The management of patients with International Neuroblastoma Staging System (INSS) stage 3 neuroblastoma (NB) is not consistent worldwide. We describe a single centre approach at Memorial Sloan-Kettering Cancer Centre (MSKCC) from 1991 to 2007 that minimizes therapy except for those patients with MYCN-amplified NB.
In this retrospective analysis of 69 patients, tumour MYCN was not amplified in 53 and amplified in 16. Event-free survival (EFS) and overall survival (OS) were determined by Kaplan–Meier analysis.
Fourteen patients with non-MYCN-amplified tumours were treated with surgery alone (group A) and the remaining 39 (group B) with surgery following chemotherapy that was initiated and administered at non-MSKCC institutions. Chemotherapy was discontinued after surgery in 38/39 of the latter. The 10-year EFS and OS for all patients with MYCN-non-amplified NB were 74.9 ± 16.9% and 92.6 ± 5.5%, respectively. There was no difference in OS between groups A and B (p = 0.2; 10-year OS for groups A and B was 84.6 ± 14% and 97.1 ± 2.9%, respectively). Patients with MYCN-amplified disease (group C) underwent dose-intensive induction, tumour resection and local radiotherapy: 13 achieved complete or very good partial remission, and 10 received myeloablative chemotherapy. 11/16 patients also received 3F8-based immunotherapy: 10 remain free of disease. The 10-year EFS and OS for patients with MYCN-amplified neuroblastoma treated with immunotherapy were both 90.9 ± 8.7%.
Patients with MYCN-non-amplified stage 3 NB can be successfully treated with surgery without the need for radiotherapy or continuation of chemotherapy. Combination of dose-intensive chemotherapy, surgery, radiotherapy and immunotherapy was associated with a favourable outcome for most patients with MYCN-amplified stage 3 NB.
Stage 3 neuroblastoma; Immunotherapy; Prognosis
The development and acceptance of the digital communication in medicine (DICOM) standard has become a basic requirement for the implementation of electronic imaging in radiology. DICOM is now evolving to provide a standard for electronic communication between radiology and other parts of the hospital enterprise. In a completely integrated filmless radiology department, there are 3 core computer systems, the picture archiving and communication system (PACS), the hospital or radiology information system (HIS, RIS), and the acquisition modality. Ideally, each would have bidirectional communication with the other 2 systems. At a minimum, a PACS must be able to receive and acknowledge receipt of image and demographic data from the modalities. Similarly, the modalities must be able to send images and demographic data to the PACS. Now that basic DICOM communication protocols for query or retrieval, storage, and print classes have become established through both conformance statements and intervendor testing, there has been an increase in interest in enhancing the functionality of communication between the 3 computers. Historically, demographic data passed to the PACS have been generated manually at the modality despite the existence of the same data on the HIS or RIS. In more current sophisticated implementations, acquisition modalities are able to receive patient and study-related data from the HIS or RIS. DICOM Modality Worklist is the missing electronic link that transfers this critical information between the acquisition modalities and the HIS or RIS. This report describes the concepts, issues, and impact of DICOM Modality Worklist implementation in a PACS environment.
DICOM; PACS; worklist
Teaching files are integral to radiological training. Digital Imaging and Communication in Medicine compatible digital radiological data and technological advances have made digital teaching files a desirable way to preserve and share representative and/or unusual cases for training purposes. The Medical Imaging Resource Community (MIRC) system developed by the Radiological Society of North America (RSNA) is a robust multi-platform digital teaching file implementation that is freely available. An emergency radiology training curriculum developed by the American Society of Emergency Radiology (ASER) was incorporated to determine if such an approach might facilitate the entry, maintenance, and cataloguing of interesting cases. The RSNA MIRC software was obtained from the main MIRC website and installed. A coding system was developed based on the outline form of the ASER curriculum. Weekly reports were generated tallying the number of cases in each category of the curriculum. Resident participation in the entry and maintenance of cases markedly increased after incorporation of the ASER curriculum. The coding schema facilitated progress assessment. Ultimately, 454 total cases were entered into the MIRC database, representing at least 42% of the subcategories within the ASER curriculum (161 out of 376). The incorporation of the ASER emergency radiology curriculum greatly facilitated the location, cataloguing, tracking, and maintenance of representative cases and served as an effective means by which to unify the efforts of the department to develop a comprehensive teaching resource within this subspecialty. This approach and format will be extended to other educational curricula in other radiological subspecialties.
Electronic supplementary material
The online version of this article (doi:10.1007/s10278-009-9178-8) contains supplementary material, which is available to authorized users.
Medical Imaging Resource Center (MIRC); electronic teaching file; emergency radiology; experiential; Extensible Markup Language (XML); web technology; computers in medicine; computer communication networks; data mining; database management systems; digital libraries; education; medical; image libraries; radiology teaching files; teaching
Fiber tracking allows the in vivo reconstruction of human brain white matter fiber trajectories based on magnetic resonance diffusion tensor imaging (MR-DTI), but its application in the clinical routine is still in its infancy. In this study, we present a new software for fiber tracking, developed on top of a general-purpose DICOM (digital imaging and communications in medicine) framework, which can be easily integrated into existing picture archiving and communication system (PACS) of radiological institutions. Images combining anatomical information and the localization of different fiber tract trajectories can be encoded and exported in DICOM and Analyze formats, which are valuable resources in the clinical applications of this method. Fiber tracking was implemented based on existing line propagation algorithms, but it includes a heuristic for fiber crossings in the case of disk-shaped diffusion tensors. We successfully performed fiber tracking on MR-DTI data sets from 26 patients with different types of brain lesions affecting the corticospinal tracts. In all cases, the trajectories of the central spinal tract (pyramidal tract) were reconstructed and could be applied at the planning phase of the surgery as well as in intraoperative neuronavigation.
Diffusion tensor imaging; fiber tracking; pyramidal tract; cortico-spinal tracts; neurosurgical planning and navigation; DICOM
As radiology makes advances toward filmlessness, all of medicine is headed, just as rapidly, toward paperless transmission of patient information. While there are obvious advantages to this electronic approach, and several standards to conform to for the transmission of textual (Health Level 7 [HL-7]) and image (Digital Imaging and Communications in Medicine [DICOM]) data, it is the integration of these two data sets that is clinically essential and yet poorly defined. This report defines an approach for, and the successful implementation of, the integration of radiologic image data with textual data contained within the electronic patient record (EPR) through the use of standard internet protocols. Incorporation of medical images in the EPR has proven to be critical to the successful deployment of picture archiving and communications systems (PACS) and the reduction of film consumption at Massachusetts General Hospital (MGH). Since the installation of the first internet-based Image Data Repository (IDR) at MGH in 1995, the system has adequately served to meet the needs of clinical requests by both radiology-only browser users and users of the EPR. It has drastically reduced the need for film and provided concurrent display of images and text throughout the institution and beyond. *** DIRECT SUPPORT *** A00RM031 00009
Radiology workflows have become more distributed and complicated, and fewer tangible cues are available to the radiologist to help optimize task prioritization and selection. Additionally, faster scanners, more detailed exams, and increased demand for imaging services have precipitated a potential image overload for today's radiologists who are pressured to provide efficient, quality service in less time. Radiologists are faced with the task of operating within complex systems but are lacking tools to efficiently and effectively monitor these systems in real time. Dashboard technology can help address this deficiency in radiology and facilitate informed, optimized decisions about workflow. Possible areas of application include workflow consolidation, workload distribution, and urgency evaluation. Dashboards should be optimized, context-sensitive, customizable, and workflow-integrated. Further research is needed to identify the most important dashboard metrics, determine their optimal display, and validate their utility.
Dashboard; workflow; radiology informatics; user–computer interface
At the Istituto Nazionale Neurologico C. Besta in Milano a network architecture has been developed to connect computers and diagnostic modalities, based on Intranet technology in order to allow the hospital to have an external access through the Internet. The Internet technology has become the "glue" that allows to link different computers and to develop applications able to work independently from the hardware/software platform. Using a PACS (Picture Archiving and Communication System) system integrated to the diagnostic modalities by means of the standardized DICOM image format, the digital radiological images can be transferred, displayed and processed on special visualization workstations all around the hospital. From the workstations the same images can be transferred in DICOM format to a teleconsulting workstation. In fact the hospital is involved in a national project for the remote connection between many Italian hospitals. This national network is linked to already developed regional networks like the Toscana MAN and the ATM Sirius Network. Some links are performed directly in ATM (155 Mbps), others are based on CDN (Direct Numerical Connection, 2Mbps), others are simply based on ISDN connections. The system allows to make it simpler and faster the already established daily exchange of radiological reports between the involved hospitals, especially from Istituto Nazionale Neurologico and Istituto Nazionale deiTumori. All the actions performed by the radiologist are translated by the software into "events" and replied to the remote workstation and vice-versa. In this way the radiologists can see each others, speak together and act in real time on a common "board" of diagnostic images, each one with his own pointer. The adopted technology is evolving on a system based on a web architecture and Java applications, useful for small clinical centers not endowed with expensive information systems. These centers will be able to get consulting performances by the excellence centers, making available accurate diagnoses and therapy protocols.
The current array of PACS products and 3D visualization tools presents a wide range of options for applying advanced visualization methods in clinical radiology. The emergence of server-based rendering techniques creates new opportunities for raising the level of clinical image review. However, best-of-breed implementations of core PACS technology, volumetric image navigation, and application-specific 3D packages will, in general, be supplied by different vendors. Integration issues should be carefully considered before deploying such systems. This work presents a classification scheme describing five tiers of PACS modularity and integration with advanced visualization tools, with the goals of characterizing current options for such integration, providing an approach for evaluating such systems, and discussing possible future architectures. These five levels of increasing PACS modularity begin with what was until recently the dominant model for integrating advanced visualization into the clinical radiologist's workflow, consisting of a dedicated stand-alone post-processing workstation in the reading room. Introduction of context-sharing, thin clients using server-based rendering, archive integration, and user-level application hosting at successive levels of the hierarchy lead to a modularized imaging architecture, which promotes user interface integration, resource efficiency, system performance, supportability, and flexibility. These technical factors and system metrics are discussed in the context of the proposed five-level classification scheme.
PACS; 3D imaging (imaging, three-dimensional); Computer systems; Advanced visualization; Server-based rendering; Application hosting
The United States Department of Veterans Affairs is integrating imaging into the healthcare enterprise by using the Digital Imaging and Communication in Medicine (DICOM) standard protocols. Image management is directly integrated into the VistA Hospital Information System (HIS) software and clinical database. Radiology images are acquired with DICOM and are stored directly in the HIS database. Images can be displayed on low-cost clinician’s workstations throughout the medical center. High-resolution diagnostic quality multimonitor VistA workstations with specialized viewing software can be used for reading radiology images. Two approaches are used to acquire and handle images within the radiology department. Some sites have a commercial Picture Archiving and Communications System (PACS) interfaced to the VistA HIS, whereas other sites use the direct image acquisition and integrated diagnostic display capabilities of VistA itself. A small set of DICOM services has been implemented by VistA to allow patient and study text data to be transmitted to image producing modalities and the commercial PACS, and to enable images and study data to be transferred back. DICOM has been the cornerstone in the ability to integrate imaging functionality into the healthcare enterprise. Because of its openness, it allows the integration of system components from commercial and noncommercial sources to work together to provide functional cost-effective solutions.
HIS/RIS; DICOM; PACS
Dietary supplement use has increased exponentially in recent years despite the lack of regulatory oversight and in the face of growing safety concerns. This paper provides an overview of the public health implications and safety concerns associated with dietary supplement use, especially by cancer patients. Botanical research is actively pursued at the Memorial Sloan-Kettering Cancer Center (MSKCC) Integrative Medicine department. Work of the MSKCC Center for the Study of Botanical Immunomodulators is described, and guidelines for cancer patients’ use of dietary supplements outlined. Herbs and other botanicals are complex, physiologically active agents, but little is known about most of the popular, widely available dietary supplements. Herb-drug interactions, a major concern, are exacerbated in the cancer setting. Biologically active agents may interfere with chemotherapy and other prescription medications. They may exert anti-coagulant activity at rather inconvenient times such as during surgery, and create other serious problems. Research on the bioavailability, effective dosage, safety and benefits of these complex agents is sorely needed. Oncology professionals and other healthcare providers should educate themselves and their patients about these issues. Probably the largest, continuously-updated free information resource is MSKCC’s AboutHerbs website (www.mskcc.org/AboutHerbs).
Dietary supplements; botanicals; herbal medicines; legislation/jurisprudence; cancer; product labeling
Paragangliomas are rare neuroendocrine neoplasms arising in extra-adrenal chromaffin cells of autonomic nervous system and histologically akin to chemodectomas. They are rare, affecting about 1 in 2,000,000 population. It is a generic term applied to tumors of paraganglia regardless of the location. In rare instances, paragangliomas present around and involve the pancreas, thereby mimicking any one of the more common primary pancreatic lesions. Pancreatic paraganglioma is an extremely rare tumor. It grows slowly, so radical resection is recommended to achieve curability with good prognosis. These neoplasms present considerable diagnostic difficulty not only for the clinician and radiologist but also for the pathologist. Here, we report a case of a 55-year-old woman who presented with a left-sided abdominal swelling for 3 months duration, initially having clinical suspicion of an ovarian tumor. The radiological imaging revealed a lesion in the tail of pancreas with a differential diagnosis of pancreatic carcinoma and metastatic tumor. Only after exploratory laparotomy, the diagnosis was made as a rare case of pancreatic paraganglioma on the basis of histological examination and immunohistochemistry.
Chromogranin A; immunohistochemistry; pancreas; paraganglioma
The Department of Defense (DoD) undertook a major systems specification, acquisition, and implementation project of multivendor picture archiving and communications system (PACS) and teleradiology systems during 1997 with deployment of the first systems in 1998. These systems differ from their DoD predecessor system in being multivendor in origin, specifying adherence to the developing Digital Imaging and Communications in Medicine (DICOM) 3.0 standard and all of its service classes, emphasizing open architecture, using personal computer (PC) and web-based image viewing access, having radiologic telepresence over large geographic areas as a primary focus of implementation, and requiring bidirectional interfacing with the DoD hospital information system (HIS). The benefits and advantages to the military healthcare system accrue through the enabling of a seamless implementation of a virtual radiology operational environment throughout this vast healthcare organization providing efficient general and subspecialty radiologic interpretive and consultative services for our medical beneficiaries to any healthcare provider, anywhere and at any time of the night or day.
In this work, we describe the digital imaging network (DIN), picture archival and communication system (PACS), and radiology information system (RIS) currently being implemented at the Clinical Center, National Institutes of Health (NIH). These systems are presently in clinical operation. The DIN is a redundant meshed network designed to address gigabit density and expected high bandwidth requirements for image transfer and server aggregation. The PACS projected workload is 5.0 TB of new imaging data per year. Its architecture consists of a central, high-throughput Digital Imaging and Communications in Medicine (DICOM) data repository and distributed redundant array of inexpensive disks (RAID) servers employing fiber-channel technology for immediate delivery of imaging data. On demand distribution of images and reports to clinicians and researchers is accomplished via a clustered web server. The RIS follows a client-server model and provides tools to order exams, schedule resources, retrieve and review results, and generate management reports. The RIS-hospital information system (HIS) interfaces include admissions, discharges, and transfers (ATDs)/demographics, orders, appointment notifications, doctors update, and results.
The radiology information system (RIS) provides patient and examination information that is used in setting up and performing a radiologic procedure. In a digital imaging environment, information from the RIS can also be used to populate fields in the Digital Imaging and Communications in Medicine (DICOM) image header. Ideally, information from the RIS should be available at the modality at the time of the examination, and automatically be attached to the image in the appropriate DICOM fields before storage in the picture archiving and communications system (PACS). We have designed a highly integrated RIS interface for a digital radiography (DR) system. This interface employs browser technology to make RIS information conveniently available at the modality, and DICOM modality performed procedure step (MPPS) for RIS/DR information exchange. A novel feature of our approach is that a single display screen at the modality is used to alternatively display either the modality control window or the RIS window. Full access to RIS capabilities is available at the modality, including worklists and prior reports.
The integration of images with existing and new health care information systems poses a number of challenges in a multi-facility network: image distribution to clinicians; making DICOM image headers consistent across information systems; and integration of teleradiology into PACS. A novel, Web-based enterprise PACS architecture introduced at Massachusetts General Hospital provides a solution. Four AMICAS Web/Intranet Image Servers were installed as the default DICOM destination of 10 digital modalities. A fifth AMICAS receives teleradiology studies via the Internet. Each AMICAS includes: a Java-based interface to the IDXrad radiology information system (RIS), a DICOM autorouter to tape-library archives and to the Agfa PACS, a wavelet image compressor/decompressor that preserves compatibility with DICOM workstations, a Web server to distribute images throughout the enterprise, and an extensible interface which permits links between other HIS and AMICAS. Using wavelet compression and Internet standards as its native formats, AMICAS creates a bridge to the DICOM networks of remote imaging centers via the Internet. This teleradiology capability is integrated into the DICOM network and the PACS thereby eliminating the need for special teleradiology workstations. AMICAS has been installed at MGH since March of 1997. During that time, it has been a reliable component of the evolving digital image distribution system. As a result, the recently renovated neurosurgical ICU will be filmless and use only AMICAS workstations for mission-critical patient care.
Teleradiology is one of the most evolved areas of telemedicine, but one of the basic problems which remains unsolved concerns system compatibility. The DICOM (Digital Imaging and Communications in Medicine) standard is a prerequisite, but it is not sufficient in all aspects. Examples of other currently open issues are security and cooperative work in synchronous teleconferences. Users without a DICOM radiological workstation would benefit from the ability to join a teleradiology network without any special tools. Drawbacks of many teleradiology systems are that they are monolithic in their software design and cannot be adapted to the actual user's environment. Existing radiological systems currently cannot be extended with additional software components. Consequently, every new application usually needs a new workstation with a different look and feel, which must be connected and integrated into the existing infrastructure.
This paper introduces the second generation teleradiology system CHILI. The system has been designed to match both the teleradiology requirements of the American College of Radiology (ACR), and the functionality and usability needs of the users. The experiences of software developers and teleradiology users who participated in the first years of the clinical use of CHILI's predecessor MEDICUS have been integrated into a new design. The system has been designed as a component-based architecture. The most powerful communication protocol for data exchange and teleconferencing is the CHILI protocol, which includes a strong data security concept. The system offers, in addition to its own secure protocol, several different communication methods: DICOM, classic e-mail, Remote Copy functions (RCP), File Transfer Protocol (FTP), the internet protocols HTTP (HyperText Transfer Protocol) and HTTPS (HyperText Transfer Protocol Secure),and CD-ROMs for off-line communication. These transfer methods allow the user to send images to nearly anyone with a computer and a network. The drawbacks of the non-CHILI protocols are that teleconferences are not possible, and that the user must take reasonable precautions for data privacy and security.
The CHILI PlugIn mechanism enables the users or third parties to extend the system capabilities by adding powerful image postprocessing functions or interfaces to other information systems. Suitable PlugIns can be either existing programs, or dedicated applications programmed with interfaces to the CHILI components. The developer may freely choose programming languages and interface toolkits.
The CHILI architecture is a powerful and flexible environment for Picture Archiving and Communications Systems (PACS)and teleradiology. More than 40 systems are currently running in clinical routine in Germany. More than 300,000 images have been distributed among the communication partners in the last two years. Feedback and suggestions from the users influenced the system architecture by a great extent. The proposed and implemented system has been optimized to be as platform independent, open, and secure as possible.
Teleradiology; Telemedicine; Remote Consultation; Diagnostic Imaging; Computer-Assisted Image Interpretation; PACS; Middleware; TLS; Security; Plugin; Visualization
Cholangiocarcinoma is the second most common primary malignant tumor of the liver. Perihilar cholangiocarcinoma or Klatskin tumor represents more than 50% of all biliary tract cholangiocarcinomas. A wide range of risk factors have been identified among patients with Perihilar cholangiocarcinoma including advanced age, male gender, primary sclerosing cholangitis, choledochal cysts, cholelithiasis, cholecystitis, parasitic infection (Opisthorchis viverrini and Clonorchis sinensis), inflammatory bowel disease, alcoholic cirrhosis, nonalcoholic cirrhosis, chronic pancreatitis and metabolic syndrome. Various classifications have been used to describe the pathologic and radiologic appearance of cholangiocarcinoma. The three systems most commonly used to evaluate Perihilar cholangiocarcinoma are the Bismuth-Corlette (BC) system, the Memorial Sloan-Kettering Cancer Center and the TNM classification. The BC classification provides preoperative assessment of local spread. The Memorial Sloan-Kettering cancer center proposes a staging system according to three factors related to local tumor extent: the location and extent of bile duct involvement, the presence or absence of portal venous invasion, and the presence or absence of hepatic lobar atrophy. The TNM classification, besides the usual descriptors, tumor, node and metastases, provides additional information concerning the possibility for the residual tumor (R) and the histological grade (G). Recently, in 2011, a new consensus classification for the Perihilar cholangiocarcinoma had been published. The consensus was organised by the European Hepato-Pancreato-Biliary Association which identified the need for a new staging system for this type of tumors. The classification includes information concerning biliary or vascular (portal or arterial) involvement, lymph node status or metastases, but also other essential aspects related to the surgical risk, such as remnant hepatic volume or the possibility of underlying disease.
Hilar cholangiocarcinoma; Klatskin tumor; Perihilar cholangiocarcinoma; Bile duct cancer
We present a retrospective study depicting the incidence and outcome of soft tissue sarcomas (STSs) in patients admitted in a District Government Hospital situated in coastal belt of Southern India for a period of four and a half years. The hospital is a district referral centre catering to rural and urban poor population of 1,900,000 people.
Histologically proven soft tissue STS patients admitted in Department of General Surgery in District Government Wenlock Hospital, Mangalore, from January 2002 to July 2007 were included in the study. The incidence, age distribution, gender distribution, histological subtypes, site of tumour, and clinical outcome were the parameters studied. The above parameters were then compared with Memorial Sloan and Kettering Cancer Centre (MSKCC) study.
Fifty-one cases of STS were reported out of 7674 (0.65%) patients with cancer in the said period. Ninety percent belonged to adolescents and adult age group. Liposarcoma (18%) is the most common subtype followed by leiomyosarcoma, Ewings’ sarcoma. 66.6% originated in the extremities and rest being intra-abdominal and retroperitoneal. The age of presentation was a decade less than MSKCC study. The alarming yet expected fact was 35% of patients came with delayed presentation of the disease and refusal for surgery. Thirty-nine percent of patients were treated surgically.
Majority of patients presenting to our institution in advanced stage of the disease, indicating ignorance, fear and reluctance for surgery; as well as economic constraints, that delay early detection and initiation of proper treatment. The incidence appears to be increasing, targeting the younger population. There is a definite need to incorporate drug trials in rural set up so that patients can be benefited.
Soft tissue sarcoma; Incidence; Dakshina Kannada; District Government Wenlock Hospital
Most organizations planning to implement picture archiving and communications systems (PACS) are aware of the need to integrate the hospital information system (HIS) and radiology information system (RIS) with the PACS, yet few are acutely aware of the challenges associated with this requirement. This report highlights the results of collaborative efforts between Children’s Hospital Medical Center-Cincinnati (CHMC) applications specialists with expertise in the HIS and CHMC information system, radiology staff familiar with the enterprise and radiology workflow and data flow requirements; and General Electric integration engineers familiar with the SMS HIS and RIS, and GE PACS. CHMC received Board approval, including full funding of the entire PACS project, in October 1998. An aggressive time frame for installation was established, as CHMC’s PACS leadership committed to the selection, design, and implementation of PACS and computed radiography (CR) within 18 to 20 months. CHMC selected GE (Milwaukee, WI) as its PACS vendor in July 1999, and began its implementation in November 1999. We will present the four-stage integration process undertaken at CHMC: (1) planning the integration effort, (2) designing the Interface, (3) building the interface, and (4) testing the Interface.
A considerable amount of research has been concerned with the development of natural language systems to automate the encoding of clinical information that occurs in textual form. The task is very complex, and not many language processors are used routinely within clinical information systems. Those systems that are operational, have been implemented in narrow domains for particular applications. For a system to be truly useful, it should be designed so that it could be widely used within the clinical environment. This paper examines architectural requirements we have identified as being necessary for portability and describes the architecture of the system we developed. Our system was designed so that it could be used in different domains to serve a variety of applications. It has been integrated with the clinical information system at Columbia-Presbyterian Medical Center where it routinely encodes clinical information from radiological reports of patients.
A demonstration implementation of a distributed data processing hospital information system using an intelligent local area communications network (LACN) technology is described. This system is operational at the UCSF Medical Center and integrates four heterogeneous, stand-alone minicomputers. The applications systems are PID/Registration, Outpatient Pharmacy, Clinical Laboratory and Radiology/Medical Records. Functional autonomy of these systems has been maintained, and no operating system changes have been required. The LACN uses a fiber-optic communications medium and provides extensive communications protocol support within the network, based on the ISO/OSI Model. The architecture is reconfigurable and expandable. This paper describes system architectural issues, the applications environment and the local area network.
To present the experience in patient dose management and the development of an online audit tool for digital radiography.
Materials and methods:
Several tools have been developed to extract the information contained in the DICOM header of digital images, collect radiographic parameters, calculate patient entrance doses and other related parameters, and audit image quality.
The tool has been used for mammography, and includes images from over 25,000 patients, over 75,000 chest images, 100,000 computed radiography procedures and more than 1,000 interventional radiology procedures. Examples of calculation of skin dose distribution in interventional cardiology based upon information of DICOM header and the results of dosimetric parameters for cardiology procedures in 2006 are presented.
Digital radiology has great advantages for imaging and patient dose management. Dose reports, QCONLINE systems and the MPPS DICOM service are good tools to optimise procedures and to manage patient dosimetry data. The implementation of the ongoing IEC-DICOM standard for patient dose structured reports will improve dose management in digital radiology.
Digital radiography; patient dose; DICOM header audit; quality assurance
Information technology (IT), long taken for granted in commercial settings, is now being utilized for healthcare applications. Medical imaging has lagged comparatively due to the extremely vast data content of each frame; thus, the requirement for expensive high-end components. Further, IT in radiology has evolved from two distinctly separate camps—information systems, known as RIS (radiology information systems) and PACS (picture archiving and communications systems). Both RIS and PACS applications have migrated to the PC environment, enabling cost-effective implementation, but from two backgrounds: RIS from vendors using conventional information systems platforms and products, and PACS from radiographic film and modality vendors. The radiology department at Texas Tech University has assembled a seamlessly integrated, enterprise-wide RIS/PACS/teleradiology intranet. The design criteria include user-friendliness, flexibility to respond to changing needs, and open modular architecture to assure interoperability, cost-effectiveness, and future-proofing of investment. Since no single venor could provide an integrated system meeting our specifications, we decided to assume the burden of constructing our own system. As the system integrator, we embrace open architecture, thus enabling the incorporation of industry-standard-compliant, COTS (commercially off the shelf) products as modules. Microsoft Windows NT operating system, Visual C++ programming language, TCP/IP (transmission control protocol/internetworking protocol), relational SQL (structured query language) database, ODBC (open database connectivity), HL-7 (health level seven) and DICOM (digital imaging and communications in medicine) interfaces are utilized. The usage of COTS components reduces the cost to very affordable levels. With this approach, any module in our system can be replaced when outmoded, without affecting other modules in our system, making it truly future-proof. Construction and evolution of our system (TECHRAD) is reviewed.
Large-scale picture archiving and communication systems (PACS) have not been widely implemented in this or other countries. In almost all radiology departments film remains the medium for diagnostic interpretation and image archive. Chest imaging is the dominant screening examination performed within most imaging departments and as such, is an extremely high-volume, low-margin examination. Digital technologies are being applied to chest imaging to overcome limitations of screen-film receptors (limited latitude) and current film management systems (singleimage copy). Efficient management of images and information is essential to the success of a chest imaging program. In this article we report on a digital imaging and communications in medicine (DICOM)-based centralized printing network for chest imaging. The system components and their operational characteristics are described. Our experience integrating DICOM-compliant equipment supplied by several vendors is described. We conclude that the print model supported by DICOM is adequate for cross-sectional (eg, computed tomography and magnetic resonance) imaging but is too simplistic to be generally applied to projection radiography.
mini-PACS; digital imaging and communication (DICOM); laser cameras; print spooler
We propose a novel framework for management of cancer survivorship: electronic patient Self-Assessment and Management (SAM). SAM is a framework for transfer of information to and from patients in such a way as to increase both the patient's and the health care provider's understanding of the patient's progress, and to help ensure that patient care follows best practice.
Patients who participate in the SAM system are contacted by email at regular intervals and asked to complete validated questionnaires online. Patient responses on these questionnaires are then analyzed in order to provide patients with real-time, online information about their progress and to provide them with tailored and standardized medical advice. Patient-level data from the questionnaires are ported in real time to the patient's health care provider to be uploaded to clinic notes. An initial version of SAM has been developed at Memorial Sloan-Kettering Cancer Center (MSKCC) and the University of California, San Francisco (UCSF) for aiding the clinical management of patients after surgery for prostate cancer.
Pilot testing at MSKCC and UCSF suggests that implementation of SAM systems are feasible, with no major problems with compliance (> 70% response rate) or security.
SAM is a conceptually simple framework for passing information to and from patients in such a way as to increase both the patient's and the health care provider's understanding of the patient's progress, and to help ensure that patient care follows best practice.