eddp2010/ Tel. +971 4 3365161
intraoperative Fax +971 4 3364021
February 26-28, 2010 e-mail: hospitalbuild@[Link]
radiotherapy Sharn Anesthesia Inc
2010 First International [Link]
procedures that Tampa, FL, USA Meeting on Cardiac Problems in
are carried out [Link] & search 45474 Pregnancy (CPP) June 10-13, 2010
Valencia, Spain 15th Congress of the European
during surgery, Tel. +41 22 5330948 Hematology Association
the LIAC sys- e-mail: secretariat@[Link] Barcelona, Spain

tem from the Notebook-based ultrasound system [Link] Tel. +31 70 3455563
Fax +31 70 3923663
Italian company Sordina uses an electron beam The ClarUs March 4-8, 2010 e-mail: info@[Link]
ECR 2010 [Link]
to treat neoplastic tissue that is exposed during ultrasound Vienna, Austria
surgery. Thanks to the ability to rapidly position system has Tel. +43 1 533 40 64 - 0 June 12-15, 2010
Fax +43 1 533 40 64 - 448 Euroanaesthesia 2010
the system and the intensity of its radiation, the been devel- e-mail: communications@[Link] Helsinki, Finland
LIAC is suitable for all intraoperative therapies oped as a com- [Link] Tel. +32-2-743 3290
Fax +32-2-743 3298
and does not result in any lengthening of the pact and light- March 9-12, 2010 e-mail: registration@euroanaes-
duration of even short surgical interventions. The weight colour 30th international Symposium on [Link]
Intensive Care and Emergency [Link]
innovative characteristics of the LIAC, such as its system for
Medicine (ISICEM)
small size, safety features and variable power set- applications Brussels, Belgium June 16-19, 2010
tings of the electron beam mean that it is possible in obstetrics Tel. +32 2 555 3631 World Congress of Cardiology
Fax +32 2 555 4555 Scientific Sessions 2010
for the system to be used in any operating room and gynaecology, general and musculoskeletal imag- e-mail: sympicu@[Link] Featuring the 3rd International
without the need for any structural alterations. ing, vascular access and other fields. The system is [Link] Conference on Women,
Heart Disease and Stroke
flexible and easy to use, thus making it an excellent March 15-18, 2010 Beijing, China
Sordina choice for any practice wanting a high quality colour World of Health IT e-mail: congress@[Link]
Conference & Exhibition [Link]
Saonara, Italy Doppler imaging system. Supporting a wide range of Barcelona, Spain
[Link] & search 45476 linear, convex and microconvex transducers, the unit Tel. +32 2 793 76 37 June 16-19, 2010
Fax +32 2 793 76 31 CARDIOSTIM 2010
provides a platform that is versatile and offers great e-mail: customerservice@worldof- 17th World Congress in
expansion potential as needs grow. Providing uncom- [Link] Cardiac Electrophysiology

Endotracheal tube introducer promising quality of images along with precision [Link] & Cardiac Techniques
Nice , France
Combining the benefits of an introducer and stylet measurement, storage, recall and convenient commu- March 18-21, 2010 [Link]?xtor=ADI-5
KIMES 2010
in one device, the new purple - coloured malleable nication capability, the system incorporates variable Seoul, Korea August 28 –
endotracheal tube introducer features an internal wire frequency and focusing, an extended cine memory Tel. +82 (2) 551 0102 September 1, 2010
that allows the “bougie” to be pre-bent for optimum and the ability to output data in a variety of formats. Fax +82 (2) 551 0103 ESC Congress 2010
e-mail: kimes@[Link] Stockholm, Sweden
use. There are graduation marks every 5 cm which [Link] Tel. +33 492 947 600
enables the depth of placement to be controlled. The Telemed Ultrasound Medical Systems Fax +33 492 947 601
April 14-16, 2010 [Link]/congresses/
new introducers can be used with ET tubes, rigid bron- Vilnius, Lithuania Med-e-Tel 2010 esc-2010
choscopes, laryngeal mask airways and double lumen [Link] & search 45489 Luxembourg, Luxembourg
Tel. +32 2 269 84 56 September 15-17, 2010
Fax +32 2 269 79 53 Medical Fair Asia 2010
e-mail: medetel@[Link] Suntec Singapore
[Link] Tel: + 65 6332 9620
Fax: +65 6332 9655 / 6337
April 18-21, 2010 4633
Your deadlines: 63rd CMEF Spring 2010 e-mail: medicalfair-asia@mda.
Shenzhen, China [Link]
Abstract Submission January 11, 2010 Tel. +86 10 6202 8899 ext 3825 [Link]
Early Fee Registration April 5, 2010 Fax +86 20 6235 9314
e-mail: jin.liu2@[Link] October 9-13, 2010
[Link] ESICM 2010
Barcelona, Spain
[Link] May 11-13, 2010 Tel. +32 2 559 03 55
Medical Fair Australia 2010 Fax +32 2 527 00 62
June 16-19, 2010 Sydney, Australia e-mail: Barcelona2010@[Link]
17th World Congress Nice Acropolis • French Riviera Tel. +1 312 781 5180
Fax +1 312 781 5188
[Link]

in Cardiac Electrophysiology & Cardiac Techniques Reg

e-mail: info@[Link]
[Link]/shows/medfair-
iste
Scientific & Organizing Committee Now r [Link]

Philippe Ritter (Bordeaux, FRA) !

May 19-20, 2010
Pierre Bordachar, Stéphane Garrigue, Sylvain Reuter (Bordeaux, FRA)
World Health Care Congress -
David Hayes (Rochester, USA), [Link] Daubert (Rennes, FRA), Douglas Zipes (Indianapolis, USA), Nadir Saoudi (Monaco, MCO)
Europe 2010
For more events see
Brussels, Belgium [Link]/events/
Tel. +1 800 767 9499 Dates and descriptions of future events have
Cardiostim / Reed Expositions France Fax +1 781 939 2692 been obtained from usually reliable official
Tel.: +33 (0)1 47 56 24 56 - Fax: +33 (0)1 47 56 24 55 cardiostim@[Link] In collaboration with e-mail: wcreg@[Link] industrial sources. IHE cannot be held respon-
Tour Vista - 52-54, quai de Dion-Bouton - CS80001 92806 Puteaux Cedex - France sible for errors, changes or cancellations.
[Link]/europe

pubcom136x86_v2.indd 1 6/10/09 [Link]

[Link] & search 45230