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D-85375 Neufahrn . Fon +49-(0)180-5 372683 . www.esaote.de . [email protected]

6Surgery

IGS: The GPS ofarteries, plus

branched stentgrafts and minigamma camera

12Cardiology

Heart disease &women, stem

cells, stents,pulmonary

resuscitation

T H E E U R O P E A N F O R U M F O R T H O S E I N T H E B U S I N E S S O F M A K I N G H E A L T H C A R E W O R KEUROPEAN HOSPITAL

practitioners’ surgeries and hos-pitals but aneroid devices aremore frequently the choice due totheir mobility, as well as recenthealth/environment concernsabout the mercury equipment.

The study concluded that ifblood pressure readings are beingover-estimated by 3mmHg acrossthe population, the number ofpatients diagnosed as hyperten-sive would increase by 24%.Underestimation by the sameamount would result in 19%being diagnosed with betterblood pressure than was the case.

The Department of Health isreviewing the Blood PressureCommittee’s recommendations -which include calibrating aneroiddevices at least once a year - andnew guidance is expected shortly.

News . . . . . . . . . . . . . . . . 1-3IT & telemedicine . . . . . .4-5Surgery . . . . . . . . . . . . . .6-7Cardiology . . . . . . . . . . .8-15Respiratory medicine .16-17Radiology . . . . . . . . . .18-20Oncology . . . . . . . . . . . . . .21Laboratory &pharmaceuticals . . . . .16-19Awards . . . . . . . . . . . . . . .23

contents

High flyers andhigh earnersMoscow - Earlier this year four

Russian doctors were acquitted ofcharges of murder and attemptedmurder. Now, however, the prosecu-tors have succeeded in gaining a re-trial. They claim that the four doctorswere behind an organ-stealinggroup. The main case against theminvolves a man who had been treatedfor head injuries by the doctors, but,before this patient’s death, the prose-cution claimed they had prepared hisbody for organ removal and hadeven signed the death certificate.

One problem appears to be that, inRussia, doctors are allowed toremove organs for transplantationwithout family permission, and if norelatives object. Added to this, volun-tary organ donation has not beenwidely accepted in Russia.

Thus, during the doctors’ initialtrial, with inevitably high press cov-erage affecting the public, organtransplantation took a huge plunge.(Surgeons had also become wary ofcarrying out transplants, lest theyalso be charged with offences). Forkidney patients the situation is nowdire, because Russia also does nothave a sufficient number of dialysiscentres to treat patients.

Re-trial forRussian doctors

V O L 1 4 I S S U E 4 / 0 5 A U G U S T / S E P E M B E R 2 0 0 5

Thousands of foreign medicalprofessionals underpin theUK’s National HealthService (NHS). In 2004, of

the country’s newly registeredmedics, two thirds of the doctors,and over 40% of the nurses, hadcome from other countries. Intotal, about 72,000 of the UK’s212,000 registered doctors are notBritish. That figure includes, forexample, around 12,500 doctorsfrom Africa and, from the EU,3,764 from Germany.

Now a newer phenomenon haspresented itself: ‘the weekender’.

Wanting to race for a Fridaynight flight after a week’s work inyour own country, then to toil onmedical emergencies through toMonday, in a foreign countrywhere you often experience lan-guage difficulties, is not difficult tounderstand, if you know you willreturn home with €4,350 - just for

ends. Naturally, many do not. Inaddition, the British Government’smove to reduce the number ofdoctors recruited from Africa, fol-lowing pressure to prevent short-ages in their own nations, may beanother contribution factor.

The shortages of British doctors,and the supply and demand situa-tion, led health recruitment agen-cies - which supply the NHS withdoctors and nurses, for high fees -have flourished. Given the short-age of British doctors, naturallythey have also trawled further fordoctors. Thus, last year alone, 771German doctors registered for thefirst time to work in the UK.

To work in the UK, each foreigndoctor must register with theGeneral Medical Council. Thisprocedure involves a doctor goingthere in person, providing official-ly translated documents to provemedical qualifications, and thenpaying a fee of about €1,740 - lessthan half the fee mentioned forone weekend ahead.

United Kingdom - 53% ofaneroid sphygmomanometersused to measure blood pressuregave inaccurate readings during astudy led by Professor AndrewShennan, the Government’s chiefadviser on blood pressure mea-surement (Pub: Blood PressureMonitoring. 10(4):181-188,August 2005). Overall one in fivedevices was found to be of poorquality or faulty, indicating thepotential for misdiagnosis thatcould affect treatment decisions.Professor Shennan pointed outthat among over 100 modelsavailable on the market under adozen would pass validationtests.

Currently aneroid, mercuryand automated sphygmo-manometers are used in general

4IT & Telemedicine

ConnectedHealth in

Europe,trouble for

UK IT and adigital pen

€4,350 perweekend lures

Europe’s doctorsto UK

Illegal removalof organs

Danger Inaccurate sphygmomanometers

Hospital doctors’ salaries

Country Salary in €

Britain 104,000The Netherlands 97,000France 90,000Italy 81,000Sweden 56,000Denmark 50,000Germany 46,000Spain 44,000

These euro sums are approximate, and based on a

study by the UK’s National Health Service (NHS)

Germany: Breakdown of approximate monthly incomes in euros

Hospital doctors’ salaries vary according to age/grade

Junior doctor (aged 32, single) 3,500

Specialists or those who remain in the same grade for 5+ years 3,950

Senior physicians or heads of small departments (married with one child) 4,700

Head of large department with some head physician duties 5,300

Last year, the number of Germandoctors registering in Britain, com-pared with 2003, more than dou-bled. Frank Montgomery, Head ofthe Marburger Bund (Germany’sbiggest medical union) said that, ofthe country’s 145,000 hospitaldoctors, about 6,000 younger oneswork abroad permanently. Hebelieves this is due to the workinghours, hospital hierarchy, and thelow income in their own country.Only after aged 28 do they earnbetter figures, yet their workinghours can reach 80 per week. Tenyears ago, he added, almost allmedical students completed train-ing, but now a quarter abandonstudies, and another 25% choosedifferent professions after qualify-ing.

In Germany there have been payprotests and even strikes, and diffi-cult negotiations continue forlabour agreements. However,Frank Montgomery also believesdiscussions should also be focusedon German academic and publicsector structures. Why, he asks,cannot a senior physician receivethe equivalent of a private-sectorsalary?

Meanwhile, in Britain, somedoctors have expressed concernthat their foreign counterparts donot understand dialects in variousareas of the country, so cannotcommunicate well enough withpatients - nor do they understandthe healthcare system sufficiently.In addition, some of the incomingdoctors have spent hours in transitto the UK - too many to be alertenough to work.

one weekend’s work. Just comparethe annual income of doctors inthe eight EU countries and themonthly figures presented in theboxes. The fee earned in thatweekend nears what a seniorphysician earns in Germany after amonth’s work. No wonder an esti-mated 2,600 German physiciansnow regularly take those Fridayflights.

What caused this situation? TheUK is short of doctors. On top ofthis, last year, the NHS gave itsgeneral practitioners (GPs) theoption not to work during week-

2nd European Health Care CongressContact, Communication, Cognition,Contract. 28 – 29 November 2005.Düsseldorf

▼

2 EUROPEAN HOSPITAL Vol 14 Issue 4/05

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Ultrasound

wherever

you are

whenever

you need it.

High

Performanc

e

without

Compromis

e

MyLabWorld

new

new

new

new

new

new

new

VISIT THE

NEW MYLAB

WORLD AT ESC

STOCKHOLM

INTERNATIONAL FAIRS,

SEPT 3RD - 6TH 2005

BOOTH NO. 15.31

HALL C

ESAOTE BIOMEDICA Deutschland GmbH . Hanns-Braun-Straße 50

D-85375 Neufahrn . Fon +49-(0)180-5 372683 . www.esaote.de . [email protected]

6Surgery

IGS: The GPS of

arteries, plus

branched stent

grafts and mini

gamma camera12Cardiology

Heart disease &

women, stem

cells, stents,

pulmonary

resuscitation

T H E E U R O P E A N F O R U M F O R T H O S E I N T H E B U S I N E S S O F M A K I N G H E A L T H C A R E W O R K

EUROPEAN HOSPITAL

practitioners’ surgeries and hos-

pitals but aneroid devices are

more frequently the choice due to

their mobility, as well as recent

health/environment concerns

about the mercury equipment.

The study concluded that if

blood pressure readings are being

over-estimated by 3mmHg across

the population, the number of

patients diagnosed as hyperten-

sive would increase by 24%.

Underestimation by the same

amount would result in 19%

being diagnosed with better

blood pressure than was the case.

The Department of Health is

reviewing the Blood Pressure

Committee’s recommendations -

which include calibrating aneroid

devices at least once a year - and

new guidance is expected shortly.

News . . . . . . . . . . . .

. . . . 1-3

IT & telemedicine . . . . . .4-5

Surgery . . . . . . . . . . . .

. .6-7

Cardiology . . . . . . . . . . .8

-15

Respiratory medicine .16-17

Radiology . . . . . . . . . .18-20

Oncology . . . . . . . . . . . .

. .21

Laboratory &

pharmaceuticals . . . . .16-19

Awards . . . . . . . . . . . .

. . .23

contents

High flyers and

high earnersMoscow - Earlier this year four

Russian doctors were acquitted of

charges of murder and attempted

murder. Now, however, the prosecu-

tors have succeeded in gaining a re-

trial. They claim that the four doctors

were behind an organ-stealing

group. The main case against them

involves a man who had been treated

for head injuries by the doctors, but,

before this patient’s death, the prose-

cution claimed they had prepared his

body for organ removal and had

even signed the death certificate.

One problem appears to be that, in

Russia, doctors are allowed to

remove organs for transplantation

without family permission, and if no

relatives object. Added to this, volun-

tary organ donation has not been

widely accepted in Russia.

Thus, during the doctors’ initial

trial, with inevitably high press cov-

erage affecting the public, organ

transplantation took a huge plunge.

(Surgeons had also become wary of

carrying out transplants, lest they

also be charged with offences). For

kidney patients the situation is now

dire, because Russia also does not

have a sufficient number of dialysis

centres to treat patients.

Re-trial for

Russian doctorsV O L 1 4 I S S U E 4 / 0 5

A U G U S T / S E P E M B E R 2 0 0 5

Thousands of foreign medical

professionals underpin the

UK’s National Health

Service (NHS). In 2004, of

the country’s newly registered

medics, two thirds of the doctors,

and over 40% of the nurses, had

come from other countries. In

total, about 72,000 of the UK’s

212,000 registered doctors are not

British. That figure includes, for

example, around 12,500 doctors

from Africa and, from the EU,

3,764 from Germany.

Now a newer phenomenon has

presented itself: ‘the weekender’.

Wanting to race for a Friday

night flight after a week’s work in

your own country, then to toil on

medical emergencies through to

Monday, in a foreign country

where you often experience lan-

guage difficulties, is not difficult to

understand, if you know you will

return home with €4,350 - just for

ends. Naturally, many do not. In

addition, the British Government’s

move to reduce the number of

doctors recruited from Africa, fol-

lowing pressure to prevent short-

ages in their own nations, may be

another contribution factor.

The shortages of British doctors,

and the supply and demand situa-

tion, led health recruitment agen-

cies - which supply the NHS with

doctors and nurses, for high fees -

have flourished. Given the short-

age of British doctors, naturally

they have also trawled further for

doctors. Thus, last year alone, 771

German doctors registered for the

first time to work in the UK.

To work in the UK, each foreign

doctor must register with the

General Medical Council. This

procedure involves a doctor going

there in person, providing official-

ly translated documents to prove

medical qualifications, and then

paying a fee of about €1,740 - less

than half the fee mentioned for

one weekend ahead.

United Kingdom - 53% of

aneroid sphygmomanometers

used to measure blood pressure

gave inaccurate readings during a

study led by Professor Andrew

Shennan, the Government’s chief

adviser on blood pressure mea-

surement (Pub: Blood Pressure

Monitoring. 10(4):181-188,

August 2005). Overall one in five

devices was found to be of poor

quality or faulty, indicating the

potential for misdiagnosis that

could affect treatment decisions.

Professor Shennan pointed out

that among over 100 models

available on the market under a

dozen would pass validation

tests.Currently aneroid, mercury

and automated sphygmo-

manometers are used in general

4

IT & TelemedicineConnected

Health in

Europe,

trouble for

UK IT and a

digital pen

€4,350 per

weekend lures

Europe’s doctors

to UK

Illegal removal

of organs

Danger Inaccurate sphygmomanometers

Hospital doctors’ salaries

CountrySalary in €

Britain

104,000

The Netherlands97,000

France

90,000

Italy

81,000

Sweden

56,000

Denmark

50,000

Germany

46,000

Spain

44,000

These euro sums are approximate, and based on a

study by the UK’s National Health Service (NHS)

Germany: Breakdown of approximate monthly incomes in euros

Hospital doctors’ salaries vary according to age/grade

Junior doctor (aged 32, single)

3,500

Specialists or those who remain in the same grade for 5+ years3,950

Senior physicians or heads of small departments (married with one child) 4,700

Head of large department with some head physician duties

5,300

Last year, the number of German

doctors registering in Britain, com-

pared with 2003, more than dou-

bled. Frank Montgomery, Head of

the Marburger Bund (Germany’s

biggest medical union) said that, of

the country’s 145,000 hospital

doctors, about 6,000 younger ones

work abroad permanently. He

believes this is due to the working

hours, hospital hierarchy, and the

low income in their own country.

Only after aged 28 do they earn

better figures, yet their working

hours can reach 80 per week. Ten

years ago, he added, almost all

medical students completed train-

ing, but now a quarter abandon

studies, and another 25% choose

different professions after qualify-

ing. In Germany there have been pay

protests and even strikes, and diffi-

cult negotiations continue for

labour agreements. However,

Frank Montgomery also believes

discussions should also be focused

on German academic and public

sector structures. Why, he asks,

cannot a senior physician receive

the equivalent of a private-sector

salary?Meanwhile, in Britain, some

doctors have expressed concern

that their foreign counterparts do

not understand dialects in various

areas of the country, so cannot

communicate well enough with

patients - nor do they understand

the healthcare system sufficiently.

In addition, some of the incoming

doctors have spent hours in transit

to the UK - too many to be alert

enough to work.

one weekend’s work. Just compare

the annual income of doctors in

the eight EU countries and the

monthly figures presented in the

boxes. The fee earned in that

weekend nears what a senior

physician earns in Germany after a

month’s work. No wonder an esti-

mated 2,600 German physicians

now regularly take those Friday

flights.

What caused this situation? The

UK is short of doctors. On top of

this, last year, the NHS gave its

general practitioners (GPs) the

option not to work during week-

2nd European Health Care Congress

Contact, Communication, Cognition,

Contract. 28 – 29 November 2005.

Düsseldorf

▼

Signature Date

Please inform me about the Hospital AdministratorForum at the ECR 2006.

N E W S

Smoking linked to atherosclerosisAlthough, smoking kills so manypeople in the world the knowledgeabout pathophysiological processesis still extremely sparse, says DrDavid Bernhard, Head of theVascular Biology Working Party, inthe Experimental Pathophysiologyand Immunology Department,Biocentre Innsbruck, InnsbruckUniversity. ‘With the help ourresearch we were able to shed lighton how the atherosclerosis-riskfactor smoking causes atheroscle-rosis.’“When we started to focus ourresearch on the interaction ofsmoking and atherosclerosis, theonly thing that was well estab-lished, was the firm clinical andepidemiological knowledge thatsmoking causes/accelerates athero-sclerosis. This knowledge wasexpanded by a study from ourgroup (Knoflach M. Circulation;2003 Sep 2;108(9):1064-9.), wherewe demonstrated that cigarettesmoking is indeed the most impor-tant risk factor for early atheroscle-rotic vessel wall changes in healthyyoung adults. To our surprise,when we screened the literature toread about the pathophysiologicalprocesses that connect smokingwith atherosclerosis, we found veryfew studies. Despite the existence ofan enormous number of excellentex vivo analyses that correlatesmoking with atherosclerosis-asso-ciated factors, mechanistic studieswere missing. Probably, the mostlikely explanation for this was thefact that good in vitro models tostudy these phenomena were miss-ing.

This prompted us to set up an invitro system that mimics the in vivoproperties of the lung enabling theexchange of the smoke chemicals. Itwas our plan to set up a system

with in vivo-like chemical transferform the gas phase into the circula-tion. We designed and optimisedthe system in co-operation withchemists from the Institute forAnalytical Chemistry andRadiochemistry in Innsbruck.Cycles of system adjustment, chem-ical analyses of the generatedextracts, and comparison to smok-er blood chemical content, finallyled to the present chemically, welldefined and in vivo-like system.

After having set up the ‘smokingmachine’ we added the smoke con-stituent (SC) extracts to vascularendothelial cells, which are knownto represent the primary site of ves-sel wall damage that initiates ather-osclerosis. The smoke chemicalconcentrations were applied at‘physiologically’ relevant concen-trations.

The effects observed could bedivided into three phases:Damage phase: SC-mediated cellu-lar protein oxidation followed by afast, yet reversible contraction ofendothelial cells within one hourafter SC addition.Alert & repair phase of the cellswith massive up-regulation of oxi-dant defence and a secretion ofcytokines and chemokines.A decision phase (not startingbefore 12 hours of treatment) char-acterised by either an induction of anecrosis-like cell death or survivalcharacterised by the return of cellu-lar transcription activity as in cellsbefore the addition of SC.

Further, we could show that ciga-rette smoke contained metals in co-operation with carbon and nitrogenbased radicals oxidise endothelialcell proteins. Most importantly,this leads to damage of the struc-tures of the microtubule system cul-minating in their collapse.

Consequently, cytoskeletal andintermediate filaments collapsedresulting in vascular endothelialcell contraction. Electron micro-scopic analyses highlighted thatnot only gaps between cellsopened, but also that transcellularpores opened. Since increased per-meability of the vascular endothe-lium is known to constitute a pre-requisite for lipid deposition andinfiltration by monocytes of thevessel wall, these findings highlightfor the first time a functionalpatho-mechanism via which smok-ing causes vessel wall changesknown to contribute to atherogen-esis.

In addition, we demonstratedthat endothelial cells stressed withsmoke chemicals start secreting P-selectin, cytokines, chemokines,and present heat shock protein 60on their surface. By comparingthese results with patient sera (owndata and literature) it could beshown that the in vitro data accu-rately reflect events that occur invivo. Finally, depending on thedose and duration of the treat-ment, endothelial cells underwentcell death, with clear signs ofnecrosis. However, this cell deathdid not occur before 12 hours oftreatment, which is not typical forclassic necrosis. Some recent evi-dence suggest that this cell deathmight be the result of the cells‘will’ to undergo apoptosis, butthis seems to be inhibited by smokechemicals. As a result vascularendothelial cells switch on a rescuepathway that leads to necrosis.Necrosis is known to cause inflam-mation, and since inflammationcontributes to all stages of athero-genesis, necrotic endothelial celldeath by smoke chemicals is likelyto initiate this vicious circle.”

‘Non-beating heart’lung transplantsThe Netherlands - Two lung transplants, usinglungs from ‘non-beating’ donors, have beensuccessfully performed at Groningen UniversityHospital for the first time in this country. Thehospital now expects to increase lung trans-plants by 25% - about 50 operations annually.

Lung transplants in the Netherlands havedoubled in the last two years due to the accep-tance of less severe criteria for the acceptanceof donor lungs; better preservatives for theorgans and the opening of the country’s secondlung transplant centre. Nonetheless, costs plusthe shortage of donor lungs still leave an ever-growing list of patients awaiting transplants. Tomeet the shortage, along with its ‘beatingheart’ donations - from brain dead donorswhose breathing and blood circulation wereartificially induced till the moment of organextraction - the university hospital began its‘non-beating heart’ lung donation. This meansthat the donor’s blood circulation and hearthave stopped and the patient is dead.

The first pair of lungs was transplanted in toa patient with cystic fibrosis, with extremely lit-tle lung function, whilst the second pair wasimplanted in a patient suffering emphysema. Inboth cases the donors had severe brain damage,in whom no brain death could be diagnosed.After diagnosis of the death of both donors thelungs were washed with preservatives andremoved within 30 minutes. Later, the lungswere implanted in the patients.

Non-beating heart donations of kidneys andlivers have take place for several years in theNetherlands, and those results are comparablewith results of transplants with organs fromheart-beating donors. Lungs are the last organsadded to the non-beating heart donation pro-tocol and they can be removed along withother organs from a formerly fit donor.

By MichielBloemendaal

The Netherlands - On 25 May 10,000 Dutch GP’s went on strike inthe Hague, blaming the minister of health, Mr. Hans Hogervorstfor too little pay per patient and their fear of too much interven-tion from insurance companies regarding treatments. What elsecould they do to pressure the minister? No evening and weekendduties? Or ask for fresh negotiations?

The minister believed he had negotiated sufficiently, and said soin letters to the doctors, which many returned them unread. Theminister had offered €48 per annum per patient and €7 per visit.However, the GP’s feared that when, on 1st January the newhealth system would begin, their income would be drasticallyreduced and they would face far more administration to negoti-ate with health insurers. (In the new system, GP’s would have tohand over a part of their expenses remuneration to the insurers,which they had fought against since November).

What was the reaction of their counterparts in the hospitals?They only feared extra work, but they did make arrangementsand planned extra staff in first aid units during the strike.Checking on several hospitals in the region I discovered barely aproblem, and patients did not suffer, except financially. (InHolland a health service patient receives a bonus at the end of theyear if he/she has not visited a GP too often. Visiting a hospitalreduces that bonus).

Negotiations began again. This time, it was successful. With thehelp of a mediator, first members of the Dutch association of GPsagreed with new financial plans. In addition, the Minister ofHealth said he was pleased with the result - indeed, he receivedthe cabinet’s blessing: by reshuffling a few million he hasremained within the limitations of his budget. As for the insur-ers, although they had to accept some measures that were lessattractive than those in the original plans, they too opted toaccept the final propositions.

The plan: From 1st January 2006, GPs will be paid €52 per reg-istered patient per annum and Ä 9 per visit. (Originally the doctorsasked €55 and €11.56 respectively. Additionally, doctors can askinsurers for means to finance and support their practices: €49 mil-lion compensation for work in poor districts and those with manyelderly patients, about €25 million and for modernisation andnew local initiatives. Furthermore, there will be no alterations inthe general policy in the next two years.

GP’s and minister onspeaking terms again

EUROPEAN HOSPITAL Vol 14 Issue 4/05 3

www.siemens.com/medical

M-Z

91

5-1

-76

00 Proven Outcomes in Healthcare. Cutting

costs. Optimizing workflow. Advancing the

quality of care. Impossible? On the contrary: We can prove

it. Across every clinical setting, we are helping health-

care become more efficient, more effective, and more

profitable.

With solutions that apply cutting-edge technology and

strategic problem solving. So you can focus on essentials –

and make the vision of the fully integrated hospital a

reality. These are the Proven Outcomes that are trans-

forming the delivery of healthcare. Today.

We see a way to obtain 80% more examinationswithout a major increase in staff

Proven OutcomesRecouping days of productivityand millions in revenue.

Siemens Medical Solutions that help

Results may vary. Data on file.

N E W S

8th European Health Forum Gastein (EHFG)Austria - The politics of health-care, specifically in Europe, willattract ever more participantsfrom political arenas, healthcareadministrators and medical com-panies to Bad Gastein this year.Along with the EU HealthCommissioner Markos Kyprianou,Ministers and Secretaries of Statefrom Austria, Finland, Ireland,Lithuania, Romania, Slovakia andHungary have already confirmedtheir attendance.

The focus will be on e-healthand personal responsibility, and aseparate event will cover infra-

structure investments. Pointingout that, along with plenary ses-sions and 14 workshops, there willbe six forums, and a separateevent with over 100 specialist lec-tures by leading experts and politi-cians involved in healthcare, cover-

Nominationssought forDan David

PrizeIsrael - For the fifth consecutiveyear, the Dan David Prize, head-quartered at Tel Aviv University,will award three prizes of US$1million each for achievements hav-ing an outstanding scientific, tech-nological, cultural or social impacton the world. Named after DanDavid, international businessmanand philanthropist, the prize isfunded by the Dan DavidFoundation.

Each year, fields are chosenwithin three ‘time dimensions’ -past, present and future, and lau-reates for a given year are chosenfrom these fields. This year theselected fields are: PreservingCultural Heritage: Individuals’Contributions (past); Journalists ofPrint Media (present); and ‘CancerTherapy (future).

The laureates annually donate20 scholarships of US$15,000 eachto outstanding young researchers(doctoral and post-doctoral stu-dents) throughout the world in thechosen fields.

The 2006 Dan David Prize inthe Future Time Dimension(Cancer Therapy) will recogniseindividuals’ initiatives aimed atreducing cancer-related mortalityand alleviating the daily sufferingof cancer patients. It will honourindividuals who have made out-standing contributions to thedevelopment of the field of cancertherapy in its classical aspectsincluding surgery, chemotherapyand radiotherapy, or in more con-temporary aspects such as genetherapy, immunotherapy, biologi-cal therapy and targeted therapy.

Bucharest-born Dan Davidfounded the Prize in 2001. Aspresident of Photo MeInternational PLC, which makesautomatic colour photo boothsand other professional photo-graphic equipment, Mr Davidbecame a philanthropist and hassince wished to aid and fosterthose involved in developing andadvancing world knowledge of thepast, present and future.

ing the following areas: ● Civic participation and personal

responsibility ● Health as a burden... or as a

growth factor?● New impulses from the

European Commission (EC). ● E-health● Promoting investment in the

framework of the EU StructuralFunds.

The EHFG will hold a separateevent on 4 October, where high-ranking representatives of the EC,OECD and the WHO will be pre-sent. This aims to inform and pre-

pare decision makers.It has always been the most impor-

tant objective of the EHFG to intro-duce new developments in health-care politics and administration, andto be a think tank for these, theEHFG president Gûnther Leinerpointed out. ‘With our key topics weare tackling the “hottest potatoes”in current healthcare politics - if nosignificant progress is made in theseparticular areas, the enormous scien-tific progress in modern medicinewill be of little benefit.’Details: [email protected] www.ehfg.org

Electronicregister to speed

treatmentsGermany - An electronic register,set up by the health fund TechnikerKrankenkasse (TK) and the GermanFederal Association of Cardiologists(BNK), has enabled clinics andrehabilitation centres in Munich andHamburg to gain direct access toelectronic patients’ records (EPRs).Doctors at the centres are now co-ordinating their work to achievespeedier responses and treatments -not just in emergencies.

TK and BNK report that thesystem is to be extended to furtherregions around Germany this year.

4-8 October 2005


I T & T E L E M E D I C I N E

Filing and mailing in one smooth move

By MichielBloemendaal, ourcorrespondent inthe Netherlands

The Netherlands - Sending mailwhen on a train, or filing handwrit-ten notes in the PC without carryinga laptop, seemed but a dream. Toadd patients’ medical details directlyto their files was even more of afantasy. That is, until a new systemlanded in the Netherlands fromGermany. I recently visited the firmMeetpapier, based in Wormer, nearAmsterdam, to see the phenomenon- Dotform technology.

Meetpapier is well known inDutch healthcare for delivering, forover 30 years, all kinds of paperproducts, e.g. formulas for ECG andEEG registration. However, due tothe burgeoning use of computersand printers in healthcare institutesand hospitals, Meetpapier neededto present other products. The firm’smother company, DiagrammHalbach, in Germany, had the solu-tion: Anoto-technology, in which aspecial pen writes on digital paperand then those details can be filed ina PC.The digital pen - This can store upto 150 pages of written data and,when ready, it can be uploaded fromthe pen to a server - automatically -whenever the pen is inserted into adocking station connected to thecomputer by USB cable or byBluetooth link to a mobile phonethat links to a web server. Powerrecharging is via the docking stationor a separate power cable. The datain the pen includes all positioningco-ordinates and the time they wererecorded, plus the pen’s individualID number. Digital paper - The second compo-nent is a dotform digital form, whichresembles any other form, and isprinted on the same paper or sub-strate as a regular form. The onlydifference is a very fine dot gridprinted on the background. The penreads this dot grid as absolute co-ordinates, which tell it where and onwhich page it is writing. Diagramm

Halbach is the first printer inGermany to undergo certificationfor this process, and they are certi-fied to print forms with that dotgrid. Printing - A special Swedish tech-nique is used to print the paper. Thedots are placed in the matrix of 6x6with a surface of 1.8 millimeter2whereby a per-dot space of 0.3 by0.3 millimetre is available. Due tothe method of production, eachsheet of paper printed in this wayhas a completely unique character,so it is always clear what informa-tion is imported to which place. Thusthe pen can register what has beenwritten, then the written text can beused in various systems, and it is alsoclear when the data were importedand by whom. Via a minuscule cam-era, the pen records written text inits own memory - storing 100 writ-ten forms. The pen not only fileswritten text, but also registers themoment it was filed, proving theauthenticity of written text, bywhich mailed signatures are autho-rised. Hospital applications Possibilities are enormous - there isample need to send e-mails withouta PC or notebook, but the big advan-tage of this system is the chance toregister medical data, for example,in an electronic patient’s file. The

data are written on a specially devel-oped form and could be filed imme-diately in the computer system, tobe turned by ASCII into reports andother documents.

It is even possible to mark on aform, via a ‘painline’, how muchpain a patient is experiencing, whichcan be shown immediately on acomputer screen. Another option:on a form showing a drawing of ahuman body, the position where apain is located could be marked,eliminating the need to describe thezone.

A further advantage is that,although each ward may design itsown form, all data could be filed ina uniform way, for use in all wards,without extra handling and adapta-tion, thus saving considerable time.Try it - The new system, presentedby Diagramm Halbach in Europe asDotforms, is offered as a starter kit.For six months, a hospital, ward orindividual doctor can use the pen,plus a pack of paper and othernecessities, to explore the possibili-ties, develop their own forms anddevelop these further with helpfrom Dotform.

Finally: This system is not only forpatients’ data filing, but also forcoping with statistics availableonline or as stand-alone. E-mail details: [email protected]

Information is as vital aresource in healthcare today

as the scalpel, writes KevinDean, adding that patients

also expect to have access tothe same level of high-

quality, timely, customer-centric healthcare services as

they have for banking,insurance, travel, and retail

interactions. So why, he asks,do healthcare services still lag

behind other organisations?The author also outlines how

far some EU countries haveprogressed today

In the late 1990s, the healthcareindustry incubated a series of e-health initiatives but today e-health is still viewed as ‘special’projects, outside of the normalday-to-day management of care,and there are powerful barriers toextending the use of IT in health-care. However, healthcare servicescan no longer ignore the impor-tance of accurate and timely infor-mation.

However, to be truly effective,that information must be securelyconnected across organisations,professional specialisations, andincreasingly, national boundaries.

Thus e-health must evolve into‘Connected Health’, meaning thatwe must focus on ensuring thesecure and timely flow of patient-care information to its point ofneed. A modern health systemmust have a portfolio of activitiesthat connect citizens, patients, clin-icians and managers:● Clinical information and tools

dealing with complete informa-tion set on patient treatment

● Continuous retraining of profes-sionals (and patients) in themost effective treatments andprevention of diseases

● Operational management ofhealthcare organisations (HR,finance, supply chain)

● Patient/public engagement tohelp them manage lifestyle,chronic diseases, and communi-cations when under treatment

● Public health and performancemonitoring across regional ornational health systems.Such activities must be under-

pinned by a secure and increasing-ly interactive infrastructure thatallows data to be shared safelyand effectively for treatment andprevention. Making this connect-ed environment possible is a CiscoMedical-Grade Network that actsas a digital nervous system,securely and reliably carryingdata, voice and video to whereverneeded.Creating Connected Health inEurope - Fortunately, manyregional and national govern-ments in Europe have recentlyrecognised the importance of con-nected information in healthcare.The key change is an increasedeffort to move from isolated e-health projects to a systematicapproach that ensures access,quality, and lower cost of careacross wide communities.However, each country’s individ-ual culture, funding, and adminis-trative systems determine very dif-ferent approaches to creating aConnected Health environment.

Two countries with contrastingapproaches are England andDenmark. In 2002 England’sNational Health Service (NHS)created a single national pro-gramme that provides standard-ised clinical information tools andrecord management. Resultingfrom ambitious goals and sched-ules, England now has a strongnational IT governance structuresupported by a multibillion-Eurofund, nationally led procurementand specification of informationand technology services, a criticalinfrastructure that links regionaland local organisations securely,and a newly formed organisationthat creates national plans andprovides resources.

1,000,000e-cardsdeliveredAustria - The millionth social insurance e-card has been delivered since national dis-tribution began at the end of May.

At the Munich-based firm Giesecke &Devrient (G&D)*, which provides the card,Michael Nitz, head of the Industry andGovernment division, predicted that alleight million cards will have been deliv-ered by November.

Aiming to replace Austria’s currentpaper-based healthcare vouchers with anup-to-date electronic health card, in April2004 the Federation of Austrian SocialInsurance Organisations commissionedG&D to develop a high-performancesmart card. (This e-card is also theEuropean Health Insurance Card). By theend of that year, in an initial test phasethe e-card went on trial in two practicesin Burgenland, in real-time operation.When the tests had been completed suc-cessfully at the end of February this year,the trial was expanded to take in 80 med-ical practices with around 110,000patients in the Eisenstadt, Neusiedl, andRust districts. After that successful trial,countrywide delivery of the e-card began.

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30 Nov - 1 Dec 2005Bremen Fair CenterBremen Germany

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The fi rst focused business forum for• Voice Communication• Voice over IP• IP Security• Wireless Communication• New Systems• Possible Applications• Cost Saving Potentials

United Kingdom - The £2.3 billionNational Programme for IT (NPfIT),being set up for the National HealthService (NHS), is under threatbecause there was so little consulta-tion and communication from NPfITofficials and this posed a threat tothe programme being successful,according to a study carried out atthe London School of Hygiene andTropical Medicine (LSHTM) and pub-lished in The British Medical Journal.The LSHTM study also suggeststhat, although planned to be opera-tional by the end of 2007, the NPfITprogramme is falling behind sched-ule in key areas.

Dr Naomi Fulop, LSHTM healthpolicy researcher, added that,among the 23 managers and clini-cians interviewed in four hospitalTrusts, some clinicians felt unin-volved and wondered if the newsystem would actually meet theirneeds.

The researchers also warned that,while the new system is beingdeveloped, hospitals must continue

TROUBLE for the world’sbiggest healthcare IT project

to use their old IT systems - includ-ing, in some cases, those in radio-logy and pathology. ‘A new patientadministration system has to beinstalled in every Trust. WhileTrusts are waiting for this, thereare concerns, including concernsfor patient care,’ Dr Fulopexplained.

Although hardware/software forthe new IT system will be centrallyfunded, managers also said theywere uncertain about where fund-ing would come from for stafftraining and to cope with otherwork changes foreseen when thenew NHS system goes online.

‘We are not saying the introduc-tion of a new system is not a goodthing,’ Dr Fulop concluded. ‘It is,and it will take the NHS forward.’However, unless these concerns areaddressed, she added, ‘There willbe delays in implementation and aless-than-optimal use of the newsystem when it is finally intro-duced. And this will be a bad thingfor all concerned.’


I T & T E L E M E D I C I N E

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Kevin Dean, Director ofPublic Sector Healthcare,Internet BusinessSolutions Group, CiscoSystems Inc. helpspublic sector healthcareorganisations todevelop policies,strategies andimplementation plansfor connecting healthcare supported by IT.His team works with many governments,as well as regional and local publichealthcare providers around Europe. He iseditor of the IT book Connected Health -Essays from Health Innovators (ISBN 0-9546445-0-6. Premium Publishing, 2003/4),and he has produced, in conjunction withthe Healthgrid Association, a Whitepaperdiscussing the use of grid technology inHealthcare (November 2004).

Denmark, on the other hand,has seen comparatively slow, large-ly user-led and modest increases infunctionality over the past 10years. Led by MedCom, a tempo-rary project organisation chairedby the Danish MoH, the countryhas sustained standards for clinicalmessaging. With modest budgetsand light staffing, direction isdetermined by consensus overtime. Clinical acceptance has beenhigh, and Denmark is now sharingmany lessons learned with other

Along with eight million cards, G&D isdelivering a complete solution thatincludes an electronic card managementsystem. The numerous functions on anindividual card were made possible bythe Card Application ManagementSystem (CAMS), which manages all dataand applications on the card throughoutits life. ‘A system such as this is essentialif future additions to the card function-ality - whether already planned orpotential options - are to be managedwithout replacing the cards,’ G&D pointsout.

Starting in 2006, the Austrian govern-ment is said to be planning additionalapplications for the e-card: it is pre-setto be used as a citizen’s card and idealfor use as a high-tech ID document in e-government applications, as envisagedby the Austrian authorities, G&D says.‘Official requirements for signature func-tions, encryption processes and storagecapacity are already met in full.’* In 1852, Munich-based Giesecke &Devrient began as a printer of securities,then specialised in banknote production.Since 1970, the firm has developed solu-tions and complete systems for auto-matic currency processing. Today theinternational company produces smartcards and provides solutions in telecom-munications, electronic payments, iden-tification, health, transportation, and ITsecurity.

ciently. However, its fragmentednational, regional, and local man-agement; and its relationship tosocial security for payment makesfor some difficult decisions interms of budget creation, gover-nance model, and balance betweencentralised and localised solutions.In the meantime, leading hospitalssuch as the Centre Hospitalierd’Arras are demonstrating theimportance of Connected Healthsystems. The hospital has trans-formed its operation from the

ground up by re-building the cam-pus, automating administrativeprocesses and enabling a newwork culture. A state-of-the-artCisco medical-Grade Network hasprovided mobile access to cen-tralised data for hospital staff andregional health centres, helping toimprove efficiency, reduce costsand enhance patient care.

Most interesting is the contrastbetween Western and EasternEurope. Western European coun-tries, with decades of legacy sys-

tems, may well proceed slowlycompared to their Eastern neigh-bours. The new EU membersHungary, Estonia, Slovenia, aswell as Bulgaria are developingremarkably sophisticated commu-nication infrastructures, have littlelegacy and scepticism to overcome,and often have a more generalhealthcare reform programme todrive information usage. Thesecountries have the opportunity toleapfrog to a Connected Healthsystem in short order and, in the

next few years, deliver world-leadinghealth systems where informationand knowledge are among thepatients’ and clinicians’ most impor-tant tools.

For all European countries, the‘acid test’ for their development ofConnected Health is to assess thecompleteness of their vision andfunded plans for IT in healthcare.These include clinical treatment,knowledge and learning, operationalmanagement, patient engagementand public health supported by asecure, resilient, and interactiveinfrastructure. Those with a compre-hensive vision for Connected Healthwill gain immense benefits frominformation-transforming healthcare.

Connected Health in Europe

countries (e.g. Baltic E-HealthExchange).

Alternative approaches can beseen in Germany and France.Germany, with its compulsory,highly regulated care system, hasfew options to encourage dramaticchanges in the use of informationin healthcare. However, Germanycreated a national smartcard pro-gramme with rapid implementa-tion targets to give each of its 80million citizens access to a trans-portable identifier and basic med-ical record. To increase safety andcitizen mobility, the country is alsotaking a leading role in Europeaninteroperability initiatives.

France is looking for ways tocontrol growing healthcare costsby transferring health recordsbetween organisations more effi-


S U R G E R Y

IGSThe GPSof arteries

Image-guided surgery (IGS) isbased on an evolving technol-ogy, and is mainly developedfor minimally invasive proce-dures. Minimally invasivetreatment has expandedtremendously during recentyears. It represents a

decreased trauma to the patientcompared with open surgery. Thiscould again lead to shorter conva-lescence and hospital stay and lesspostoperative pain for the patient.

So far, the majority of developedsystems for IGS have beendesigned for neuro-surgery, butother clinical applications areemerging, such as otologic proce-dures, hepatic surgery, orthopaedicsurgery and endovascular proce-dures. In the most advanced sys-tems available today, IGS providesthe surgeon with a two- (2D) andthree-dimensional (3D) visual‘road map’ of the patient’s anato-my, including the surgical instru-ments used during the procedure.This is similar to the situationwhere a ship with a GPS (globalpositioning system) installed canplot its position on a map (fig 1).Surgical navigation depends on a‘map’ of the body, such as a CT-volume combined with informa-tion about where the surgeon’stool is located. The latter is pro-vided by a positioning system.Prior to the development of IGS,surgeons performing minimallyinvasive surgery (MIS) could onlysee the surface area visible fromthe end of the imaging device, e.g.a laparoscope. IGS overcomes thislimitation and provides the sur-geon with real-time enhanced visu-alisation. Thereby the surgeon cangain access to anatomic areas thatotherwise would be difficult toreach.

An IGS system combines a high-speed computer system, specialisedsoftware and tracking technology.On this computerised system theactual movements of the surgical

instruments are correlated with thepatient’s preoperative medicalimages and are displayed on thesystem’s monitor. The precision ofcomputerised instrument localisa-tion and navigation is critical formanoeuvring safely within con-cealed anatomy and for the sur-geon to perform more precise andcareful surgery. However, mostIGS systems are based on preoper-ative images, sometimes acquiredthe day before surgery. This meansthat, as surgery proceeds, theimages could become continuouslyless representative for the actualanatomy of the patient.Introducing intra-operative imag-ing modalities, such as ultrasound,can solve this problem.

Prior to surgery, the MR/CTimages are imported into our in-house developed navigation soft-ware, CustusX, and reconstructedinto a regular 3-D volume. Thepreoperative MR/CT images areregistered to the patient. Surfacesof a few essential organs areextracted from the image data andvisualised in a 3-D scene. The sur-gical tool controls the visualisa-tions on the navigation monitor,and these images are updated con-tinuously (in real time) accordingto both position and orientation ofthe pointer.

In addition it is possible to dis-tribute the 3-D intra-operativescene to the radiology departmentusing CustusX. Both the radiolo-gist and the surgeon in the operat-ing room are able to interact withthe data. With this collaborativefeature it is possible for the sur-geon to get expert advice withouthaving the radiologist present inthe operating room.

Endovascular therapyEndovascular techniques areincreasingly used in the treatmentof diseases of the main blood ves-sel (aorta) in the chest orabdomen. Previously, it was neces-

sary in all cases to use large inci-sions and these operations weremore traumatic, necessitating alonger stay in the intensive careunit (ICU) and the ward. Followingminimally invasive surgery e.g. ofan abdominal aortic aneurysm, thepatient can get out of bed after afew hours and prepare his ownbreakfast the next morning.

However, so far some patientscannot be treated by endovasculartechnique because the disease israther extensive without a place forfixation of the stentgraft. A stent-graft is a synthetic prosthesis con-sisting of a textile part with a thinmetal net on the inside. The stent-graft is compressed and deliveredinto an introducer system. Thisimplant is introduced into the vas-cular system through a small inci-sion in the femoral artery in thegroin and regional anaesthesia isapplied. As soon as the properposition for the stentgraft isobtained the introducer system iswithdrawn and the stentgraftexpands. It is fixed to the arterialwall by radial forces, hooks andbarbs. The patient is awake duringthe procedure. In most cases thistechnique is used for aorticaneurysmal disease (dilatation ofthe aorta) or so-called aortic dis-section where the blood is runningin a false lumen within the arterialwall.

In order to offer endovasculartechniques to a broader group ofpatients, there is a need for stent-grafts with side branches or fenes-trations, which can lead the bloodfrom the main prosthesis into themajor arterial branches to thehead, arms, kidneys (fig 2), liverand bowel. To obtain this there isneed for a new prosthesis, as men-tioned. Furthermore, we need flexi-ble introducer systems and thestentgrafts with the side branchesneed to be deployed accurately andeasily.

The surgical tools used inendovascular therapy areguidewires and catheters.Therefore, navigation will dependon well-functioning micro-position-ing sensors, which can be adaptedto these small instruments. We alsothink it is possible to adapt micro-positioning sensors (<1mm) to thestentgraft itself. We are looking forindustrial collaborators who cancombine the small sensor withcatheters, introducers or perhapsstentgrafts, and think that this isgoing to expand the indications forendovascular therapy in general.For navigation our own systemCustusX meets these requirements.

We are also using the so-calledDYNA CT principle (Siemens)where the C-arm of an angiogra-phy unit rotates providing us withreal-time 3D-images of the vasculartree. With these techniques wethink that within a few years wewill be able to repair most parts ofthe arterial system using minimallyinvasive technique.

The navigation system could alsobe useful for re-operations wherearteries and other structures areembedded in heavy scar tissue andwhere dissection is difficult.Development and clinical testing ofCustusX will be one of the mainactivities within the endovascularFuture Operating Room project atSt. Olavs Hospital in Trondheim.Contacts: [email protected] [email protected] Details: www.stolav.no/FOR www.sintef.no/Medtech

Figure 1: GPS navigatorindicating the position of a ship.Below: A similar situation within

an aneurysm of the abdominalaorta. A position sensor indicates

the tip of an introducer system,which is useful for exact

deployment of a stentgraft usedto repair the aneurysm

Figure 2: Abdominal aortic aneurysmstarting near the renal arteries. One ofour main goals is to apply a stentgraftwith side branches. In this case, a sidebranch has been introduced into theleft renal artery. In the right renalartery the side branch is about toexpand and the position sensor can beobserved in the artery

In our last issue we featured the Future OperatingRoom Project developed at St Olavs

Hospital, University Hospital ofTrondheim, Norway, a collaboration

between the hospital and theNorwegian University of Science and

Technology. There, highly promisingresearch on navigation is being

carried out in co-peration with the research foundationSintef Health Research. Professor of Surgery Hans O

Myhre (above) of St Olavs and Senior Research ScientistJon Harald Kaspersen PhD (below), of Sintef, describe the

project’s aims, their development andclinical testing of the navigation

system CustusX, and the need thathas now arisen for industrial

collaborators to take the team’sdiscoveries forward to expand

indications for endovasculartherapy in general


S U R G E R Y

Germany - Chromophare D510, D540 and D660 sur-gical lights - newly launched by

Berchtold GmbH & Co KG, of Tuttlingen, incorporatethe firm’s new Reflective Illumination Technology(BRITe), providing 50% more total light while ensuringsurgical site coolness. The maker reports that the halo-gen light technology has a unique internal bulb coat-ing that reflects radiant energy back to the bulb fila-ment and generates more useful light: ‘Combinedwith our custom colour-correction filters and provenpolygon reflector, the natural colour-rendering prop-erties of the Chromophare series have been main-tained. The new surgical lighting system delivers uni-formly brilliant, penetrating and shadow-free lighting

Mini gamma camerafor radio-guided surgery

to surgeons performing both large-surface and deep-cavi-ty procedures.’

Along with the Chromophare range, also produces theSupersuite Integrated OR Solution, Orics operating theatrecommunication equipment and Operon Surgical Tables foroperating theatres.

France - The first EC marked miniambulatory gamma camera hasbeen launched by Euromedical,which specialises in antra-opera-tive detection and is part of theEurorad group. Named Minicam,the system was developed forradio-guided surgery, to preciselylocate radioactive-tagged tissues(sentinel node, tumour etc.) emit-ting gamma radiation, whichallows the smallest possible inci-sion to be made.

‘With its CdTe technology detec-tor head (camera) and a g-Camelectronics module, the Minicamsystem ensures very rapid detection(one minute) of the sentinel nodeor tumour, saving a significant

of the kind of picture wanted for dis-play as well as various acquisitionparameters.

The system, which is installed onan ambulatory cart, is fixed and setup with a Geomed Assisto fixing arm(stand).

Currently the Minicam system is inuse at the Institut Curie and InstitutGustave Roussy, and several are usedin Spain, the Netherlands and theUnited Kingdom. Details: www.em-instruments.com

OphthalmologyPerforating keratoplastyGermany - Four penetrating kerato-plasties using the Femtec femtosecondlaser have improved the vision of allthe patients, according to a reportfrom 20/10 Perfect Vision OptischeGeräte GmbH.

Dr Mark Tomalla, of the Centre forRefractive and Ophthalmic Surgery inDuisberg-North’s eye clinic, used thesystem to treat transparent as well asscarred corneal tissues. Apart fromflap preparation during Lasik proce-dures, the Femtec femtosecond laserwas reported as very effective in thepreparation of tunnels before implant-ing ICRS (intracorneal ring segments)and performing cuts for AK (astigmat-ic keratotomy) with ‘impressive post-operative results’

50% more light yet cool

amount of time and providing again in precision for the surgeon,’the firm announced. ‘Speciallydesigned for small operative fields,the MINICAM also helps to easecongestion in conventional nuclearmedicine departments, that canthus be reserved for examinationsrequiring more cumbersome equip-ment.’

Connected to a desktop comput-er, the Minicam system providesvisualization of images being taken(acquisition software installationdisk supplied). The detector head,made with cadmium telluridedetectors (CdTe or CdZnTe), isdesigned for low-energy detection(30 - 200 keV). ‘It has excellentspatial resolution and provideshigh quality pictures,’ the firmpointed out.

The camera contains all neces-sary modules for signal processing,and the software allows selection


C A R D I O L O G Y

So far, 2005 has been abusy year for therapidly evolving tech-nique of stenting.There have been newdevices, new guide-lines, and the resolu-tion of a major

debate. The stent and more so thedrug-eluting stent (DES) story willbe taken forward at this year’sEuropean Society of Cardiology(ESC) Congress (see box) with thepresentation of the latest researchfindings in this exciting therapeuticarea.

The ESC presentations comple-ment data presented at otherrecent major cardiology meetings.At the EuroPCR 2005 meeting

Interventional Cardiology Unit,Clinique Pasteur, Toulouse, France,and Professor Sigmund Silber,Gemeinschaftspraxis Hospital,Munich, Germany) reviewed thedata, they concluded that the riskof thrombosis associated with thetwo stents could not be shown todiffer, neither could the clinicaloutcomes.

Professor Silber, who is alsoChairman of the ESC Task Forceresponsible for drafting the firstEuropean Guidelines onPercutaneous CoronaryInterventions (PCI) (Silber et al.Eur Heart J 2005;26:804-47), saidthe REALITY trial would need tohave recruited more than 10,000patients to have been adequately

Professor Silber said that all DESmust prove their efficacy in ade-quately powered randomised trialswith a primary clinical endpoint.‘So far only three DES haveaccomplished their homework -Cypher, Taxus and Endeavor,’ hesaid. The panel agreed thatresearch should move away fromtrying to prove superiority of oneof the current DES over the other,and should focus on new innova-tive developments in the field ofDES. Of these there have been sev-eral. In July 2005 Medtronicannounced that they had receivedCE (Conformité Européenne)mark approval for Endeavor, thefirst cobalt alloy DES. Choice ofstent will be further enhanced in

CABG and PCI using BMS or DEShave been limited to highly select-ed patient populations. The study’sprimary endpoint is the 12-monthmajor adverse cardiac and cerebralevent (MACCE) rate, whichincludes death, myocardial infarc-tion, repeat revascularisation andstroke. SYNTAX will also analysethe long-term health economicimplication of DES versus CABG.

Economic impactHealthcare providers are increas-ingly interested in the cost-effec-tiveness of new therapies. To datethere have been no studies com-paring the cost-effectiveness ofDES and CABG in randomisedclinical trials. Recent studies from

NewESC PCI

GuidelinesEarlier this year the EuropeanSociety of Cardiology (ESC)released the first EuropeanGuidelines on PercutaneousCoronary Interventions (PCI).According to these guidelines,PCI can now be regarded as thefirst option for a larger group ofpatients with acute coronarysyndromes than before. Recenttechnical and pharmacologicalimprovements have developedPCI into a procedure that can besafely and effectively applied topatients with various types ofcoronary lesions and patientswith and without myocardialinfarction.

The guidelines can be viewed at: http://www.escardio.org/knowledge/guidelines/PCI-Guidelines.htm?1703

Figure 2: European conversion rates from BMS to DES

powered to show a difference inrates of stent thrombosis for Taxusversus Cypher (in fact only 1,353patients were recruited). The panelalso pointed out that the recom-mendations regarding antithrom-bolytic therapy post-DES implan-tation varied, and that comparedto previous studies with bare metalstents (BMS), DES have been scru-tinised significantly more vigilantlyfor thrombosis and other risks.

Professor Marco added that reg-istry data comparing Taxus and

the coming months with thelaunch of the ‘next generation’Taxus Liberté DES (Figure 1),which is claimed to be specificallydesigned for improved deliverabili-ty - a crucial consideration forsmall vessel stenting.

Indeed, the move towardsincreased use of stents for complexlesions has been a recurrent themeof 2005 developments. At the ESCCongress, the landmark SYNTAXtrial, which has recently startedpatient enrolment, will be present-

(Paris, France, in May) an impor-tant debate amongst stent manu-facturers was finally settled - atleast according to the attendingmedical community.

At a plenary session entitled‘Direct comparison between DES:a burning issue’, a panel of leadinginterventional cardiologistsannounced a draw between theCypher and Taxus stents, with nei-ther showing clinical superiorityand both having similar safetyprofiles - specifically rates of stentthrombosis.

The debate was a keynote ses-sion of EuroPCR, which althoughonly half the size of the ESC, wasnevertheless attended by some10,000 interventional cardiologistsfrom over 90 countries. Thedebate was scheduled because ofclaims and counter claims aboutcompeting stent systems followinga number of recent small- to medi-um-sized single and multicentrecomparative trials.

The two stents - the sirolimus-eluting Cypher stent (Cordis) andthe paclitaxel-eluting TaxusExpress stent (Boston Scientific) -went head-to-head in the Cordis-sponsored REALITY trial, alsopresented earlier this year at theAmerican College of Cardiology(ACC) meeting in Orlando,Florida. The trial failed to meet itsprimary endpoint, with no differ-ence in the rates of in-stent and in-lesion (primary endpoint) binaryrestenosis at eight-month follow-up. Cordis claimed a significantdifference in stent thrombosis froman on-treatment secondary end-point data analysis. However,when a nine member EuroPCRpanel (Chaired by Professor JeanMarco, Director of the

New researchto be presented atthe ESC Congress

By Ian Mason

Italy and Germany indicate that ifDES could reduce the number ofmulti-vessel patients undergoingCABG surgery, this may reducemedical care costs (Fricke F-U,Silber S. Herz 2005;30:332-8;Sangiorgi G et al. Ital J HeartSuppl 2005;6:145-56). Within theGerman healthcare system, Frickeand Silber calculated that PCI oflong and complex lesions withpaclitaxel-eluting stents signifi-cantly reduced costs as comparedto CABG (by €4,574 per patient).An economic sub-study of theSYNTAX will show how PCI withDES compares with CABG interms of initial hospital cost aswell as follow-up cost.

DES news at ESCThe symposium ‘Controversies incoronary revascularisationtherapy’ will take place at the ESCCongress, taking place inStockholm, Sweden, between

3-7 September 2005. The con-gress is Europe’s largest medicalmeeting and a major event in theworld of cardiology, with over25,000 attendees registered.

On Sunday 4 September (11.00-12.30, Budapest, Red Zone) thedebate will examine whetherpatients with severely depressedleft-ventricular function shouldundergo PCI, rather than bypass,and whether patients with diabetesshould receive DES rather thanbypass surgery.

On Tuesday 6 September(14.00-15.30 Athens, Blue Zone) asymposium, chaired by MCMorice (Massy, France) and EGrube (Siegburg, Germany) willreview the latest clinical results forDES, including stent-to-stent com-parisons, data from the MILE-

STONE II (challenging patientsubsets), HORIZON (DES inacute MI) and SYNTAX studies.

On Wednesday 7 September, a‘Featured Research’ session(08.30-10.00 Oslo, Green Room)chaired by F Schiele (Besancon,France) and D Baumgart (Essen,Germany), will look at some of theremaining problems associatedwith DES.

A poster presentation (P3384)reviews data from an audit ofmore than 100,000 PCI proce-dures in 220 French centres(Morice MC et al). Their findingsconfirm that PCI can be performedsafely and successfully in mostpatients, but the best results wereachieved in centres performing the

Figure 1: Taxus Liberté is expectedto launch in Q3 2005 (CE markpending; currently not availablefor sale in the EU or USA)

Drug-eluting stents

highest number of stenting proce-dures.

Already more than two millionof DES have been implanted. DESare rapidly becoming the goldstandard for percutaneous coro-nary revascularisation in Europe(Figure 2) as well as the US.Recently UK specialists predictedthat all stents used in that countrywill be drug-eluting within fiveyears (Cardiology News2005;8:42-3).

ed - this is a multicentre, prospec-tive trial involving over 4,200patients at up to 90 sites in Europeand the US. The study is compar-ing the performance of DES withbypass surgery in the most com-plex patient subsets: those withcoronary artery disease in all threecoronary arteries, in the left maincoronary artery, or both.

SYNTAX is an important studybecause although DES have beenproven to be superior to tradition-al BMS at reducing the rate ofrepeat procedures due to resteno-sis, previous studies comparing

Cypher should also be interpretedwith care and cannot be used toprove that one stent is better thananother. ‘Subgroup analyses ofrandomised trials and registries areseverely underpowered and shouldtherefore be interpreted with cau-tion.’

In addition it was noted that thedefinitions used for outcomes andMACE (major adverse cardiacevents) rates varied greatlybetween individual trials and reg-istries, making it even more diffi-cult to draw conclusions by indi-rect comparison of studies.

Professor Sigmund Silber


N E W SC A R D I O L O G Y

BALTIC SUCCESSLithuania - ‘A country’s overall development level is demonstratedby the level that cardiac surgery has reached,’ said Valdas Adamkus,President of the Republic of Lithuania (right) at the opening of the15th Congress of The World Society of Cardio-Thoracic Surgeons,held in Vilnius this June.

Lithuania, which gained EU membership about a year ago, hasthree public and one private heart centres. Performing interventionsfrom coronary surgery using the Ross procedure to organtransplants, the country provided 794 heart operations per millionpeople in 2002, positioning it between France (635) and the UK(636), and Austria (868) and Denmark (882).

Seekingcardiac

stem cellsStem cells have been found inmany organs, including the brain,but many researchers are not con-vinced that the heart contains any.However, leading stem cellresearcher Dr Pierro Anversa,Professor of Medicine andDirector of the CardiovascularInstitute at New York MedicalCollege, has suggested that heartcells undergo an ongoing turnoverfuelled by stem cells, and in Junehe published a study that identi-fied cardiac stem cells in animalmodels that repaired tissue dam-aged by an adverse cardiac event.

Steven Houser PhD (above),Director of the CardiovascularResearch Centre at TempleUniversity School of Medicine,Pennsylvania, USA, whose ownresearch had focused on cardiacreaction to hypertensive diseasesthat can lead to congestive heartfailure, recently joined ProfessorAnversa, and the team has receiveda NIH grant to study whether thereare autologous stem cells in theheart.

Early in this disease, heart muscleincreases and chambers stretch inan attempt to increase contractingpower. Part of this enlargement isdue to increased muscle mass, buthow the chambers grow is less cer-tain. Traditionally it is thought thatcardiac cells simply grow larger toaccommodate the increased need,but Dr Houser and Prof. Anversahave developed a different theory:spurred by cardiac stem cells, car-diomyocytes actually increase innumber in response to the heart’straumatic condition. In their study,after inducing hypertension in ananimal model to distress the heart,the team will study the heart tissueand count cells, first in the normalheart, then in the harder workingheart. If, according to their theory,there are more cardiomyocytes inthe heart, rather than simply largercells, they could conclude that stemcells are attempting to repair theheart. Based on a report by Eryn Jelesiewiczat Temple University.Source: www.medicalnewstoday.com

The recently convened ESC Policy Conferencetitled Women at Heart was chaired byProfessor Marco Stramba Badiale, of theIRCCS Istituto Auxologico Italiano,Milan, Professor Silvia Priori and ProfessorKim Fox. We asked Professor Badialeabout progress in the understanding ofwomen and heart disease

Prof. MarcoStramba-Badiale


C A R D I O L O G Y

Clinical manifestations ofischaemic heart disease inwomen may differ fromthose commonly observed in

males and this factor may accountfor under-recognition of thedisease,’ the professor pointed out.‘Some diagnostic tests andprocedures may not be as accuratein women, so physicians may avoidusing them and a heart attack orstroke may not be detected inwomen until later, with moreserious consequences. An exercisestress test, commonly use todiagnose ischemic heart disease,may be less accurate in women: inyoung women with a low

women who participate in thesestudies and, even more recently,trials have been targeted solely onfemales patients. Most progress inthis direction have occurred in theUSA, as a direct consequence of thecommitment of funding agenciesthat have provided economicsupport to clinical trials only whena balanced gender presence wasassured in the design of the trial. InEurope, there is no regulation ofthis type and therefore there is lesssensitivity to the issue. Once again,

BASICcardiopulmonary

resuscitation

Professor Paul Pepe and Dr JaneWigginton discuss current

research and concepts that willaffect the future of basic CPR

Jane G Wigginton MD, is AssistantProfessor of Emergency Medicine, atthe Department of Surgery,University of Texas SouthwesternMedical Centre, and AttendingEmergency Physician, ParklandHealth and Hospital System;Assistant Medical Director forResuscitation Research, DallasMetropolitan BioTel (EMS) System.

likelihood of coronary heartdisease, an exercise stress test maygive a false positive result. Incontrast, single-vessel heartdisease, which is more common inwomen than men, may not bepicked up on a routine exercisestress test. These importantdifferences in clinicalmanifestation of heart disease infemales are not familiar tophysicians who may thereforeunder treat their female patients.

Symptoms - Women have agreater tendency to have atypicalchest pain or to complain ofabdominal pain, dyspnoea, nauseaand unexplained fatigue. Since

For over forty years, basiccardiopulmonaryresuscitation (CPR) hasbeen performed bylaypeople and healthprofessionals with

significant life-saving effects.Today basic CPR training alsoincludes training in the use ofautomated external defibrillation(AED). Along with earlydefibrillation, research has shownthat CPR is the only well-provenlife-saving procedure for suddencardiac death. Although they mayvery well be effective in aggregate,to date, none of the drugs and noother advanced cardiac lifesupport techniques currently in usehave been proven explicitly ascontributing to long-term survivalwith intact neurological functionin the clinical setting. Therefore,although it is still infrequentlyperformed in many communities,basic CPR remains a criticalcomponent of community-widelife-saving efforts.

Basic CPR also has regainedcentre-stage in resuscitationresearch efforts. In addition toevaluating the concept of markedlyabbreviating the time to provideeffective training, recentinvestigations suggest that currentCPR procedures can be modifiedeasily to significantly improveoutcomes beyond what they cando today. Specifically, renewedfocus has been directed at notinterrupting chest compressionsand on a de-emphasis of rescuebreathing, especially in the firstfew minutes after collapse. Inaddition, evidence has beengrowing steadily for deferringinitial defibrillation attempts untila brief period of chestcompressions can first beperformed.

Here we briefly highlight eachconcept and provide some insightto the future of basic CPR. Abbreviated Training - Research

Paul E Pepe MD MPH FACEP FCCMFACEP, is Professor of Medicine,Surgery, Public Health and Chair,Emergency Medicine, University ofTexas Southwestern MedicalCentre, Dallas, USA, and theParkland Health and HospitalSystem; Medical Director, DallasMetropolitan BioTel (EMS) System.

abrupt falls in coronary perfusionpressure (CPP) and thatrestoration of a reasonable CPPwill take at least 10-15 secondsafter resumption of chestcompressions. This means thatCPP is inadequate throughout themajority of the resuscitation effort.Also, exacerbating this concern,rescuers actually take longer toprovide mouth-to-mouth breathsand defibrillation than one wouldpresume. Furthermore, even a 10-15 second delay in delivering the

the numbers of persons trained inCPR. Specifically, new initiativesand teaching techniques thatinvolve video-based adult learninghave demonstrated theeffectiveness of 20-30 minutetraining [8]. More recently,resuscitation researchers in Dallashave begun to test a combinedCPR-AED training course that isless than 30 minutes. Preliminaryinformation demonstrates thatimmediate retention andeffectiveness of performance are at

least similar. This new trainingtechnique may eventually prove tobe even better because theabbreviated course focuses on theactual skills used and notdidactics. It is also less intensive interms of trainers, allowing large-scale classes to be conducted by asingle instructorUninterrupted Compressions -Research has confirmed thatinterrupting chest compressions toperform defibrillation or toprovide rescue breaths, causes

has confirmed that the averageperson is less likely to learn CPRunless they are compelled to do sofor a job or school requirement.One of the rate-limiting stepstoward implementing workplaceand school-based requirements isbeing able to make the requisitetime commitment considering thatseveral hours of work would needto be interrupted to train allemployees using current courses.

Fortunately, recent research hasindicated some hope for expanding

scientific societies should play amajor role in ensuring that genderspecific issues are sought and, whenidentified, gender specific responseto therapy should be investigated inclinical trials.

What doctors need to know -Coronary artery disease is theleading cause of death for men andwomen in the western world.About 40% of all female deaths arecaused by cardiovascular disease,especially coronary artery diseaseand stroke. However,

The Policy Conference was convenedby the European Society of Cardiology.ESC President Professor Michal Tendera Women and heart disease

women tend to have heart attackslater in life than men, they oftenhave other diseases that can maskheart attack symptoms.Furthermore, ischemia may bemore often silent in women and theproportion of unrecognizedmyocardial infarction is greater inwomen than in men.

Therapies - Women have beenunder represented in randomisedclinical trials and only recently hasthere been a significant increase inthe number and proportion of

unfortunately women, and theirphysicians, underestimate the riskof heart disease because of theperception that women are‘protected’ against ischemic heartdisease. What is not fullyunderstood is that women, whenfertile, have a lower risk of cardiacevents, but this protection fadesafter the menopause, leavingwomen with untreated risk factorsvulnerable to develop myocardialinfarction, heart failure andsudden cardiac death.

shock (after the order to ‘haltCPR’ has been given), will lead todramatically diminished rates ofresuscitation. Therefore, recentefforts have gone into developingAED devices that can analyse thecardiac electrical activity withoutinterruption of compressions anddeliver the shock at the momentthe rescuer backs away from thechest. Also, to maintaincontinuous chest compressions,scientists are investigating theefficacy of deleting rescue breathsduring the first minutes aftercardiac arrest, particularly whengasping is present. Compressions-only CPR - Asmentioned, recent studies haveconfirmed that compressions-onlyCPR may be even more effectivethan traditional CPR thatincludes mouth-to-mouthventilation, particularly in thefirst few minutes following asudden cardiac arrest. Not onlydo the rescue breaths frequentlyinterrupt compressions and thusthe maintenance of adequate CPP,but it also can add to inhibitedvenous return because of thepositive intra-thoracic pressuregenerated by the positive pressureventilation.

In fact, significant gas exchangestill occurs without rescuebreathing. Chest recoil afterrelease of the compression tendsto move air into the airways(assuming the airways are open).Also, most people likely tosurvive a cardiac arrest will begasping, a unique respiratoryevent that not only can rapidlyexpand a larger volume ofdependent lung spaces, but alsogenerates a stronger intra-thoracicvacuum than a normal breath. Inturn, this generates betterpulmonary oxygenation and moreCO2 clearance, while alsogenerating better venous return.In addition, by not interruptingchest compressions, perfusion tothe brain and respiratoryapparatus is better sustained, thusprolonging gasping and, in turn,better oxygenation, CO2clearance and circulation.Paradoxically, by not stopping tobreathe for the person,respiratory functions are actuallyprolonged and improved.

The problem is that gaspseventually deteriorate and, also,not all patients gasp and not allcardiac arrests are sudden.Therefore, some lung inflationwill need to be provided sooneror later. Nevertheless, even whenbreaths are provided, they are notneeded as often as previouslythought. The traditional 15:2compression-ventilation ratio maybe better at 100:2 or 50:2 formany of the reasons statedpreviously and becauseventilation should matchperfusion. In low blood flowstates like CPR situations, CO2 isnot produced as readily and, evenwhen it is, it is not circulatedback to the lungs for removal.Therefore, ventilatory demandsare low until full circulation andstrong pulses are restored.Although theoretical modelsindicate that children shouldreceive breaths more often, theneed is much less than the current5:1 ratio proscribed for children.CPR Before Defibrillation -Growing evidence has indicatedthat once ventricular fibrillation(VF) has been prolonged beyond


C A R D I O L O G Y

four or five minutes, remainingcardiac energy supplies willbecome depleted and a relativelyde-oxygenated heart is less apt torespond to defibrillation. It hasbecome apparent that, once severalminutes of VF have elapsed,preparing the heart fordefibrillation with basic CPRand/or certain medications, willmake a heart more amenable tosuccessful defibrillation withreturn of spontaneous circulation.Although it is clear that immediatecounter-shock is the most effectivestrategy in the first few minutesafter onset of VF, laboratory

studies support the use ofvasopressor drugs to enhance CPPduring CPR conditions prior todefibrillation. Furthermore, tworecent clinical studiesdemonstrated the probable valueof providing a brief period (1.5 to3 minutes) of basic CPR prior todefibrillation. While these studieshave their limitations, they are thebest available data and clearlyindicate the value of chestcompressions prior todefibrillation unless it is awitnessed collapse in the presenceof a defibrillator. Combined withthe information previously

discussed, it is clear that a re-focus on chest compressions mustbe emphasized in CPR trainingand performance.Caveats - Although the researchdiscussed here is compellingenough to indicate a need tochange current CPR techniques,there still is no worldwideconsensus on these issues nor, insome cases, is there conclusiveenough evidence to effectworldwide changes in CPRtraining. Nevertheless, it remainsclear that many of these proposedchanges will eventually becomemainstream as the evidence grows

and more data are accumulated.There is little doubt that moreemphasis should be placed on theperformance of aggressive,continuous chest compressionsthat are interrupted onlyinfrequently, if at all. Mostimportantly, this discussion againportrays the critical importanceof basic CPR and our need toensure that every person istrained and knows how toperform this life-savingintervention when it is needed. Reprints/references andcorrespondence:[email protected]

Progress


N E W SC A R D I O L O G Y

Our raison d’étre

Cardiologists,radiologists,physicists, vascularbiologists, and otherspecialists arriving atAlpbach, Germany,could not fail to

admire their surroundings.‘Alpbach is very beautiful and hasa long tradition as a place foruniversities and the EuropeanForum, which seemed aparticularly attractive combination

that can produce slice images ofadequate resolution. As such, thiscould diagnose millimetrestructures in the vascular walls.

This is possible using CT, butthere are major problems - even tobe able to see wall thickness andcalcification. Conversely, by usingMRI one can determine thedifferent quality of tissue andobtain a resolution of practicallymicroscopic quality, without usingradiation. Imagine how exciting it

individual proteins or otherenzymes are known and could beconsidered as a target for specificbinding sites, because this hasimplications for the combinationof contrast media. In future it iseven conceivable - should it bepossible to identify such proteinsand enzymes - to also use these fortreatment, because you can seewhere and how the therapeuticagent acts at a specific site. Thisconjures up futuristic images andis based on the assumption that wework at obtaining high resolutionof local visualisation and onidentification of receptor proteins.’

Multidisciplinary research suchas this, drawing together biologistsand chemists as well as medical

inflammation and is expressed inlarge quantities in an area - reallycapable of binding, and, assumingthe answer is yes, just what thatmeans. If you have a moleculewith an adequate number ofreceptors that you can bind to thevessel wall, you should be able tosee this site well - if enoughcontrast medium is given. Thenthere are special contrast mediathat give good signals in a magnet- paramagnetic beads. These are

investigation system, whileselectively using MRI to generatethe high resolution needed.However, we believe that in futureusing MRI alone we will be ableto visualise specific binding formsand thus achieve the requisiteprecision.

‘We have been aware for yearsthat conventional diagnosticmodalities were not enough andthat we would have to achievehigher quality using less invasiveapproaches. Our insights to datecome from relatively highlyinvasive procedures. This issomething that we would like tochange - particularly in preventivemedicine. We do not want tosubject healthy, or potentiallyhealthy, individuals to a battery oftests that, in some cases, couldcause disease themselves. Wetherefore need data that will, apriori, assure equal, if not better,precision. Indeed, medicine hasalways explored such investigationprocedures, be it nuclear medicineprocedures or ultrasound, etc. Butall the procedures mentionedsuffer the drawback that localresolution is not good enough. Forthat reason we began working inthis field as soon as thetechnology- fast computers forimage reconstructions and strongmagnets that can acquire therequired signal - becameavailable.’

for our meetings. It provides theatmosphere you need toconcentrate on topics, combinedwith a chance to relax in pleasantsurroundings,’ said Professor Fleck,explaining the choice of venue.

Here, the present and futureissues to be faced in cardiology arediscussed, centred on twoapproaches: ‘First, theenhancement of diagnostics todetect potential dangers at an earlystage - meaning not just in time,’the professor explained. ‘Second:What treatment? If one bears inmind that arteriosclerosis will notonly continue to persist but alsoincreasingly prove a general healthproblem, then of course diagnosticconsiderations of this nature are ofparamount importance. In 2020cardiac diseases, and particularlycoronary heart disease, will be thenumber one cause of death,worldwide, and not just inindustrialised countries as atpresent. At the moment, infectiousdiseases hold that position, but, aspointed out, this will changeworldwide, mainly because ofchanging dietary habits and thatpeople are living increasinglylonger. Arteriosclerosis willultimately affect us all, if we live tobe old enough.’

At the Alpbach meeting theconvergence of imaging andtreatment was constantlydemonstrated. ‘The critical areas ofinterest to us are plaqueformations, that is deposits onlocal vascular wall sites, somethingthat we cannot really detect fromthe outside. We need in vivoinformation about this. To date,imaging is conducted within thevessel itself; not onlyangiographically showing theinternal volume but attempts aremade to depict the wall. This ispossible, for example withultrasound and new modalities

small, non-magnetic iron particles.If we could bind these beads tospecific molecules, which, in turn,would dock on to receptors, thenyou would have created apermanent link at this site, whichcould be visualised with MRI -assuming that a sufficiently largequantity is available. If all that ispossible, you could localize aparticular site.’

Professor Fleck agreed that theMRI-PET scanner would be auseful machine is such a situation,

‘... because it appears to be mucheasier to establish the specialbinding forms I spoke of earlier -in nuclear imaging. It would workvery well with PET, but the onlydrawback with PET is that it doesnot at all have the kind of localresolution we need. If MRI couldbe used here, for example, incombination with specific contrastmedia, then one would probablynot need PET anymore. PerhapsPET can be used as a general

practitioners, must be exciting.‘Yes, it is,’ Prof. Fleck confirmed.‘The purpose of our workshop isto try to have completely differentapproaches and viewpoints bounceoff each other, for scientists toengage in cross-talk, so that onegroup grasps what others need andvice versa. Because one cannotassume that a chemist, who isthoroughly conversant with specialbinding issues, will understandwhat he should really do if he is

Fig 1. Coronary magnetic resonance angiography (MRA) visualising the left system of thecoronary arteries originating from the aorta (red). Cardiac chambers (blue transparent)

Fig 2 (left). Coronarymagnetic resonanceangiography (MRA)visualising the coronaryvessels and the aorta (red)as well as the large thoracicvessels and the chambers(blue transparent)

Fig 3 (below). Reconstructionof a 3D data set (wholeheart coronary angio-graphy), visualising thesurface of the heart, thedescending large thoracicvessels and the coronaryarteries on the heart

Scientific meetings held since 1998 at Alpbach, Germany, have attracted thesponsorship of leading associations and companies such as the Philip MorrisExternal Research Programme, the Donors’ Association of German Science,Swiss National Fund, the German Heart Centre Foundation, Berlin, and PhilipsMedical Systems. At the 4th Alpbach Meeting, which focused on MagneticResonance, Contrast Mechanisms and Molecular Imaging of Coronary ArteryPlaques, Daniela Zimmermann spoke with Professor Eckart Fleck of Berlin’sGerman Heart Centre (Deutsches Herzzentrum Berlin) about the constantlyincreasing importance of this event and its current aims

not made aware of the context andcannot understand what it’s allabout - and, of course, vice versa.What do you do with an imagewhen you do not know how it wasgenerated and thus misinterpret?So we must know relatively a lotabout the local circumstances, notonly about diagnosis of disease.We should know what specificparticles are used and whetherthese really do bind as selectivelyas desired. Or is the receptor - agood early marker of

is to conduct histology in a bodythat is completely penetrated bylight. This is possible not onlythanks to the resolution but alsoby marking those sites that youseek. The combination of thesetwo approaches is the focus of theAlpbach meeting. The scientistsponder what are the potentialbinding possibilities and what


C A R D I O L O G Y

T h e A r t o f D i a g n o s t i c s

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moves from one monitor to the other. The tests are initiated and terminated by clicking on a defined icon on the screen. The CARDIOVIT

CS-200 Ergo-Spiro is an easy to handle system, offering valuable assistance to physicians. Why carry out each test separately, if the

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Visit us at the ESC Congress, Stockholm-Sweden3-7 September 2005, booth C35:31, hall Cand the European Respiratory Society Annual CongressCopenhagen-Denmark, 17-21 September 2005, booth C4 – 021

THE ARTIFICIAL PATIENTHolger Zornreports on a

new dimensionin medical

trainingPilots train on simulatorsand so do doctors whospecialise in emergencycare, because, in extreme

situations, doing the right thingis not something that can belearned from books - it requirespractice, without endangeringpassengers or patientsrespectively. However, althoughparamedics and anaesthetistshave used simulators duringtheir training for several years,one of the most complextreatments - extracorporealcirculation, i.e. taking over thecardiovascular functions of apatient - had not attracted thatmuch interest. Now, the firstsimulator for extracorporealcirculation during heartsurgery- has been introduced.

Named CardioSim, theworld’s first PerfusionSimulator was introduced toclinical users during the 34thAnnual Meeting of the GermanSociety for CardiovascularEngineering in May this year.CardioSim simulates critical

the trainers can step in at criticalmoments and analyse anyincorrect reactions, because thesystem offers real-time control.The simulator is not only beingused for safety training but alsoto train cardiac technicians.

CardioSim was developed underProfessor Gerd Haimerl MD Dipl-Ing. (BA) at the Centre forApplied Simulation, TechnicalUniversity Furtwangen,Department Villingen-Schwenningen, in co-operation

situations that can occur in apatient or the heart lung machineduring extracorporeal circulation.For example, tubes might kink,cannulas twist, air might enter thevenous system, cooling watercould enter the bloodstream,blood filters become blocked, gasmembranes leak, the pH-valuemove. All these are extremely rareincidents but require immediateaction to avoid damage to apatient. Every action is recordedand evaluated. Using CardioSim,

Cocoa may be beneficial for thosesuffering heart disease and stroke,according to researchers at theSouthampton University HospitalsNHS Trust, UK, whose study was pre-sented in August, at the 20thCongress of the InternationalSociety on Thrombosis &Haemostasis, in Sydney, Australia,by consultant haematologist DrDenise O’Shaugnessy. According tothe research, cocoa inhibits plateletfunction, so it has been suggestedthat drinking a cup of cocoa couldprevent potentially fatal blood clots.‘Cocoa contains flavinoids, whichare also present in red wine. Thesecan be preventive for coronary heartdisease. However, our researchuncovered another ingredient incocoa that may be responsible forplatelet inhibition.’ The finding, sheadded, may lead to important newtherapies to prevent heart diseaseand stroke.

with the Department for Cardiacand Vascular Surgery at theUniversity Hospital Freiburg.The project, which to date hascost around €500,000 is fundedby the Ministry for Science,Research and Arts in Baden-Wuerttemberg and by theGerman Society forCardiovascular Engineering.

The simulator is to be used asa platform for research andinnovation in extracorporealcirculation. Additionally, Prof.Haimerl believes that, one day, itwill be able to simulate allorgan-preserving systems, fromdialysis to the artificial heart.

Ingredientin cocoa

may combatCHD

MD, PhD, Director ofCardiovascular MRI & CT,Cardiovascular ResearchFoundation and Chief ofCardiovascular MRI, Lenox HillHospital. ‘Real-time image qualityis robust even in patients withirregular cardiac rhythms whocannot breath-hold.’ReportCARD - This innovative toolsignificantly reduces review,analysis and cardiac MR reportingtime. ‘ReportCARD is an integratedtool for reviewing, analysing, andreporting Cardiac MRI studies.There is nothing else like it. I can’timagine doing cardiac MR withoutit,’ Dr Wolff observed.


C A R D I O L O G Y

Exclusive HDMR imagespresented at

ESC2005

Sweden - GE Healthcare at TheEuropean Society of Cardiology(ESC) in Stockholm will presentexclusive cardiac imagingtechniques produced via the world’sfirst high-definition magneticresonance (HDMR) system. ‘GE’sHDMR is an extremely fast dataprocessing engine coupled withhigh-density surface coils andextremely accurate gradients. Theresult is unique balancedacquisition architecture; withindividual receive channelsconnected to dedicatedreconstruction engines. This allowsus to develop entirely newapplications available only withHDMR,’ said Stefano Vagliani,General Manager MR Europe at GEHealthcare.

The ‘only-GE’ cardiovascularimaging techniques include:1.5T EXCITE HD MR Echo CardiacImaging - Real-time cardiacimaging with the resolution of MRat the speed of ultrasound, withoutthe need for breath-holding or ECGgating.

One in three cardiac patientscannot hold their breath longenough for an image to be made.Frequently, cardiac patients are tooill to hold their breath and haveweak or arrhythmic heartbeats,resulting in special imagingchallenges. GE’s MR Echo produceshigh-definition cardiac images inreal-time, from the most unwellpatients, providing clinicians withthe contrast detail of MR with thereal-time speed and ease of use ofechocardiography, the firm reports.

‘It’s the ease of echo with thedetail of MR,’ said Steven D Wolff,

Johannes Brachmann MD, and Harald Rittger MD, ofthe Klinikum Coburg, Coburg, Germany, describe theuse of a highly precise three-dimensional diagnosticimaging tool that enables quick, accurate visualisationand quantification of coronary artery lesions

IC3D INVOLVES selecting a lesion of a certain coronary vessel segment withas few as two standard angio images (see a and b) to create a three-dimensional (see c) volume image of the segment of interest. The IC3Dreconstruction enables highly accurate quantitative measurements and canbe visualised from any chosen angle.

In interventional cardiology,accurate lesion assessmentplays a vital role, particularlywhen determining theappropriate stent size andlength. Interviewing Cardiac

Imaging (IC3D), a highly precisethree-dimensional diagnostic tool,increases diagnostic assessmentcapabilities.

IC3D involves selecting a lesionof a certain coronary vesselsegment with as few as twostandard angio images. From thosetwo different projections, a three-dimensional volume image iscreated that can be visualised fromany chosen angle.

One of the reasons for theaccuracy of this application lies inthe fact that a three dimensionalreconstruction is not subject to theso-called foreshortening effects,thereby enabling lengthmeasurement with a higher degreeof accuracy. Another reason is thegreater precision with which thediameter profile and relatedparameters can be assessed -making IC3D a particularlyvaluable tool for selectingappropriate stent lengths anddiameters. The IC3D model can befreely rotated in space and viewedfrom various angles, allowing aselection of optimal workingprojections for use during theintervention.

TreatmentPCI of LAD: Balloon angioplastyand implantation of two stents inthe proximal two LAD lesions;stent implantation in LADbifurcation lesion*.LAD Proximal Two Lesions:

With Interventional Cardiac 3D(IC3D), precise three-dimensionalvessel reconstruction was possible,supporting an optimal therapeuticstrategy for this 81-year-old manwith renal failure.

In the angiographic scenes [1A-C], the lesions are difficult toevaluate. Foreshortening effectscomplicate exact lesion lengthcalculation with QCA. 3D-reconstruction with IC3D

HDMR: Overcoming currenttechnology limitations - GE’s HDMR,available on GE Signa 1.5T and 3.0TMR systems, enables massivelysimultaneous imaging in multiplechannels in increments of 16. HDMRfeatures unique balanced acquisitionarchitecture, with individual receiveschannels connected to dedicatedreconstruction engines.

As channels are added (in units of16, 32, 48, 64 and more), image-processing power increases inproportion. The coil elements thatdetect the signal, the receivers thatdigitise it and the array processorsthat perform calculations are scaledtogether, so that massivelysimultaneous imaging can beperformed without image processingdelays. This technology sets a newstandard for acquisition, gradientsand the human interface.

GE’s exclusive Excite technology hasalready enabled three exclusive,targeted MR applications withmeaningful clinical benefits: Vibrantfor bilateral breast imaging in asingle exam; Tricks for MRangiography of the legs; andPropeller for high-quality brainimaging that is extremely resistant tomotion artifacts. Excite HD bringseach of these new applications intohigh definition.

‘HD technology paves the way foran extremely wide range of targetedapplications,’ Stefano Vaglianipointed out. ‘The possibilities arelimited only by clinicians’imaginations. This new technologynow allows physicians to imagepatients where it was previouslyimpossible to consistently obtaindiagnostic images.’

Patient History81-year-old male; weight 75 kg;height 175 cm; history of renalfailure; the patient was diagnosedwith three-vessel disease includingmoderate left main (LM) disease.The patient refused to undergoCABG (coronary artery bypasssurgery). Therefore PCI(percutaneous coronaryintervention) of RCA has beenperformed. After intervention,moderate increased serumcreatinin level and ongoing stableangina CCS III.

Concerning renal failure, anoptimal therapeutic strategy with aminimum dose of contrast mediumis necessary for the plannedtreatment of the LAD lesions.

DiagnosisThree-vessel disease: 50% LMstenosis; RCA 25% re-stenosisafter stent placement; LADproximal 85% stenosis with severecalcification continuing to the midLAD; in the distal part of the LADbifurcation 70% stenosis; normalleft ventricular function; EF >60%.

side branch is close to 90∞ and not asacute as estimated from theangiographic data [1A-C]. Treatmentof a bifurcation lesion with an acuteangle of the side branch requires a‘kissing balloon’ procedure to ensurethat the side branch will remain openand will not be closed by a plaqueclot. The kissing balloon procedure isvery time-consuming and requires alot of angiographic scenes, including alot of contrast medium and radiationexposure. Because 3D-reconstructionverified that we were dealing with anopen angle, we decided in this casethat no kissing balloon procedure wasneeded to ensure that the side branchwould remain open.

Due to knowledge of themorphology of the three lesions withIC3D, the optimal stent sizes andlengths, as well as the method ofimplanting the stents, had beenchosen. Using IC3D was ideal in thiscase. The patient benefits are various:exact lesion calculation enabled us tokeep the procedure time, radiationexposure and usage of contrastmedium at a minimum. Additionally,the complete coverage of the lesionsreduces the risk of re-stenosis.* Information about this product ispreliminary. The product is underdevelopment and not commerciallyavailable in the USA.

InterventionalCardiac 3D Imaging

Improved therapy planning for LAD lesion patients

Figure a

Figure c

Figure b

[2A+B] shows the morphologyand length of the proximal twostenoses, with 37.6 mm in total.With regard to the supposedcalcification, especially in theproximal long lesion, balloonangioplasty is performed. Due tothe difficulty in inserting theballoon through the two difficultlesions and the total lesion lengthof 37.6 mm, the decision wasmade to implant two proximalstents.

LAD Bifurcation LesionIC3D [2C+D] provides excellentknowledge of the bifurcationmorphology*. The angle of the

C A R D I O L O G Y


This day’s activities in a 100 countries include health checks,walks, runs, rope jumps, fitness sessions, public talks, stageshows, scientific forums, exhibitions, concerts and sportstournaments to emphasise physical fitness to reduce bodyweight. Men with waist sizes above 94cm (37 inches) andwomen above 80 cm (32 inches) are considered at significantrisk of developing heart disease and stroke. ‘Waist size is likeblood pressure and cholesterol level, another one of thosenumbers that we should all know, understand and watchclosely,’ explained Dr Sidney Smith, Chairman of theScientific Advisory Board at the World Heart Federation,through which the international member organizationsarrange the events. Details: www.worldheartday.com

Canada - The US Patent andTrademark Office has grantedNovadaq Technologies Inc, ofToronto, a patent for its SPY Intra-operative Imaging System, whichalso has 510(k) clearance from theUS Food and Drug Administration(FDA) for use during CABG surgery.

In 1995, the Hamburg-based firmLife Systems Medizintechnik-Service GmbH (part of the KrauthGroup) was formed to develop anew, multi-supplier, full serviceconcept for cardiac-perfusionunits for cardiology and radiologydepartments. The companyexplained that the structure hasthree independent modules:● medical supplies and dispos-

ables

FULL SERVICE CONCEPTS Walk run jump!

SPY SYSTEMGAINS US

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● capital equipment● specialised personnel (40 perfu-

sionists among its 50 employ-ees)and that the advantages for

clinics include:● cost transparency through

changeover from fixed to vari-able costs

● free financial resources throughavoidance of capital commit-ment

● planning reliability for all themodules

● cost reduction by realisation ofsynergistic effects.‘With this innovative full service

concept, Life Systems graduallyincreased its market shares. Today,approximately 20% of all perfu-sions in Germany are provided byan external service. In this marketsegment, Life Systems is not onlyestablished, but is also the marketleader,’ the firm added. The com-pany is currently negotiating withseveral German and otherEuropean clinics to strengthen thatmarket position and internation-alise the business. Details: www.life-systems.com

The patent, titled ‘Method andApparatus For Performing Intra-Operative Angiography’, describesSPY as an intra-operative fluores-cent imaging system that enablescardiac surgeons to confirm thelocation of coronary arteries duringcoronary artery bypass graft (CABG)procedures and visually assess andvalidate the functionality of bypassgrafts. Novadaq adds that the sys-tem allows the surgeon to view,record, replay, print and archivehigh quality real-time images of thecoronary arteries and bypass grafts.

SPY’s core imaging technology isalso used in Novadaq’s OPTTXSystem, for the diagnosis, evalua-tion and treatment of wet age-related macular degeneration(AMD). OPTTX is currently beingevaluated in clinical trials.Details: www.novadaq.com

25 Sept2005

WorldHeart Day

Thousands of diseases chal-lenge human survival on ourplanet. However, a few ofthese represent a major cause

of mortality and morbidity world-wide. Respiratory diseases areamong the leading health problemsfor human beings. In particular, res-piratory tract infections, includingtuberculosis and lung cancer,account for a large portion ofhuman suffering and death.Chronic inflammatory disorders ofthe airways, such as bronchial asth-ma in infants and chronic obstruc-tive pulmonary disease (COPD) inadults, embody the highest preva-lence, respectively, in Europe. Theformer is mainlyrelated to the‘allergy march’,whereas the latteris strongly relatedto tobacco con-sumption, thoughother factors suchas occupationaland environmen-tal pollution alsosignificantly con-tribute to theoverall preva-lence. It has beenestimated that thetotal financialburden of lungdiseases in Eur-ope amounts tonearly €102 bil-lion.

The prevalenceof COPD is rising worldwide, and ithas been estimated that, in 2010,COPD will be the 4th leading causeof death in Europe, immediatelyafter cardiovascular diseases andlung cancer. Asthma is the mostcommon chronic disorder in chil-dren in Europe. There is no funda-mental therapy for asthma.However, inhaled corticosteroidsare effective to control symptomsand to reduce the risk of exacerba-tions substantially. Inhaled bron-chodilators are also helpful.

In COPD, smoking cessation isthe most effective measure to slowdown the progression of the disease.However, the inflammatory processdoes not reverse after smoking ces-sation. Therefore a treatment forCOPD is needed. Regular therapywith long acting inhaled bron-chodilators is effective to reducedyspnoea, as well as to improveexercise tolerance. The addition ofinhaled corticosteroids may help toreduce the frequency and severity ofexacerbation in severe patients.

Although available asthma andCOPD treatments, inhaled corticos-teroids and long acting bronchodila-tors respectively, are effective toreduce symptoms and to improve thequality of life, the lack of a real,prime therapy for those diseases stim-ulates a lot of basic and clinicalresearch aimed to elucidate the fun-damental bio-cellular mechanisms aswell as to find new drugs active atthat level. It should be mentioned thatboth asthma and COPD are widelyunder-treated because they are under-diagnosed due to the limited use ofspirometry as a diagnostic tool.Spirometry should become part of theroutine assessment of health status.

A major problem in clinical respira-tory medicine isacute respiratoryfailure; namelyhypoxemia oftenassociated withhypercapnia andrespiratory acido-sis. An extraordi-nary advance inthe managementof acute respirato-ry failure is aworldwide suc-cess, as well as theuse of non-inva-sive positive pres-sure ventilation(NPPV). This is amode of artificialventilation thatdoes not requireendotracheal intu-bation, becausemechanical assis-

tance is delivered through a facemask. NPPV dramatically reducesmortality in critically ill patientsbecause it decreases the frequencyand severity of complications, partic-ularly infections, associated with theendotracheal tube. NPPV can bedelivered in the intensive care unit aswell as the ward for less severepatients (pH <7,30).

Although there are some promisingprospectives and new treatments areunder evaluation, the mortalityremains high for patients with lungcancer and for patients with intersti-tial lung disorders. There is a lot ofeffort in those areas, but until nowsuccess is minimal.

In conclusion, respiratory diseasesare among the leading causes of mor-tality and morbidity in Europe as wellas worldwide. There is a need formore basic research as well as formore epidemiological data. Someeffective treatments are available andthey should be more widely used.New, more effective therapies areexpected in the next years.


R E S P I R A T O R Y M E D I C I N E

Denmark - In the year of hisPresidency of the ERS, Ronald Dahlwas pleased that, by coincidence, thecongress was to take place in hishomeland, also coincidentallycelebrating the 200th anniversary ofHans Christian Andersen. ‘The ERS Annual Congresshas become a major event in respiratory medicineand science, and has developed from a Europeanevent into a conference that attracts delegatesfrom all over the world,’ he pointed out. However,this expansion, Dr Dahl added, would progressivelylimit venues able to host the growing number ofparticipants. Others, he suggested would visitCopenhagen’s many cultural sites - as well as join insome of the many Andersen festivities.

Earlier this year, the ERS launched the RomainPauwels Research Fund, worth €50,000annually and sponsored by GlaxoSmithKline

(GSK), to help support up-and-comingyoung researchers in their quest to

understand and treat respiratoryillnesses. This was named after the late Professor RPauwels, who had said, before his untimely death thisyear: ‘Having spent more than 30 years in respiratoryresearch, I am proud to have contributed to ourpresent understanding of respiratory diseases and cansee just how far this understanding has improved theway clinicians treat patients. However, we still have alot to learn, and with increased mortality predicted forrespiratory disease like COPD, it is vital that wecontinue to support respiratory research.’

Facing the future A European perspective by Dr Philip Tønnesen(Dr Med. Science), Chair of the pulmonarymedicine department at Gentofte UniversityHospital, Copenhagen, Denmark; President ofthe Danish Respiratory Society and Vice-Chairof the European Respiratory Society AnnualCongress 2005 (17-21 September)

Respiratory diseases have animportant negative impact onmorbidity and mortality andthis impact appears to be

increasing, mainly due to smoking-induced disorders such as COPDand lung cancer. Also, during thelast decade, and mainly in westernEurope, an increasing incidence ofasthma patients has appeared.

During coming decades we willhave to deal with an increase inCOPD patients as well as patientswith other chronic diseases, andpatients in the future will demandfar more of us, all of which willchallenge healthcare systems inmany ways. Co-operation betweenhospitals, general practitioners andprimary healthcare groups must beoptimised, harmonized and we needto use similar clinical guidelines.Prompt exchange of patient healthinformation’s calls for fast imple-

Belgium - A new version of theSERVO-i Infant neonatal ventilator,featuring additional treatment func-tions and an optional colourful,child-friendly design, is to belaunched by MAQUET Critical Careat the European Society ofPaediatric and Neonatal IntensiveCare (ESPNIC) Annual Conference inSeptember. The equipment will alsobe on show at the European Societyof Intensive Care Medicine (ESICM)Congress in Amsterdam (25-28September, booths 77-79 and 82-84).

New features in the neonatal ven-tilator include nasal continuous pos-itive airway pressure - Nasal CPAP -an option that can be used with avariety of patient interfaces, Maquetreports. ‘New hardware has also

been introduced. Anew Y-piece mea-surement sensorallows near-patientmeasurements of pres-sure and flow withminimal dead space.’ Other new features:● FiO2 trend values

can be storedand viewed

● Referenceloops can bepresented on screen together withthe current loop

● The patient circuit can be testedindependently of the pre-usecheck

● Alarms for airway pressure upperlimit can be muted

● Apnea alarm limit isextended from 15 to 45secondsMAQUET Critical Care’sSERVO-i offerings for neona-tal, pediatric and adultpatients will be on display atLung recruitment and clinical

performance will be the majorfocus of MAQUET’s presentation.A key highlight will be demon-strations of the system’s out-

standing transport capabili-ties.

The company alsoreports that the September

issue (number11) of Critical CareNews (distributed globally to

40,000 physicians, therapists andnurses in intensive care) willhighlight ICU centers around

the world where changes inventilatory care procedures havehad an impact on staff treatmentroutines and patient outcomes.These include the Prince of Waleshospital ICU in Hong Kong, which

From burden to therapy

mentation of the electronic patientrecord (EPR) and in a few years itwill probably be customary, duringdischarge from hospital, for apatient to have personal healthinformation downloaded on to hisor her own pocket computer. TheEPR will be a very big step forwardin terms of the availability of healthinformation and quality control.

In hospitals, an increasing burdenwill be more COPD patients ofgreater age. Until now the monitor-ing of acute admitted COPDpatients have been relative sparseand in many departments not opti-mal. A simple comparison can bedone with patients with acutemyocardial infarction and in factthe mortality is as high in patientsadmitted with COPD. There is aneed to increase the quality of mon-itoring of COPD patients and otherpatients with acute respiratory dis-

tress. In the next decade continuousmonitoring of oxygen, carbon diox-ide, respiratory rate, etc. should bestandard during the first days ofhospitalisation and easier ways toassess pH is strongly wanted.

Non-invasive ventilation (NIV)will also be standard in all depart-ments who receive acute COPDpatients and this therapy will notonly decrease acute mortality butalso increase the prestige of respira-tory medicine among our colleaguesin internal medicine.

New studies will show whetherlong-term home NIV will be effec-tive or the use of NIV should beused to prevent exacerbations inCOPD.

Long-term oxygen treatment(LTOT) will be demanded by manymore COPD patients than today,and our role will be to prescribeoxygen according to clinical guide-lines. Ambulatory oxygen will havean increasing use and further devel-opment of lightweight portable oxy-gen with long duration will bedemanded.

In the next decade, I suspect adramatic increase in the quality ofcare for patients with respiratorydiseases and a demand for moreoptimal monitoring and treatmentequipment.

Last but not least, we must notforget that smoking cessation is ofmajor importance to prevent COPDand lung cancer.

implemented new precautions androutines after the SARS outbreak,and developed a comprehensivestrategic planning process for futurecrisis management scenarios.

‘The magazine also features a pre-sentation of post-graduate lungrecruitment workshop activities inSweden and the Netherlands, whichlook at the mechanisms of atelectasisand lung recruitment strategies inorder to provide more optimal venti-lation procedures.

‘The special needs of the CICU envi-ronment are also highlighted, exam-ining the benefits one CICU has expe-rienced from implementing a fast-track extubation procedure,’ Maquetadds. ‘The feature article focuses onthe challenges of refining ventilatorycare processes in the paediatric inten-sive care environment. We visitArkansas Children’s Hospital, a pri-vate non-profit paediatric medicalcentre that offers a range of ventila-tory treatments, and one of thelargest of its kind in the US.’

By Andrea Rossi MD, Directorof the Respiratory Division atBergamo General HospitalBergamo, Italy, andChair of theScientificCommittee ofthe EuropeanRespiratorySociety

Respiratorydiseases

New features and a colourful design

The SERVO-i Infant

The European Respiratory Society(ERS) 15th Annual Congress ERS President

Ronald Dahl

Maquet Critical Care AB 171 95 Solna, SwedenPhone: +46 8 730 73 00www.maquet.com/criticalcare

MMEEMMBBEERR OOFF TTHHEE GGEETTIINNGGEE GGRROOUUPP

Helping clinicians to meet the very special

demands of neonatal care is a key priority for

MAQUET. That’s why the SERVO-i ventilator

platform provides unmatched sensitivity and

advanced functionality for treating the smallest

patients. After all, every birthday is an occasion

to celebrate.

SERVO-i offers one platform for a wide range of

patient treatments. A state-of-the-art ICU ventilator

with outstanding capabilities for treating neonates,

the system senses and reacts to the minutest

changes in patient conditions.

This latest release introduces many new features

for neonatal patients. Nasal CPAP provides less

invasive ventilation, with stable CPAP pressure. As

an alternative to integrated monitoring, Y Sensor

measurement lets the clinician measure pressure

and flow close to the patient.

Please visit us at the ESPNIC congress in

Antwerp, Belgium, 15-17 September, booth 13-14

For more information visit

www.maquet.com/criticalcare

MAQUET – The Gold Standard.

SERVO-i FOR NEONATESANOTHER HAPPY BIRTHDAY

John sends you all his wishes and thanks


R E S P I R A T O R Y M E D I C I N E

Giessen Teamat base camp

DRUGEASES LUNGFUNCTION

The Netherlands - A randomisedtrial of roflumilast, led by researchersat Leiden University, has shown thatthe anti-inflammatory drug improvedlung function in patients with moder-ate to severe chronic obstructive pul-monary disease (COPD), according tothe results published in The Lancet inAugust.

The investigators, Klaus Rabe et al,tested for effects of the drug, a phos-phodiesterase-4 inhibitor, on the lungfunction and health-related qualityof life in 1,157 COPD patients, in cen-tres in 11 countries. These had beenrandomly prescribed 250 mg of roflu-milast, 500 mg of roflumilast or aplacebo. When compared with theplacebo, roflumilast was found tohave improved lung function andreduced worsening of respiratorysymptoms. The researchers alsofound that patients on the drug hadgreater improvements in health-related quality of life than thosegiven the placebo. ‘Roflumilast waseffective in improving lung functionand reducing exacerbations in a pop-ulation of patients with moderate tosevere COPD. The phosphodi-esterase-4 inhibitor class showspromise as a new therapeutic strate-gy for patients with COPD,’ Dr Rabeconcluded.

Science can be breathtaking atUGLC: The ‘Giessen EverestExperiment’, a challenginghigh altitude study organised

by a team of physicians (picturedabove), is an extreme example ofclinical research; it is also a mile-stone in the recent approval ofRevatio, better known as Viagra,by the US Food and DrugAdministration (FDA) as a treat-ment for pulmonary arterialhypertension (PAH).

At sea level, in the heart ofGermany, interested members ofthe public and patients can moreeasily benefit from and share inUGLC’s collective research spirit,for the centre constitutes a busyscientific network that incorpo-rates 20 research groups with over120 basic scientists and clinicians.

Close interaction on the GiessenUniversity Hospital campusensures that UGLC members canwork effectively to meet patient’sneeds and match capabilities. ‘Webelieve in translational science,’says Professor Werner Seeger,chairman of the renowned centre,‘and we aim to deliver ourresearch directly from bench tobedside.’ With the orchestratedpursuit of clinical, research and

training activities in pulmonarymedicine, UGLC members seek anew approach to understand,treat, and ultimately prevent lungdiseases. The clinical departmentsof medicine, surgery and paedi-atrics offer modern patient careand services to juvenile and adult

ry care facilities for all generallung diseases, as well as specificpulmonary infections (i.e.HIV/AIDS, avian influenza), juve-nile and adult mucoviscidosis, lungcancer, fibrotic or chronic obstruc-tive lung diseases including asth-ma, pulmonary hypertension, andsleep related disorders. Some ofthese facilities, namely those focus-ing on pulmonary hypertensionand lung fibrosis, care for thelargest patient groups in Europe.

Daily, UGLC clinicians are sup-ported by the skilled diagnosticexperts in the Institutes ofMicrobiology, Virology, Pathologyand Pharmacology.

With a continuous emphasis on

patients suffering various lung dis-eases. The UGLC also has emer-gency and intensive care units withadjoining wards, including facili-ties designed especially for treat-ment of rare and specific lung dis-eases. Additionally, the centrehosts highly specialised ambulato-

research and innovation, the centrelooks back on long traditions ofinventive treatment strategies, vac-cines, diagnostic tests, and othertechnologies that have improvedhealth. The exchange of comple-mentary scientific knowledge,skills and experience of the car-diopulmonary system is fertilisedby a joint dedication to education.UGLC faculty members activelyengage in a conjunctive concept tointegrate young scientists and clini-cians from all over the world inclinical fellowships and a PhDtraining programme specialised inpulmonary medicine and molecu-lar biology.Details: www.uglc.de

Dr Christiane Eickelberg, of the University ofGiessen Lung Centre (UGLC), outlines the centre’s

research projects, aims and academic offerings

Today’s treatmentsand training tomorrow’s specialists


R A D I O L O G Y

O P E N M I N D S

40th ANNIVERSARYfor the Annual Meeting of theGerman Society of Neuroradiology

As the German Society ofNeuroradiology 40th

annual meeting approached(Venue: Dresden. 31 August -

3 September), ProfessorsMartin Schumacher

(Freiburg), President of theGerman Society of

Neuroradiology (GSN) andRüdiger von Kummer

(Dresden), the meeting’sPresident, examine the

history and potential inthis medical field

“The programme in Dresdenreflects the unbelievable develop-ment of neuroradiology worldwide.It impressively shows the enormousupswing in diagnostics and therapyof central nervous system diseasesand particularly in brain research.

Neuroradiology in Germany isolder than the 40 years in whichregular annual meetings have beenheld. The earliest publications, in1905 (Schüller: The skull base onthe radiogram) and in 1906(Fürnrohr: X-rays in the Service ofNeurology) witness that WilhelmConrad Roentgen’s discovery wasalready in use in neurodiagnosticsonly 10 years later. Arthur Schüllerwas also the first to introduce theterm Neuro-Roentgenology in1913. For over half a century it wasthe neurosurgeons and neurologistswho practiced and developed neu-roradiology, including famousnames such as Dandy, Forrestier,Moniz, Djindjian, Krayenbühl andSerbinenko. When the GermanNeuroradiological Working Groupwas founded, in 1963, and wellbeyond the founding of the GermanSociety of Neuroradiology (1970),neuroradiology departments wereembedded primarily in neurologicaland neurosurgical hospitals. Notuntil the 1970s did the use of thesame techniques result in greaterco-operation with radiology, lead-

ing to the successful recognition ofneuroradiology in 1987. GermanNeuroradiology led the way, with astatus that even now still has to beattained in many European coun-tries. It was outdone only byPortugal, which first established thespeciality of Neuroradiology.

In evolution, those creatures sur-vive which have solid basic endow-ments which they can use for theirown further development and prof-

it additionally from favourableenvironmental conditions.Apparently neuroradiology pos-sesses these prerequisites, since ithas managed to show further deci-sive developments in the last twodecades, despite increased pres-sures. This is confirmed by a quicklook at the summaries of the scien-tific contributions to the 40thAnnual Meeting.

In diagnostics, magnetic reso-

nance imaging (MRI) has providedinsight even into microscopic areasto reveal pathological cell func-tions. Just to name a few: cellularlayer composition of the cerebralcortex or the hippocampus andpopulations of the same cells incore areas of the brain stem or thebasal ganglia can be differentiated,previously only histo-anatomicallydemonstrable fibre tracts becomevisible. Foci only millimetres in

size, which generate epilepsy, nolonger remain hidden and can be neu-rosurgically excised if they are resis-tant to medication therapy. Metabolicbrain function disorders can be classi-fied by imaging and spectroscopy,sensory and aphasic deficits in thefunction-MRI can be revealed (Fig.1).

The early diagnosis of stroke, sovital for therapeutic decisions, is pro-vided in minutes by diffusion-weight-ed sequences and enables differentia-tion of tissue at risk, which may sur-vive under rapid treatment, fromthose ischaemic areas (core infarc-tion) in which the transition fromfunctional damage to a structurallesion has already occurred (Fig. 2).

In therapy, a not inconsiderablenumber of surgical procedures hasshifted to interventional methods ofneuroradiology. Minimally invasivetherapies are now considered stan-dard, such as endovascular embolisa-tion of arteriovenous malformationsand endovascular elimination ofaneurysms by coiling (Fig. 3). Afterthe International Aneurysm StudyISAT, involving over 2,000 patients,brought convincingly better resultsthan surgical clipping, standard treat-ment of aneurysms shifted from oper-ative to endovascular techniques, sothat currently ca. 2/3 of the patientsare treated with coiling. By embolisa-tion alone of AV-malformations or incombination with surgery or stereo-tactic radiosurgery, the complicationrate could be reduced and malforma-tions treated that could not beremoved earlier due to their size orlocalisation. Likewise in recanalisa-tion of acute vascular occlusions,sophisticated endovascular tech-niques have created completely newtreatment paradigms. Re-opening,using drugs for intra-arterial fibrinol-ysis, has been increasingly supple-mented by mechanical recanalisationprocedures, whether as clot retrieversystems, vacuum-rinse systems orultrasound and laser procedures.Their application areas range over theentire central vascular system, includ-ing ocular arteries. There has alsobeen a shift in indication for the treat-ment of vascular stenoses, which areincreasingly treated by endovascularprocedures with stent-protected per-cutaneous transluminal angioplasty(PTA)(Fig. 4).

In a ranking of the 30 most-impor-tant innovations of the past 30 years,MRI and CT-Scanning were at thetop, followed in third place by bal-loon angioplasty of vascular stenoses,whereby application of these imagingmodalities play a key role in the cen-tral nervous system and the supra-aortal vessels (Fuchs VR and Sox HC,Health affairs, 2001; 20: 30-42). Thisimpressively underlines the impor-tance of neuroradiological diagnos-tics and therapy.

What will research bring? Thedecade of the brain flows without abreak into the century of brainresearch. Our high expectations ofprogress in the neurobiological exam-ination of the brain and its functionsare fully justified. Imaging procedureswill depict the highest organisationallevel of cognitive functions, memoryprocesses and even the experiencingof emotions in ever-greater detail, andeven portray the function or couplingof neuronal networks in their com-plex highly dynamic relationships.Neuroradiology stands at the middleof the co-ordination of research workin the clinical partnerships betweenneurologists, neurophysiologists,neurosurgeons, neurobiologists, psy-chologists, psychiatrists, microbiolo-gists, informatics and microsystemresearchers.

Fig. 1 (below): fMRI of a left handed female suffering from alarge temporal low-grade glioma on the right side. LanguagefMRI with semantic decision tasks for localisation of languageareas. Due to the patient’s left-handedness a right dominanceof language has to be ruled out by fMRI. The fMRI showedclear left sided dominance, thus the patient could be operatedon without any risk of speech arrest after surgery

Fig. 2 (below): 58-year-old patient with acute occlusion of the rightmiddle cerebral artery (a). DW-image (b) 45 minutes after strokeshows an ischaemic lesion in the right temporal cortex andsubcortical area with a corresponding perfusion deficit (c) in thesame area. At a higher level there is no diffusion disturbance (d) buta distinct perfusion deficit (e) indicating a diffusion-perfusionmismatch standing for the penumbra area (tissue at risk)

Fig. 3 (above): 40-year-old male withacute rupture of an aneurysm at theorigin of the right posteriorcommunicating artery (conventional DSA[a] and 3D reconstruction [b]). Completeocclusion of the aneurysm by 2 GDC-Coils (c) using remodelling technique

Fig. 4 (right): 66-year-old patientwith ulcerous stenosis at the originof the left internal carotid artery(arrow in a). Angiographic controlafter stenting with regular vessellumen (b) well demonstrated in 3Dreconstruction (c)


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R A D I O L O G Y

Belgian clinic offersTomoTherapy

Brussels - The Radiation OncologyDepartment at the Vrije UniversiteitBrussel has become the first Belgianand second European facility toinstall the TomoTherapy Hi-ArtSystem, which is the firstcommercial system specificallydesigned for IMRT (intensity-modulated radiation therapy).Chosen to complement thedepartment’s oncology treatmentsthe system is expected to reduceside effects (e.g. dry mouth in neckcancer) without compromising acure.

The TomoTherapy Hi-ArtSystem, which fuses a computedtomography (CT) imaging systemwith a dedicated system for helicaltomotherapy, or slice therapy,combines treatment planning,patient positioning and treatmentdelivery in precise treatment doses -to all body parts - withoutincreasing radiation deposited onhealthy tissue. Planning - Before beginning thistreatment, the doctor uses 3Dimages (e.g. CT) and specialsoftware to establish precisecontours for each region of interest(tumour) and any regions at risk(sensitive organs or structures). Adecision is then made about theamount of radiation to be given tothe tumour, and acceptable levelsfor surrounding structures aredefined. Then the TomoTherapyHi-Art System calculates theappropriate pattern, position andintensity of the radiation beam tobe delivered, to match the doctor’sprescription as closely as possible.Patient Positioning - A special CTscan can be made just prior to eachtreatment, so the tumour’s positioncan be verified and the patient’sposition adjusted if necessary(between treatments a patient’stumour can move). Helical Treatment Delivery - TheTomoTherapy Hi-Art Systemcombines IMRT with a helical (orspiral) pattern to deliver radiationtreatment. Photon radiation isproduced by a linear accelerator (orlinac), which travels in multiplecircles all the way around thegantry ring. Meanwhile, the couchalso moves, guiding the patientslowly through the centre of thering, so each time the linac comesaround, it directs the beam at aslightly different plane.

Poland’s $1 billion national cancer programmeTwo CT laser mammography systems purchased

Following the setting up of a US$1 billion National CancerProgramme to cover a 10-year period and provide screen-ing, diagnostic and therapeutic programmes, two CT LaserMammography (CTLM) systems, made by ImagingDiagnostic Systems Inc (IDSI), have been installed for clinicalresearch projects in the Institute of Oncology, MariaSklodowska-Curie Memorial Institute, in Gliwice.

‘The research projects we began with the Institute ofOncology, with currently over 400 cases completed in sixmonths, will now continue to conclusion,’ said Tim Hansen,IDSI CEO. ‘We expect that our global commercialisation pro-gramme will follow this pattern, one of regional clinical

investigations followed by local area sales.’ IDSL reports that the CTLM system is the first patented

breast imaging system to utilise state-of-the-art laser technol-ogy and patented algorithms to create 3-D cross-sectionalimages of the breast. ‘It is a non-invasive, painless examina-tion that does not expose the patient to radiation or requirebreast compression. IDSI has received CE Marking, CMDCAS(Canada), Canadian License, China SFDA approval, UL listing,ISO 9001:2000- 13488 certification and FDA export certifica-tion for its CT Laser Breast Imaging system. The Company isseeking PreMarket Approval (PMA) from the FDA for itsCTLM(R) system to be used as an adjunct to mammography.’

R A D I O L O G Y

Report by Michiel Bloemendaal(above) our correspondent for theNetherlands and Belgium


R A D I O L O G Y

SENOLOGY

Interdisciplinary concepts in the fight against breast cancer

“Interdisciplinary treatment in the con-text of senology is not an attractivebuzzword - it stands for life-savingstructures. For a woman withbreast cancer, interdiscipli-nary treatment means thatat each stage of her treat-ment all competencies thatshe may need are available,to ensure her best possiblecare. Hormone and chemother-apy are some of the focal points ofthis year’s joint annual meeting inStuttgart. Psychological aspects of thetherapy of mamma carcinoma, as wellas the use of new procedures in earlydiagnosis, will also be discussed.

In the last few years there have beensignificant changes in the diagnosisand treatment of breast cancer.Ductoscopy, for instance, is one of theforward-looking new procedures forearly diagnosis. This imaging proce-dure would be even better if, in addi-tion, it could help to differentiatebetween benign from malignantgrowths. How to achieve this is pre-cisely what experts at the meeting willintroduce - a novel concept. There isalso news from the neo-adjuvantchemotherapy. The smaller the tumouris at the point of surgery, the morelikely the surgeon is to be able to savethe breast. Many women feel a greatdeal of relief when the tumour alreadybecomes markedly smaller during thatphase in the treatment. Experts willdiscuss the advantages and disadvan-tages of neo-adjuvant chemotherapyduring the joint meeting.

These days, breast-preserving thera-py is becoming possible for an increas-ing number of patients. However, it is

not the end of treatment for thosepatients. Rehabilitation of a patient

after the operation, and ensuringher quality of life after breast

cancer, are important stepsin the fight against cancer.That is why we will alsobring up these aspects ofsenology at our Stuttgart

meeting. Furthermore, wewill discuss the needs of

patients whose desire for surgeryis only aesthetically motivated.Experts will be introducing the latestoperating procedures during lecturesand seminars on aesthetic breastsurgery.

We expect around 1,800 partici-pants at the meeting, who will dis-cuss these and many other currenttopics. Over 200 speakers will intro-duce the latest findings on diagnosis,therapy and aftercare of breast can-cer. The objective of our annual meet-ing is to convey evidence-based find-ings, which doctors can then put intopractice.

The registration fee is based on thedate of registration, status, length ofvisit and membership. Registration ispossible online at www.senolo-giekongress.de or through the con-gress organisers. Current informationand the programme can be found onthe society’s home page(www.senologie.org). Congress organisation: CTW, CongressOrganisation Thomas Wiese GmbH,Hohenzollerndamm 125, 14199Berlin, Germany,Tel. +49 (0)30 - 85 99 62-16Fax +49 (0)30 - 85 07 98 26e-mail [email protected]

Prostatecancer Europeantrials of HIFUtreatment areunderway

High-Intensity FocusedUltrasound (HIFU) con-verges at a selected dis-tance from the transducer

elements, and the curvature of thetransducer determines the distanceto the focal length. Although theintensity of the ultrasound is rela-tively low at the face of the trans-ducer (30 Watts), the site intensityat the focal zone can reach levelsgreater than 2,000W/cm2. This is asufficient intensity to raise the tis-sue temperature in the focal zoneto 70-100ºC in less than one sec-ond, making it a perfect energy fornon-invasive therapy - which isreal-time image-guided.

Francis and William Fry,researchers at the IndianapolisCentre For Advanced Research(ICFAR), based in Indiana, firstused HIFU in the early 70’s to treatinoperable brain tumours at theIndiana University Medical Centre.Later, under the direction of DrJohn Donahue, Department ofUrology, Indiana University,researchers began to pioneer theprostate treatment application forHIFU. From this, ICFAR foundedFocus Surgery Inc (FSI)Indianapolis, developer and pro-ducer of the Sonablate HIFU-sys-tem. In Europe, studies from theearly 90s, by Drs Gelet andChapelon, showed significant suc-cess using HIFU for prostate can-cer. Those first results have been

backed-up by other scientificresearch (e.g. 3D contrastenhancement after HIFU, Sedelaaret al: Eur Urol 2000). In 1994, theSonablate HIFU-system was usedin Europe for the first time to treatprostate cancer (Dr MichaelMarberger: Effect of High IntensityFocused Ultrasound (HIFU) onHuman Prostate Cancer, 1994).

and treatment areas are definedaccording to the shape of the indi-vidual prostate. During treatment,the transducer fires and movesunder computer-controlled real-time visualisation until the entirepre-determined volume has beentreated. Benefits of the Sonablate500-system are that it is truly non-invasive, safe and physician con-

At the end of 2001, FSI intro-duced Sonablate 500, a HIFU-sys-tem that offers a revolutionarystate-of-the-art technology thatmakes the use of HIFU for prostatecancer treatment more precise,safe, and effective.

The main advantages of thistechnology include:● the multi-focal length probe(3.0/4.0) using the same confocaltransducer for imaging and treat-ment - with visualisation duringthe whole treatment process● 3D planning software to precise-ly define the treatment zones● pre-treatment reference picturesfor each image during treatment● RIM (Reflexivity IndexMeasurement) for continuous real-time rectal wall monitoring, auto-matic temperature control, andcontinuous measurement of rectalwall distance to avoid rectum dam-age● a flexibly controlled power out-put interface that allows the adop-tion of power intensity to specialgiven tissue situations (e.g. radio-logically pre-treated prostates)● treatment in lithotomy position,which makes a special treatment-table unnecessary. This enabled thedevelopment of a compact andmobile device.

The treatment is performedunder spinal or sacral anaesthesia.After insertion of the transrectalprobe, the prostate is visualised

trolled, effective, adaptable to thephysician’s and patient’s therapeu-tic goals, repeatable, and there isno therapeutic impasse (alternativeoptions still allow post Sonablate500 therapy).

Worldwide clinical studies showup to a 90% CR (completeresponse=neg. biopsy and no PSAincrease), an average nadir PSAlower than 0.45ng/ml and a re-treatment rate of approx. 10%after one year. These data arebacked-up by a European MC-study, as well as a few additional,smaller studies done with anotherHIFU system (success rate 84%,with 5-year follow-up).

So far, over 7,000 patients havebeen treated with HIFU, and morethan 2,000 of these with theSonablate 500-system.

Furthermore, the Sonablate 500-system shows multiple-use poten-tial - prostate diseases includingcancer and BPH, liver and kidneycarcinoma applications underdevelopment, and testicle carcino-ma in clinical evaluation (first clini-cal results from Prof. Marberger, atthe AKH/University hospital,Vienna - presented by Prof. Schatzlof AKH in June 2003 at the 3rdInternational Symposium onTherapeutic Ultrasound (ISTU).Source: Misonix

At the German, Austrian and Swiss Societies forSenology joint annual meeting (Stuttgart. 8-10September), experts will discuss theinterdisciplinary treatment of diseases of thefemale breast. Professor Diethelm WallwienerMD, Chairman of the German Society forSenology and Managing Director of theUniversity Women’s Hospital Tübingen, pointsout that this is only the second time that thesubject has been aired at the meeting, butadds: ‘Only the transfer of knowledge betweenexperts of different medical disciplines willensure optimum treatment results.’


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O N C O L O G Y

By our USA correspondentKaren Dente

EU challenge to worldwide BRCA2 gene patent

Dr Karen Dente

Recently an unparalleled legalchallenge has beenunderway in the EuropeanUnion (EU) regarding the

number of human gene patentsheld by US-based corporationMyriad Genetics, for sequences oftwo genes, BRCA1 and BRCA2,mutations that indicate apredisposition to breast cancer.This type of legal challenge iscommonly known as an‘opposition’ to a granted patent

BRCA1 was successful, to theextent that it no longer providesany considerable threat todiagnostic practice in Europe, it isMyriad’s licensing rights on thesecond breast cancer gene,BRCA2, that has recently met withdisapproval among Europeanphysicians and researchers. Beforefacing opposition at the EPO,Myriad rephrased its claims forthe patent to cover the use of acertain DNA probe that

compromises a single mutation for‘diagnosing a predisposition tobreast cancer in Ashkenazi Jewishwomen in vitro.’ The mutation6974deIT, described in the patent,is somewhat more common among

Ashkenazi Jews.‘This is definitely not the way to

go,’ said Geert-Jan van Ommen, ahuman geneticist from theUniversity of Leiden, in theNetherlands. Seeking ownership ofa mutation in an ethnic group ‘...isnot acceptable to most geneticists,’said Gert Matthijs, of theUniversity of Leuven, Belgium.

The patent dispute over theBRCA2 gene is being followedclosely by researchers, physicians

under European patent law. ‘Thirdparties are allowed to challengethe validity within nine monthsfrom the grant of the patent,’explained Siobhan Yeats, theEuropean Patent Office’s directorof Examination and Opposition inBiotechnology, in an interviewwith European Hospital.

On June 29 the European PatentOffice (EPO) upheld a patentlicensed to Myriad Genetics of SaltLake City, Utah. European clinicalgroups launched an opposition tothe worldwide monopoly rightsover the breast cancer BRCA2,saying that it should be dismissedon the basis of ethical and legalreasons. Myriad has been pushingfor licensing expansion in Europe.

Between 2001 and 2003, theEPO has granted several patents toMyriad Genetics on familial breastcancer genes BRCA1 and BRCA2.These patents have permitted theUS firm to gain and retainmonopoly on BRCA1 and BRCA2testing. Although Myriad hasexclusive rights to commercialisetests based on BRCA1 and BRCA2in the United States, Europeanclinics have been opposed tosigning up for licenses. TheEuropean genetics community hasadamantly resisted Myriad’smonopoly for breast cancerscreening as they see it as aninterference with national policiessurrounding DNA-baseddiagnostic services.

Furthermore, the basis for thebreakthroughs in breast cancerresearch that led to the initialpatent claims by Myriad in 1994and 1995, was made possible as aresult of a collaborative effort onbehalf of worldwide academicresearch groups. Geneticists andhealthcare providers criticise thefact that Myriad spent minimalfunds discovering diagnostic teststhat, in addition to havinginaccurate results, are offered atvery high costs. While Myriadoffers patients a test for a fee ofabout €3,800, similar tests areoffered by German universities ata cost of around €1,800.

Whereas opposition to some ofMyriad’s claims over the gene

and policymakers both in theEuropean Union and the UnitedStates, where the permission ofexclusive monopoly rights overhuman genes in dereliction ofhealthcare and scientific researchruns contrary to the public interestand the goals of the patent system.The growing debate over genepatent domination over bothpatient care and researchillustrates the need for promptmodification of the US patent law.


Advertisers IndexCompany Page ProductAgfa 7 IT imaging solutions Aloka 9 Diagnostic ultrasoundBoston Scientific 8 Interventional cardiologyEsaote 1 Diagnostic ultrasoundGE 19 Diagnostic imaging Haus der Technik 20 Int. medical technology

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THE BALKAN CLINICAL LABORATORY FEDERATIONSuccess through collaboration

L A B O R A T O R Y & P H A R M A C E U T I C A L S

Spain & Ireland - Working on theBioFinger Project funded by theIST Programme, a team ofresearchers has begun testing asmall molecular detection toolamid expectations that a com-mercial product will becomeavailable within two to threeyears. ‘We are creating a generic,highly precise and highly versatiletool to detect and analyse mole-cules in the blood, and other flu-ids, using nano and micro can-tilevers,’ explained project co-ordinator Joan Bausells, of theConsejo Superior deInvestigaciones Cientificas,Barcelona, Spain.

Nanocantilevers, smaller thanthe surface of a fly’s eye, andtheir larger counterparts micro-cantilevers, function as sensors todetect molecules. When coatedwith antibodies they bend andresonate to changes in surfacetension and mass when fluidscontaining disease-related proteinmolecules attach to them. By see-ing whether or not the cantileversreact, doctors should be able todetermine whether or not a dis-ease is present.

Though much research hasbeen carried out on cantilevers,this has focused principally oncreating large-scale tools for useinside laboratories. But, said JoanBausells, ‘You can’t carry thosearound with you. What we’redeveloping is the first portabledevice that will allow doctors todiagnose diseases on the spot,almost immediately.’

During the present trials atCork University Hospital,Ireland, the microcantilever ver-Advanced

ADME/Toxtechnologies

and drugdevelopment

Approximately 90% of drugsfail in their development stagedue to poor absorption, distri-

bution, metabolism, elimination(ADME) or toxicity properties. Theestimated cost to pharmaceuticalfirms is US$50-$70 million.

‘It is increasingly clear that theability to detect issues with pharma-cokinetics before the drug movesinto clinical testing will ultimatelysave considerable resources in timeand money for pharmaceutical andbiotechnology companies,’ says Frost& Sullivan Healthcare Analyst atFrost & Sullivan, a global growthconsulting company, Dr AmarpreetDhiman, in his report ‘StrategicAnalysis of the ADME/ToxTechnologies Markets in Europe(B512-55).

ADME/Tox tests had beendeployed in the later stages of drugdevelopment, he points out.However, with the number of drugtargets as well as the volume ofassay points performed in high-throughput screens expanding, ithas become critical to rapidly andefficiently triage ‘potential hits’,having significant ADME and toxici-ty profiles.

Innovative technologies and solu-tions are already facilitatingADME/Tox optimisation

earlier in the drug discoverypipeline. ‘This will help yield com-pounds with good target affinity,reasonable drug-like properties andensure greater likelihood of accept-able ADME/Tox properties.Moreover, it is likely to acceleratethe selection process, reduce thecost of preclinical and clinical studies

and boost overall prospects of suc-cess,’ he points out.

Sophisticated informatics is widelydeployed to manage data for analy-sis and interpretation. Advancedsoftware with the ability to distilcompound leads with promisingdrug development potential, as wellas predict biological properties, havebeen designed. Complete solutionsthat include tools are also poised toamplify their presence within theADME/Tox tools market.

In-silico techniques - complex andaccurate models for rationalisingand predicting ADME properties -are allowing enhanced prediction ofcomplex systems (for hepatoxicityand cardiotoxicity).

Such computational technologiesand predictive solutions are likely toenhance the scope and speed atwhich drugs develop from a researchto clinical stage. At the same time,however, in order for ADME/Toxstudies to be truly beneficial, datageneration needs to be of high qual-ity, reliable and accurate. ‘The keywould be to develop tools that facil-

By Manole Cojocaru MD PhD, President of the 2004 BCLF Meeting

Research presented at the BCLF Meeting

Founded in 1993 to promotethe advancement of clinicallaboratory medicine in theBalkan region, the Balkan

Clinical Laboratory Federation(BCLF) encourages the affiliationof clinical laboratories with lead-ing international organizations,such as IFCC and FESCC.

In 2004, I was president of theBCLF. This September the 13thBCLF Meeting will be held inTirana, Albania, under the presi-dency of Professor Todor Gruev,of Macedonia.

After the successful 8th BCLFMeeting with international partici-pation in 2000, in Sinaia, I hadproposed that the 12th Meeting ofthe BCLF should be organized bythe Romanian Society ofLaboratory Medicine (RSLM), andit was organised under the aus-pices of the InternationalFederation of Clinical Chemistryand Laboratory Medicine (IFCC)and Forum of the EuropeanSocieties of Clinical Chemistry andLaboratory Medicine (FESCC).The event, in Neptun in September2004, attracted over 300 laborato-ry medicine workers from Balkancountries, and the rich scientificprogramme included 24 main top-ics. Professor H Reinauer(Germany) delivered an excellentplenary lecture on Laboratorydiagnosis and monitoring of dia-betes mellitus, and the followingresearch studies contributed tonumerous new and interestingobservations, studies, and discov-eries in all laboratory medicinebranches. Within the scope of this

review, however, only a few can bementioned (see box).

BCLF must remain basically aScientific Society, as quoted in itsname, and consider the role andimportance of scientists in the futureorientation and developments.

The link with IFCC and FESCCand recognition of a full speciality inall Europe are the keys to attractmore members and enlarge our field.Specialists in clinical laboratorymust also be aware of laboratorymedicine, to maintain a strong har-monized European speciality in allthe countries, with common trainingand CME, and free circulation.

Member societies of the BCLFand of the Executive Board of theFederation are from Albania,Bulgaria, Greece, Macedonia,Romania, Serbia and Montenegro,and Turkey; additionally, from

Microand nano–

technologies

2004, the Sarajevo-basedAssociation of MedicalBiochemists of Bosnia andHerzegovina (founded 2003, andwith about 50 members) became afull member of the BCLF.

The 12th BCLF Meeting was asuccessful congress, where the par-ticipation of professionals and thesocieties of Balkan countries jointefforts continue to improve thequality of the profession. I amdeeply indebted to many peoplewho worked together to achievethat very successful meeting.

itate data consolidation and infor-mation sharing,’ Dr Dhiman advises‘Standardised systems and solutionsthat integrate data from numeroustools and experiments need to bedeveloped while manufacturersshould develop opportunities tooffer services in data management,training, tool maintenance and oth-ers, functioning as both a serviceproviders and product developers.’

‘As companies try to decrease costsby increasingly outsourcing drugdevelopment functions, failure ratesbecome more controlled, in-silicotechnologies become more widelyadopted and a better understandingof ADME/Tox and pharmacokineticproperties motivates the use of inno-vative solutions and early ADME/Toxscreening, the European ADME/Toxtechnologies market will grow fromits current size of $384.0 million to$776.0 million by 2011. Currently,ADME/Tox services comprise thelargest market segment in Europefor ADME/Tox technologies, account-ing for nearly three-fourths of over-all market revenues. It is followed byADME /Tox tools (including systems& consumables) and in-silico ADME/Tox.

One key global trend is likely to bethe rising uptake of in-vitro screen-ingtechnologies (for screening toxiccompounds), he predicts. A streamof novel compounds movingthrough the clinical process is likelyto support the rapid development ofassays for ADME/Tox properties, cre-ating, in turn, significant long-termmarket growth opportunity for in-vitro screening technologies.Details: http://healthcare.frost.com

A world priority of the Romanian sciencefrom the discovery of the first water channelprotein (later called aquaporin I) in Cluj-Napoca in 1985 to the 2003 Nobel Prize inchemistry and the medical implications ofaquaporins (Gh. Benga, Romania); Externalquality assurance and the detections ofautoantibodies (M. Bluthner, Germany);Infection surveillance and controlprogrammes in preventing nosocomialinfections in French hospitals: nationalprogramme 2004-2007 (B. Gouget, ChairIFCC Communication and PublicationsDivision, France); Transforming growthfactor beta system in kidney diseases (T.Gruev, Macedonia); Quality control ofgenome detection in virus diagnostics (H. P.Grunert, Germany); Molecular investigationsof the hereditary cancers (Ch. Kalogera,Greece); Traditional and novel biochemical

markers of cardiovascular disease riskprevention (E. Bairaktari, Greece); Fromanalytical to clinical quality in laboratorymedicine (S. Ignjatovic, Serbia andMontenegro); Metabolic syndrome and riskof CVD (A. Tzontcheva, Bulgaria); Oxidativestress and antioxidative defence in type 2diabetic patients with cardiovascularcomplications (E. Colak, Serbia andMontenegro); Clinical relevance ofantikeratin antibodies in rheumatoidarthritis and symmetric polyarthritisassociated with hepatitis C infection (M.Cojocaru, Romania); New IgE myeloma casereport (Z. Mijushkovich, Serbia andMontenegro); Etiologic agents of urinarytract infections and their susceptibility toantibiotics (S. Berbecar, Romania); Qualitycontrol in the clinical microbiologylaboratory (R. Papagheorghe, Romania), etc.

sion of the system is being used todetect a protein associated withprostate cancer, while the nanocan-tilever system, said to detect a sin-gle molecule, is being used to testblood samples for interleukin 6, aprotein associated with inflamma-tion.

BioFinger incorporates the can-tilevers on a microchip that is dis-posable after each use, allowing itto be reconfigured with new on-chip cantilevers to detect differentsubstances, the team explained,adding that analysis can be per-formed anywhere, anytime, andtakes only 15-20 minutes. ‘In addi-tion, the system is likely to be con-siderably cheaper than traditionaldiagnosis techniques with each dis-posable chip expected to costaround 8 euros. It is also extremelyversatile,’ Bausells observed. ‘Itcould be used to detect virtuallyany disease, or as a pregnancy testor even to determine blood types.Outside of the medical field,’ headded, ‘it could be used to analysechemicals, detect bacteria in foodor test for water pollution.’Contact: [email protected]

EUROPEAN HOSPITAL

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CorrespondentsAustria: Christian Pruszinsky. Czech Republic: RostislavKuklik. Finland: Marti Kekomaki. Germany: AnjaBehringer, Annette Bus, Heidi Heinold, Max Heymann,Holger Zorn. Great Britain: Brenda Marsh, PeterHowieson. Italy: G. Sinaccio. The Netherlands,Belgium: Michiel Bloemendaal. Poland: Pjotr Szoblik.Spain: Eduardo de la Sota. Sweden: Ake Spross.Switzerland: Jaqueline Merlotti. USA: Karen M Dente,Cynthia E Keen, Ivan Oransky, Craig Webb.

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A W A R D S

The European Federation of IASPChapters (EFIC) Grünenthal Grant2005 has been awarded to young sci-entists and their research projects onpain therapy (see photo caption).

The EFIC Research Committee,which decided on the purely scientif-ic projects to be sponsored, reportedthat this year sees a variety of differ-ent approaches ranging from imag-ing of chronic pain processes in thebrain to the psychological manage-ment of pain patients following cer-vical spine injuries.

Four of the five sponsored scien-

Prof. René Bernards

€1.5 millionprize forscientificresearch

The Netherlands - The SpinozaPrize, worth €1.5 million, isawarded annually by the DutchOrganisation for ScientificResearch NWO to four topresearchers for their ‘outstanding,groundbreaking and inspiringresearch’. Professor René Bernards(52) has been named by the NWOjury as one of the prominentleaders in biomedical research.The professor uses innovativetechnologies to study fundamentalprocesses in cells, and was amongthe first to measure patterns ofgene activity by applying DNAmicro-array technology, whichpredicts accurately whether abreast cancer patient will developmetastases. More recently, heworked with RNA interferencetechnology (RNAi), a new methodthat - using a library of 24,000RNA fragments - enables shuttingdown of human genes one at atime, thus revealing their function.

Prof. Bernards is also co-founder and chief scientific officerof Agendia BV, a spin-off of theNetherlands Cancer Institute(NKI). Agendia’s MammaPrint, aprognostic test for breast cancerpatients, is based on parts of theprofessor’s work that washonoured by NWO. Theprofessor, with over 100 paperspublished in peer-reviewedjournals, is head of the division ofMolecular Carcinogenesis at theNKI, which he joined in 1992after a six-year assistantprofessorship at HarvardUniversity.

Grants for pain researchers

From left: Rob Koremans, member of the Executive Board of Grünenthal, with EGG 2005winners Dr Christina Liossi (Great Britain), Dr Helge Kasch (Denmark), Dr Anthony RHobson (Great Britain), Professor Jens Ellrich (Germany) and Harald Breivik, chairman ofthe EFIC Research Committee and immediate former president of the EFIC. The fifthlaureate Dr Irene Tracey (Great Britain) could not attend the ceremony

tists - from the UK, Denmark andGermany - have received a grant of20,000 Euros each for their researchproject. The fifth prize winner isreceiving 15,000 Euros to learn aspecial research technique at a dif-ferent institute.

Gr¸nenthal GmbH, a research-based, family-owned, pharmaceuti-cal company that focuses on paintherapy, gynaecology and new tech-nologies, donated the 100,000grants. The firm has production sitesin seven countries, representation in25 countries, affiliates in virtually all

European countries, and employsaround 1,800 people in Germanyand 4,800 worldwide.

The firm’s managing direct, RobKoremans, said: ‘Traditionalresearch prizes consider theresults of work already performedand therefore often tend to beawarded to specialists in estab-lished research centres. In con-trast, the EFIC Grünenthal Grant(EGG) sponsors planned projectsbefore they start. In particularEGG focuses on sponsoring youngscientists and the dissemination ofinnovative pain research through-out Europe.’

www.medica.de

DÜSSELDORF, GERMANYNOV. 16 – 19, 2005

37 th WORLD FORUM FOR MEDICINE

International Trade Fair with Congress

Messe Düsseldorf GmbH Postfach 1010 0640001 DüsseldorfGermanyTel. +49(0)211/45 60-0 1Fax +49(0)211/45 60-6 68www.messe-duesseldorf.de

EUROPEAN HOSPITAL

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