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A cost-analysis of computed radiography and picture archiving and communication systems in portable radiography.

A total of 40,000 portable examinations are performed each year at Shands Hospital (Gainesville, FL), a 570-bed teaching hospital. Radiographs are obtained using a screen-film combination with the films digitized for transmission to displays in four intensive care units. A cost-analysis of replacing screen-film with computed radiography (CR) integrated into a filmless picture archiving and communication system (PACS) network was performed. Equipment requirements included two CR units, three high-resolution dual monitor displays, and an archive to store 3 months of image data. The capital costs were amortized over a 5-year period. Capital and operating costs of the proposed expansion to the existing PACS network, together with anticipated cost savings, were determined. The maximum data transfer rate for portable examinations was 150 MByte per hour and approximately 400 GByte of image data are generated each year. These figures were used to determine the hardware requirements for handling the acquisition, transfer, and display of the images. Annual costs of the proposed expansion were about $220,000. Cost savings were achieved by elimination of film, including its handling by technologists/library clerks, and amounted to about $200,000 per year.

Adult↗

Picture archiving and communication systems and vascular surgery: clinical impressions and suggestions for improvement.

The purpose of this study was to determine the acceptance and clinical utility of a large scale picture archiving and communication system (PACS) for vascular surgery. Questionnaires and one-on-one interviews were conducted with physicians and nurses in the department of vascular surgery at the Baltimore VA Medical Center where PACS has been in routine, hospital-wide use for more than 2 1/2 years. The perceptions of the clinical staff were assessed to determine the efficacy of PACS in comparison to the conventional film based alternative for the practice of vascular surgery and suggestions for improvements were solicited. There was consensus among the vascular surgery staff members that the use of PACS enhanced their clinical practices, both in and out of the operating room (OR). Vascular surgeons heavily rely on image display in the OR as a "road map" to help determine their operative approach and to guide their surgery. PACS offers unique intraoperative imaging capabilities including rapid image retrieval and improved archival, cine review, the ability to modify image contrast, and the ability to obtain direct quantitative measurements of the degree of vascular stenosis. The increased accessibility and availability of images throughout the hospital enables improvement in time management and in patient care.

Baltimore↗

A literature review on communication between picture archiving and communication systems and radiology information systems and/or hospital information systems.

The purpose of this literature review is to present the concepts surrounding the issue of communication between imaging systems and information systems in radiology and the literature about them. Picture archiving and communication systems (PACS) were developed to combine viewing of modality images, archiving, and distribution of images. When PACS is integrated/interfaced with radiology information systems (RIS) or hospital information systems (HIS), it can merge patient demographics, medical records, and images. To address several issues surrounding communication between PACS and HIS/RIS and to make interface development easier and faster, various organizations have developed standards for the formatting and transfer of clinical data. Additional work continues to better handle these issues. Communication protocol Health Level 7 (HL7) is a standard application protocol used for electronic text data exchange in health care by most HIS/RIS. The imaging communication protocol for PACS is the Digital Imaging and Communications in Medicine (DICOM) standard specification protocol that describes the means of formatting and exchanging images and associated information.

Computer Communication Networks↗

Initial experience with soft-copy display of computed radiography images on three picture archive and communication systems.

We recently installed picture archive and communication systems (PACS) from three different vendors on our campus for evaluation. A major part of this evaluation involved assessing the capabilities of these systems for displaying computed radiography (CR) images for primary interpretation. The three PACS provided different functionality for CR image display in terms of availability of the proprietary Fuji CR image processing algorithms, availability of user-specified contrast look-up tables, and application of the processing at the time of CR image capture or image display. We found that the Fuji processing algorithms were important for printing film, but were not necessary for acceptable soft-copy display. Non-linear contrast processing produced superior results compared to simple linear processing (via standard window width and level controls). Display processing was best applied immediately prior to the display operation, as opposed to at the image capture time. This allows the display to be adjusted to demonstrate the full 10-bit range of the CR image, and also allows raw CR data (i.e. not optimized for any particular display device) to be stored in the long-term archive.

Algorithms↗

Content-based image retrieval in picture archiving and communications systems.

We propose the concept of content-based image retrieval (CBIR) and demonstrate its potential use in picture archival and communication system (PACS). We address the importance of image retrieval in PACS and highlight the drawbacks existing in traditional textual-based retrieval. We use a digital mammogram database as our testing data to illustrate the idea of CBIR, where retrieval is carried out based on object shape, size, and brightness histogram. With a user-supplied query image, the system can find images with similar characteristics from the archive, and return them along with the corresponding ancillary data, which may provide a valuable reference for radiologists in a new case study. Furthermore, CBIR can perform like a consultant in emergencies when radiologists are not available. We also show that content-based retrieval is a more natural approach to man-machine communication.

Consultants↗

Picture archiving and communication system bandwidth and storage requirements.

The purpose of this work was to determine the requirements for image storage and network bandwidth for a total digital department in a moderate sized academic radiology department. Data from the radiology information system was combined with image production information to produce a model of image acquisition. Destinations of images to reading rooms were studied to determine the final distributions of film. All findings were used to model the flow of data that would be expected if the images in the department were completely digital. Using today's standards, the department would produce approximately 15.7 Gbytes of data per day or 3.5 Tbytes of data per year if all acquisitions were digital. The peak acquisition rate would be 1.8 Gbytes per hour with a sustained rate greater than 1 Gbyte per hour for most of the working day. The anticipated bandwidth for the total digital department exceeded the capabilities of the existing picture archiving and communication system equipment. A distributed networked archive solution was shown to optimize access to images by radiologists and referring clinicians.

Computer Storage Devices↗

Planning for a multi-imaging center picture archiving and communications system.

There are fundamental differences in planning and configuring a picture archiving and communications system (PACS) for a multisite imaging practice as compared to a hospital-based radiology department. In the for-profit, multi-imaging center environment, return on investment is more critical and the distributed nature of radiology operations presents complex communications, infrastructure, archiving, workflow, and distribution requirements. This article discusses desired outcomes for a multi-imaging center PACS and the planning, functional, technical, and support requirements necessary to achieve those outcomes.

Ambulatory Care Facilities↗

Puncture-proof picture archiving and communication system.

As we become increasingly dependent on our picture archiving and communications system (PACS) for the clinical practice of medicine, the demand for improved reliability becomes urgent. Borrowing principles from the discipline of Reliability Engineering, we have identified components of our system that constitute single points of failure and have endeavored to eliminate these through redundant components and manual work-around procedures. To assess the adequacy of our preparations, we have identified a set of plausible events that could interfere with the function of one or more of our PACS components. These events could be as simple as the loss of the network connection to a single component or as broad as the loss of our central data center. We have identified the need to continue to operate during adverse conditions, as well as the requirement to recover rapidly from major disruptions in service. This assessment led us to modify the physical locations of central PACS components within our physical plant. We are also taking advantage of actual disruptive events coincident with a major expansion of our facility to test our recovery procedures. Based on our recognition of the vital nature of our electronic images for patient care, we are now recording electronic images in two copies on disparate media. The image database is critical to both continued operations and recovery. Restoration of the database from periodic tape backups with a 24-hour cycle time may not support our clinical scenario: acquisition modalities have a limited local storage capacity, some of which will not contain the daily workload. Restoration of the database from the archived media is an exceedingly slow process, that will likely not meet our requirement to restore clinical operations without significant delay. Our PACS vendor is working on concurrent image databases that would be capable of nearly immediate switchover and recovery.

Computer Systems↗

Finding the optimal picture archiving and communication system (PACS) architecture: a comparison of three PACS designs.

PURPOSE: At present, there are two basic picture archiving and communication system (PACS) architectures: centralized with a central cache and controller, and distributed with a distributed cache and central controller. A third architecture proposed here is an autonomous one with a distributed cache and no controller. This report will investigate the performance (as measured be central processing unit [CPU] and network load, scalability, and examination retrieval and display latency) of these three types. METHODS: The distributed PACS architecture will be simulated using an IMPAX R3.5 (AGFA, Ridgefield Park, NJ) PACS, while the centralized design will be simulated using an IMPAX R4 (AGFA) PACS. The autonomous system will be designed and implemented in-house. The autonomous system consists of two types of entities: basic components such as acquisition gateways, display stations, and long-term archives, and registry servers, which store global state information about the individual PACS components. The key feature of the autonomous system will be the replacement of the central PACS controller by the registry servers. In this scenario the registry servers monitor the interactions between the components, but do not directly govern them. Instead each component will contain the application logic it requires and will use the state information from the registry servers to take the appropriate action, such as routing images, prefetching studies, and expiring images from near line cache. In addition the routing of examinations will be optimized to reduce the duplication of image data. Display stations will be categorized by specialty (neuroradiology, pediatrics, chest, etc) and will retrieve studies for display on demand from intermediate servers dedicated to the corresponding specialty. Studies will be routed only to the intermediate servers and not to display stations. RESULTS: By distributing the application logic, an autonomous PACS architecture can provide increased fault tolerance and therefore increased uptime. In addition, the lack of a central controller and the use of intermediate servers improve the scalability of the system, as well as reduce CPU and network loads.

Computer Communication Networks↗

Automating clinically relevant prefetch processes in picture archiving and communication systems solutions.

As picture archiving and communication systems (PACS) hit the mainstream of projects gaining attention and priority in healthcare organizations, the promise of achieving better operational efficiencies in the radiology department is at the forefront of the financing discussions. Although some positive economic returns have been documented from the early proponents of PACS, most of the PACS installations are still working through operational changes in regards to digital image prefetching to achieve this objective. The lynchpin for achieving the desired operational efficiency is the enabling of an automated, clinically relevant prefetch process for comparison studies from the digital archives. This report explores the solutions deployed at two hospital systems in Minneapolis to utilize a "comparative region of interest" data element to augment the body region information typically available for prefetching in the PACS system. With this information, the prospective PACS implementer will know how to build in their body region requirements up-front in order to maximize their operational efficiency benefits later.

Humans↗

Multi-lineage interrogation of the performance characteristics of a split-signal fluorescence in situ hybridization probe for anaplastic lymphoma kinase gene rearrangements: a study of 101 cases characterized by immunohistomorphology on fixed archival tissue.

BACKGROUND: Fluorescence in situ hybridization (FISH) can identify chromosomal translocations on fixed archival tissue, but studies cross-validating the utility of FISH on lesions of different cell lineages that harbor similar translocations (e.g. those involving anaplastic lymphoma kinase [ALK]) have not been published. AIM: Our objective was to define the diagnostic utility, performance characteristics, and limitations of a commercially available, split-signal, FISH probe for ALK gene rearrangements on fixed, archived tissue from lesions of diverse cell lineage. STUDY DESIGN: The sensitivity, specificity, and positive and negative predictive values of the Vysis ALK FISH probe were compared with those of the ALK-1 antibody (Dako) in a series of 101 cases, comprising 43 hematolymphoid neoplasms, 4 reactive lymphoid controls, 50 non-hematolymphoid (including neuroectodermal, epithelial, myofibroblastic, and germ cell) lesions, and 4 early-trimester aborted fetuses that served as neuroblastic controls. METHODS: The study involved a predominantly (72%) Singaporean Chinese population aged between 9 months and 88 years (excluding the aborted fetal controls). All cases were reviewed both histologically and immunohistochemically with a wide panel of antibodies using the standard protocols in order to diagnose them according to the latest WHO classification systems. A positive cut-off value was determined, both by comparison with diagnostic categories with and without ALK translocations, as well as with negative controls. RESULTS: The ALK FISH probe suffered a 33% non-informative rate, but in informative cases it showed 94% concordance with the ALK-1 immunostain. A minimum cut-off value of 5 in 200 informative cells was adopted to make a positive call in each case. Of the ALK-1 immunoreactive lesions, nine lymphomas were concordantly ALK translocation-positive but one vesical inflammatory myofibroblastic tumor was discordantly FISH-negative. Among the ALK-1-immunonegative lesions, one case each of anaplastic lymphoma and pulmonary mycobacterial spindle cell pseudotumor were discordantly ALK FISH-positive, while a case each of intestinal myeloblastic tumor and ganglioglioma showed initial--but not reproducible--positive FISH readings. The remaining cases were concordantly negative. DISCUSSION: The discrepancies between ALK FISH results and well-established immunomorphological parameters indicate that interpretation is not always straightforward. Notably, the derivation of threshold cut-off values for positive calls on FISH assays has seldom been addressed in the literature, and has raised issues in interpreting cases with borderline positivity in this study. The factors that may influence such cut-off values are extensively reviewed. CONCLUSIONS: We propose the term 'conditional threshold positivity' to encourage the adoption of different cut-off values for making positive calls in lesions of different origin.

Adolescent↗

[Victims of Nazi euthanasia, the so-called T4 action. First results of a project at the German Federal Archives to disclose records of killed patients].

In 1990, previously unknown documents dated from the Nazi era were found in Berlin. They had been preserved in the central archives of the Ministry for State Security (MfS), the secret service of the now former German Democratic Republic (GDR). Nearly 30,000 psychiatric patient files turned out to comprise the smaller part of the records of patients who had been murdered in the 1940/41 "T4 action". More than 70,000 patients of psychiatric asylums were killed by gas in this first campaign of extermination during Nazism, and their files were believed to have been lost. Based on a project to be funded by the German Research Association, this paper offers a brief survey of the developments in historical research about Nazi "euthanasia" and the theories interpreting historical information. The paper will also present a research project dedicated to the memory of the victims of the "T4 action" and to the rediscovered files now conserved in the German Federal Archives in Berlin. The aim is to offer a systematic analysis of 3,000 records in an effort to contribute to the perception of the victims as individuals. The analysis will also include an examination of the selection criteria stipulated by the Nazi psychiatrists (hereditary illness, incurability, and incapacity to work productively) to select patients for extermination. In this way, the decision-making process, criteria, and motives that led to the killing should become more clear. This empirical analysis will help to answer questions concerning the proportion of eugenic and economic motivations and the Nazi rationale behind the extermination campaigns. The project will build upon an earlier preliminary study of a nonrepresentative sample of 185 files. As a preliminary result, it can be said that most of the victims had been hospitalised over long terms and classified as schizophrenic or feeble-minded. A third of the patients killed were considered invalid and not working, and almost 50% were described as working "mechanically". Five per cent of the victims were working "productively".

Crime Victims↗

Improved immunohistochemical staining of osteopontin (OPN) in paraffin-embedded archival bone specimens following antigen retrieval: anti-human OPN antibody recognizes multiple molecular forms.

Studies to assess osteopontin (OPN) localization in adult human bone using immunochemical techniques produce conflicting results due to variations in tissue processing or antibody immunoreactivity. The present study was designed to resolve these discrepancies using well-characterized antibodies and improved antigen detection. An anti-osteopontin (alpha-OPN) antiserum was developed that recognizes various soluble molecular weight forms of human OPN, including monomeric, cleaved, and dimerized products. An affinity column of full length recombinant human OPN (rOPN) coupled to support was used to purify alpha-OPN antibodies. Western analysis showed that the affinity-purified antibodies recognized numerous molecular weight forms of OPN. These antibodies were used to study the distribution of OPN in adult human bone using immunohistochemical techniques combined with an antigen retrieval protocol utilizing a newly developed antigen retrieval solution, Retriev-Alltrade mark (Bronco Technologies Inc, Pasadena, TX). Immunolocalization of OPN in archival bone specimens prior to antigen retrieval produced no demonstrable immunostaining even at high concentrations of alpha-OPN. Use of the antigen retrieval protocol restored OPN immunoreactivity, with strong staining apparent in cement lines, osteoblasts, osteocytes, canaliculi, osteoid, and bone matrix. We conclude that antigen retrieval restores immunochemical recognition of OPN in archival specimens containing bone without increasing nonspecific binding.

Adult↗

Human archival tissues provide a valuable source for the analysis of spatial genome organization.

Sections from archival formalin-fixed, paraffin wax-embedded human tissues are a valuable source for the study of the nuclear architecture of specific tissue types in terms of the three-dimensional spatial positioning and architecture of chromosome territories and sub-chromosomal domains. Chromosome painting, centromeric, and locus-specific probes were hybridized to tissue microarrays prepared from formalin-fixed paraffin wax-embedded samples of pancreas and breast. The cell nuclei were analyzed using quantitative three-dimensional image microscopy. The results obtained from non-neoplastic pancreatic cells of randomly selected individuals indicated that the radial arrangement of the chromosome 8 territories as well as their shape (roundness) did not significantly differ between the individuals and were in accordance with assumptions of a probabilistic model for computer simulations. There were considerable differences between pancreatic tumor and non-neoplastic cells. In non-neoplastic ductal epithelium of the breast there was a larger, but insignificant, variability in the three-dimensional positioning of the centromere 17 and HER2 domains between individuals. In neoplastic epithelial breast cells, however, the distances between centromere and gene domains were, on average, smaller than in non-neoplastic cells. In conclusion, our results demonstrate the feasibility of studying the genome architecture in archival, formalin-fixed, paraffin wax-embedded human tissues, opening new directions in tumor research and cell classification.

Breast↗

Archival, demographic and genetic studies define a Sardinian sub-isolate as a suitable model for mapping complex traits.

Genetic isolates represent exceptional resources for the mapping of complex traits but not all isolates are similar. We have selected a genetic and cultural isolate, the village of Talana from an isolated area of Sardinia, and propose that this population is suitable for the mapping of complex traits. A wealth of historical and archive data allowed the reconstruction of the demographic and genealogical history of the village. Key features of the population, which has grown slowly with no significant immigration, were defined by using a combination of historical, demographic and genetic studies. The genealogy of each Talana inhabitant was reconstructed and the main maternal and paternal lineages of the village were defined. Haplotype and phylogenetic analyses of the Y chromosome and characterisation of mitochondrial DNA haplogroups were used to determine the number of ancestral village founders. The extent of linkage disequilibrium (LD) was evaluated by the analysis of several microsatellites in chromosomal region Xq13.3, which was previously used to asses the extension of LD. Genealogical reconstructions were confirmed and reinforced by the genetic analyses, since some lineages were found to have merged prior to the beginning of the archival records, suggesting an even smaller number of founders than initially predicted. About 80% of the present-day population appears to derive from eight paternal and eleven maternal ancestral lineages. LD was found to span, on average, a 5-Mb region in Xq13.3. This suggests the possibility of identifying identical-by-descent regions associated with complex traits in a genome-wide search by using a low-density marker map. The present study emphasises the importance of combining genetic studies with genealogical and historical information.

Chromosome Mapping↗

Detection and genetic typing of type 2 porcine circoviruses in archived pig tissues from the UK.

Porcine circovirus 2 (PCV-2) is implicated as the causative agent of post-weaning multisystemic wasting syndrome (PMWS) and is also associated with porcine dermatitis and nephropathy syndrome (PDNS). The recent emergence of epidemic PMWS in the United Kingdom was predated by sporadic cases of PDNS dating back to the early 1980's. The aim of this study was to investigate whether PCV-2 DNA was present in archival tissues, and if so, to investigate the relatedness of these viruses with contemporary strains of PCV-2. DNA extracted from paraffin wax-embedded tissue blocks ( n = 68), was subjected to a TaqMan polymerase chain reaction (PCR) targeting a fragment of ORF1 of PCV-2. Positive results were obtained from 41% (9/22), 31% (4/13) and 32% (8/25) of submissions from the 1990's, 1980's and 1970's respectively. The presence of PCV-2 antigen in some of these tissues was confirmed by immunohistochemistry (IHC). A PCR targeting ORF2 was used to obtain sequence data for phylogenetic analysis. Sequences from 5 archival tissues were unique but showed high genetic identity to PCV-2 sequence obtained from a 2000 PDNS case. These data demonstrate that similar isolates of PCV-2 have been present in the UK pig population for more than 30 years.

Animals↗

Inter-laboratory comparison of DNA preservation in archival paraffin-embedded human brain tissue from participating centres on four continents.

DNA extracted from formalin-fixed and paraffin-embedded brain tissue is known to contain as yet ill-characterized inhibitors of the PCR process. As part of a project that aims to clarify the role of mitochondrial DNA sequence variation in human neurodegenerative diseases using DNA from various ethnic backgrounds, we have investigated factors that influence the preservation of archival DNA and its suitability for PCR. In this study, neuropathological tissue samples were analysed that had been routinely processed in 18 international centres on four continents. Following DNA extraction, PCR amplification of mitochondrial and nuclear DNA sequences was performed with and without additional purification of the template DNA. In addition, the DNA used for PCR was analysed by HPLC. Phosphate-buffered formalin proved to be a superior fixative compared with unbuffered aldehyde: DNA extraction resulted in greater yields, the molecular weight of the isolated DNA was higher and PCR was more successful. PCR inhibitors were identified as (1) high concentrations of small (<300 bp) DNA fragments that competitively compete with template DNA and (2) contaminants of the DNA template solution including denatured protein that cannot be completely removed by phenolic extraction. HPLC analysis did not reveal significant qualitative differences between DNA isolated from fresh-frozen tissue samples and DNA recovered from formalin-fixed, paraffin-embedded brain tissue. The fact that DNA could be amplified from the majority of tissue specimens in this study suggests that rare diseases and diseases where ethnic background plays an important role can be sampled for genetic polymorphism analysis on a global scale using archival neuropathological collections.

Alzheimer Disease↗

Unbiased stereological estimation of the spiral ligament and stria vascularis volumes in aging and Ménière's disease using archival human temporal bones.

The present study applies the unbiased stereological technique-Cavalieri principle to measure the volumes of the stria vascularis (SV) and the spiral ligament (SL) using postmortem archival human temporal bones from normal young and older subjects and subjects with Ménière's disease. Normative data was obtained from subjects without ages ranging from 15 to 84 years old who had no history of audiovestibular disease (N=25). For comparison purposes, the normative specimens were divided into three groups: group 1 (n=8) had ages ranging from 15 to 38 years old, average age=23.9; group 2 (n=8) had ages ranging from 51 to 59 years old, average age=55.1; group 3 (n=9) had ages ranging from 64 to 84 years old, average age=74.3. The average SV volume of group 3 (0.479 mm3) was significantly lower than that of group 1 (0.705 mm3) (p<0.0005) and was significantly lower than that of group 2 (0.603 mm3) (p=0.01). The average SL volume of group 3 (8.42 mm3) was significantly lower than that of group 1 (9.54 mm3) (p<0.05), but was not significantly lower than that of group 2 (8.58 mm3). Five subjects with Ménière's disease, confirmed by histopathological examination (ages ranging from 63 to 91 years old, average age=73.4), were studied. The average SV volume in Ménière's subjects (0.378 mm3) was significantly lower than age-matched controls (p<0.05). The average SL volume in Ménière's subjects (7.01 mm3) was also significantly lower than age-matched controls (p<0.05). The SV and SL volumes were unaffected by gender. The present study demonstrates for the first time the use of the unbiased stereological technique-Cavalieri principle-as a reliable and efficient method to obtain volumetric estimates of the SV and the SL by using archival human temporal bone specimens.

Adolescent↗