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The strategic and operational characteristics of a distributed phased archive for a multivendor incremental implementation of picture archiving and communications systems.

The long-term (10 years) multimodality distributed phased archive for the Medical Information, Communication and Archive System (MICAS) is being implemented in three phases. The selection process took approximately 10 months. Based on the mandatory archive attributes and desirable features, Cemax-Icon (Fremont, CA) was selected as the vendor. The archive provides for an open-solution allowing incorporation of leading edge, "best of breed" hardware and software and provides maximum flexibility and automation of workflow both within and outside of radiology. The solution selected is media-independent, provides expandable storage capacity, and will provide redundancy and fault tolerance in phase II at minimum cost. Other attributes of the archive include scalable archive strategy, virtual image database with global query, and an object-oriented database. The archive is seamlessly integrated with the radiology information system (RIS) and provides automated fetching and routing, automated study reconciliation using modality worklist manager, clinical reports available at any Digital Imaging and Communications in Medicine (DICOM) workstation, and studies available for interpretation whether validated or not. Within 24 hours after a new study is acquired, four copies will reside within different components of the archive including a copy that can be stored off-site. Phase II of the archive will be installed during 1999 and will include a second Cemax-Icon archive and database using archive manager (AM) Version 4.0 in a second computer room.

Computer Communication Networks↗

Frameless stereotaxy for transsphenoidal surgery.

OBJECTIVE: To evaluate the utility of performing transsphenoidal surgery with computer-assisted image guidance. METHODS: Thirty-seven patients underwent transsphenoidal surgery in which a frameless stereotactic system was used to confirm the trajectory to the sella and to locate the anatomic midline. This technique was compared with our standard method of using an image intensifier to confirm the approach (n = 43). The numbers of complications associated with the approach, the times required to set up and perform each operation, and the average costs for each group were compared. RESULTS: There were no complications attributable to inaccurate localization from the neuronavigational system. Additional setup time was necessary to calibrate and register the system; this represented a mean of 17 minutes in transsphenoidal procedures performed for the first time (n = 30), whereas reoperations required an average of 22 minutes (n = 7) (P < 0.05). The operative times, defined as time from incision to closure, were not statistically different (P = 0.38). To reduce assistant variation, a subset of this group in which the same assistant was used (n = 18) was analyzed. The additional setup time was reduced to a mean of 12 minutes (P < 0.05). The total case times were actually reduced in this group (127 versus 133 min), but this was not statistically significant (P = 0.75). Fluoroscopy was not required when frameless stereotaxy was used. The cost savings were partially offset by the cost of the preoperative computed tomographic study necessary for fiducial registration and the additional cost of setup time in the operating room. When all factors were analyzed, an additional cost to the patient of $318.00 was noted. The image guidance in axial, coronal, and sagittal planes provided by frameless stereotaxy was subjectively beneficial; it increased our confidence with the approach to the sella and intraoperative localization and was particularly helpful in reoperations where standard anatomic landmarks were distorted. CONCLUSION: Frameless stereotaxy is a technology that provides continuous, three-dimensional information for localization and surgical trajectory to the surgeon and can be applied to transsphenoidal surgery with minimal additional cost and time requirements.

Adult↗

[Improving productivity by implementing RIS and PACS throughout the clinic: a case study].

PROBLEM: How are improvements in productivity in connection with RIS/PACS to be defined? What do they cost? To limit the problem to the relevant topics, we first describe the objectives of a radiology department and the identified bottlenecks in the workflow. How to define and assess the improvements is discussed. METHODS: The case in question for this study is the RIS/PACS project at the "Klinikum der Universität München, Campus Grosshadern". The goals of the project and its present status are reviewed. The project is not yet completed, so this is a "midterm" report. RESULTS AND DISCUSSION: We describe the status of the achieved and not yet achieved goals and of the eliminated bottlenecks. On the plus side, for example, nearly 100% of all digitally generated images (except mammogramms) are digitally archived. They are accessible to the same percentage in radiology via PACS and in the hospital via the webbased intranet image distribution system when needed. In some radiology areas, such as multislice CT, already the reporting can no longer be performed without softcopy image interpretation. However, the full elimination of hardcopy images is still not reality, since the distribution to DICOM viewers for selected requesters with demands for almost reporting quality, high cost image displays is still in the testphase. To reduce film costs, images are being printed on a high resolution paper printer in addition to the intranet distribution during this transition period. On the negative side, due to a lack of job positions in the transcription rooms, about 40% of the reports are still being handwritten by radiologists. Furthermore, the dictated and transcribed reports are usually still not available early enough in the RIS and thereby in the intranet report distribution of the hospital. Here only a speech recognition system can remedy the situation. As soon as this problem is solved and the image distribution to the DICOM viewers works routinely, the reports and the images will be accessible within minutes to maximally within some hours after the examination. CONCLUSION: The goals reached so far suffered delays due to unforeseen problems and pitfalls. Altogether, a quieter operation and workflow in radiology has already been achieved, due to less inquiries from the requestors for unfinished examinations, images and/or image copies.

Computer Systems↗

Pinealectomy does not affect the entrainment to light nor the generation of the circadian demand-feeding rhythms of rainbow trout.

The pineal organ and its secretory product melatonin are regarded as synchronizers of daily rhythms to the external light/dark (LD) cycle. In fish, the pineal organ acts as a direct photoreceptor, transducing light information into neural and humoral (melatonin) signals. In the present study, we investigate a possible role for the pineal organ and melatonin in the regulation of feeding rhythms of rainbow trout, Oncorhynchus mykiss. We used individual rainbow trout placed in an insulated room at constant temperature (14 degrees C). Fish were self-fed ad lib by means of self-feeders coupled to a computer that continuously recorded demand-feeding activity. Before and after pinealectomy, the fish were exposed to a LD cycle of 16:8 h and then constant light (LL) to test the effect of pinealectomy on demand-feeding rhythms. Feeding records revealed that trout fed exclusively during daytime (96% of feeding confined to the light phase), and that removal of the pineal organ did not disrupt this daily feeding profile, with synchronization to the LD cycle persisting. Moreover, the appearance of circadian feeding rhythms was not affected by pinealectomy: most of the operated fish free-ran with an average tau longer than 24 h. Plasma melatonin rhythms persisted in the pinealectomized trout, but with small amplitude. These results suggest that the pineal may not be the site of the pacemaker that controls feeding rhythms in trout, although further research is required to study the involvement of other photoperiod-transducing systems and melatonin (of nonpineal origin) in the regulation and expression of circadian rhythms in this species.

Animals↗

Issues of nanoelectronics: a possible roadmap.

In this review, we will discuss a possible roadmap in scaling a nanoelectronic device from today's CMOS technology to the ultimate limit when the device fails. In other words, at the limit, CMOS will have a severe short channel effect, significant power dissipation in its quiescent (standby) state, and problems related to other essential characteristics. Efforts to use structures such as the double gate, vertical surround gate, and SOI to improve the gate control have continually been made. Other types of structures using SiGe source/drain, asymmetric Schottky source/drain, and the like will be investigated as viable structures to achieve ultimate CMOS. In reaching its scaling limit, tunneling will be an issue for CMOS. The tunneling current through the gate oxide and between the source and drain will limit the device operation. When tunneling becomes significant, circuits may incorporate tunneling devices with CMOS to further increase the functionality per device count. We will discuss both the top-down and bottom-up approaches in attaining the nanometer scale and eventually the atomic scale. Self-assembly is used as a bottom-up approach. The state of the art is reviewed, and the challenges of the multiple-step processing in using the self-assembly approach are outlined. Another facet of the scaling trend is to decrease the number of electrons in devices, ultimately leading to single electrons. If the size of a single-electron device is scaled in such a way that the Coulomb self-energy is higher than the thermal energy (at room temperature), a single-electron device will be able to operate at room temperature. In principle, the speed of the device will be fast as long as the capacitance of the load is also scaled accordingly. The single-electron device will have a small drive current, and thus the load capacitance, including those of interconnects and fanouts, must be small to achieve a reasonable speed. However, because the increase in the density (and/or functionality) of integrated circuits is the principal driver, the wiring or interconnects will increase and become the bottleneck for the design of future high-density and high-functionality circuits, particularly for single-electron devices. Furthermore, the massive interconnects needed in the architecture used today will result in an increase in load capacitance. Thus for single-electron device circuits, it is critical to have minimal interconnect loads. And new types of architectures with minimal numbers of global interconnects will be needed. Cellular automata, which need only nearest-neighbor interconnects, are discussed as a plausible example. Other architectures such as neural networks are also possible. Examples of signal processing using cellular automata are discussed. Quantum computing and information processing are based on quantum mechanical descriptions of individual particles correlated among each other. A quantum bit or qubit is described as a linear superposition of the wave functions of a two-state system, for example, the spin of a particle. With the interaction of two qubits, they are connected in a "wireless fashion" using wave functions via quantum mechanical interaction, referred to as entanglement. The interconnection by the nonlocality of wave functions affords a massive parallel nature for computing or so-called quantum parallelism. We will describe the potential and solid-state implementations of quantum computing and information, using electron spin and/or nuclear spin in Si and Ge. Group IV elements have a long coherent time and other advantages. The example of using SiGe for g factor engineering will be described.

Computer Systems↗

Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims.

OBJECTIVE: Delay in the provision of definitive care for critically injured children may adversely effect outcome. We sought to speed care in the emergency department (ED) for trauma victims by organizing a formal trauma response system. DESIGN: A case-control study of severely injured children, comparing those who received treatment before and after the creation of a formal trauma response team. SETTING: A tertiary pediatric referral hospital that is a locally designated pediatric trauma center, and also receives trauma victims from a geographically large area of the Western United States. SUBJECTS: Pediatric trauma victims identified as critically injured (designated as "trauma one") and treated by a hospital trauma response team during the first year of its existence. Control patients were matched with subjects by probability of survival scores, and were chosen from pediatric trauma victims treated at the same hospital during the year preceding the creation of the trauma team. INTERVENTIONS: A trauma response team was organized to respond to pediatric trauma victims seen in the ED. The decision to activate the trauma team (designation of patient as "trauma one") is made by the pediatric emergency medicine (PEM) physician before patient arrival in the ED, based on data received from prehospital care providers. Activation results in the notification and immediate travel to the ED of a pediatric surgeon, neurosurgeon, emergency physician, intensivist, pharmacist, radiology technician, phlebotomist, and intensive care unit nurse, and mobilization of an operating room team. Most trauma one patients arrived by helicopter directly from accident scenes. OUTCOME MEASURES: Data recorded included identifying information, diagnosis, time to head computerized tomography, time required for ED treatment, admission Revised Trauma Score, discharge Injury Severity Score, surgical procedures performed, and mortality outcome. Trauma Injury Severity Score methodology was used to calculate the probability of survival and mortality compared with the reference patients of the Major Trauma Outcome Study, by calculation of z score. RESULTS: Patients treated in the ED after trauma team initiation had statistically shorter times from arrival to computerized tomography scanning (27 +/- 2 vs 21 +/- 4 minutes), operating room (63 +/- 16 vs 623 +/- 27 minutes) and total time in the ED (85 +/- 8 vs 821 +/- 9 minutes). Calculation of z score showed that survival for the control group was not different from the reference population (z = -0.8068), although survival for trauma-one patients was significantly better than the reference population (z = 2.102). CONCLUSION: Before creation of the trauma team, relevant specialists were individually called to the ED for patient evaluation. When a formal trauma response team was organized, time required for ED treatment of severe trauma was decreased, and survival was better than predicted compared with the reference Major Trauma Outcome Study population.

Case-Control Studies↗

[Rooming-in and cesarean section in maternity hospitals in the State of Rio de Janeiro, Brazil].

OBJECTIVE: To disclose the existence of rooming-in (RI) in public and government contracted private hospitals that offer obstetric beds, in the State of Rio de Janeiro, Brazil, and to examine whether there is any association between RI and another quality care indicator which influences breastfeeding, namely the rate of cesarean section operations performed in these hospitals. METHODS: A survey was made of the existence of RI through a questionnaire sent to the Municipal Health Offices, the information collected being confirmed by telephone with each maternity hospital. The C-section rate data was obtained from the Rio de Janeiro State Health Office and divided into 2 groups: "below 40%" and "40% and above". The prevalence ratio was applied to the measurement of the association between the variables. RESULTS: A rooming-in rate of 65.2% was found for the State as a whole, with regional variations: a better situation in the capital (84.8%), an intermediate one in the interior (69.9%), and a worse one in the metropolitan belt (44.2%). The public maternity hospitals revealed a higher rate (89.7%) than that of the government contracted private hospitals (53.3%). A direct relation between the practice of RI and low C-section rates was found in the hospitals. However, this association did not present the same weight in all regions of the State. The lowest proportion of hospitals adopting RI was verified in the metropolitan belt, whereas the highest relative number of hospitals with high C-section rates was observed in the interior. CONCLUSION: It is concluded that to reverse the observed status, government authorities must fulfil their gerencial role within their own health system, as well as in the government contracted private hospitals.

Brazil↗

High-dose amrinone is required to accelerate rewarming from deliberate mild intraoperative hypothermia for neurosurgical procedures.

BACKGROUND: Since the time available to provide the cooling and rewarming is limited during deliberate mild hypothermia, the technique to accelerate the cooling and rewarming rate of core temperature has been studied. Amrinone has been reported to accelerate the cooling rate but not the rewarming rate of core temperature during deliberate mild hypothermia. The failure of amrinone effect on the rewarming rate might be due to an insufficient dose of amrinone during hypothermic conditions. The authors therefore tested whether higher doses of amrinone can accelerate the rewarming rate of core temperature during deliberate mild hypothermia for neurosurgery. METHODS: After institutional approval and informed consent, 30 patients were randomly assigned to one of three groups. Patients in the control group (n = 10) did not receive amrinone; patients in the AMR 15 group (n = 10) received 15 microg x kg(-1) x min(-1) amrinone with a 1.0-mg/kg loading dose of amrinone at the beginning of cooling; and patients in the ReAMR group (n = 10) received 5 microg x kg(-1) x min(-1) amrinone with 1.0-mg/kg loading and reloading doses of amrinone at the beginning of cooling and rewarming, respectively. Administration of amrinone was started just after the induction of cooling and continued until the end of anesthesia. Anesthesia was maintained with nitrous oxide in oxygen, propofol, and fentanyl. After induction of anesthesia, patients were cooled, and tympanic membrane temperature was maintained at 34.5 degrees C. After completion of the main surgical procedures, patients were actively rewarmed and extubated in the operating room. RESULTS: The cooling and rewarming rates of core temperature were both significantly faster in both amrinone groups than in the control group. During the cooling and rewarming periods, forearm minus fingertip temperature gradient was significantly smaller in both amrinone groups than in the control group. During the rewarming period, heart rate and mean arterial pressure in the AMR 15 group were significantly faster and lower, respectively, than in the control group. Systemic vascular resistance in the AMR 15 group was smaller than in the control group throughout the study; on the other hand, only the value after the start of rewarming in the ReAMR group was smaller than in the control group. CONCLUSIONS: Amrinone at an infusion rate of 15 or 5 microg x kg(-1) x min(-1) with a reloading at the beginning of rewarming accelerated the rewarming rate of core temperature during deliberate mild hypothermia. This suggests that high-dose amrinone is required to accelerate rewarming from deliberate mild intraoperative hypothermia for neurosurgical procedures.

Adult↗

Economic challenges in breast imaging. A survivor's guide to success.

Most breast imaging centers today operate under financial strain. Among strategies designed to improve their bottom line, more efficient use of the radiologist's time is the most fundamental strategy and the one most likely to succeed in all breast imaging centers. Tasks performed by the radiologist that are not directly related to interpretation and consultation should be shifted to other personnel. Other strategies that may help some breast imaging centers include accepting only self-paying patients, renegotiating the hospital contract, performing more interventional procedures, and extending the hours of operation. Measures that can improve the economic efficiency of screening mammography include batch interpretation of mammograms; paperwork reduction; brief automated reports; limiting requests for previous films from other facilities to only potentially necessary cases; dedicated screening mammography examination rooms; reduction in recall rates; and, in certain circumstances, extension of breast center hours. Measures that can improve the economic efficiency of diagnostic mammography performance and interpretation include dedicated diagnostic mammography examination rooms, automated film rotators, improved scheduling, and efficient work-flow patterns for examination performance. Measures that can improve the economic efficiency of both screening and diagnostic mammography include improved triage of screening and diagnostic patients, reminder telephone calls to confirm mammography appointments, greater use of medical assistants to help the radiologists and technologists, and streamlined film library procedures and operations. Measures that can improve the economic efficiency of breast interventional procedures include preprocedure work-up, establishment of scheduling protocols, and greater involvement of technologists and medical assistants in assisting the radiologist who performs the interventional procedures. All of these methods are intended to create a breast imaging center that is cost efficient while maintaining a patient-friendly atmosphere and diagnostic accuracy.

Allied Health Personnel↗

Informed consent: Part III.

Perioperative nurses are concerned about their patients understanding the procedures they will undergo. The legal system agrees that patients have the right to be informed about and consent to surgical procedures; informed consent is a legal right. No state, however, has recognized a formal role for the perioperative nurse in the enforcement of this right. Case law has consistently found that the necessary interchange for informed consent is vested in the patient-physician relationship, and it views broadening this legal responsibility as more disruptive than beneficial. When everyone is responsible, it is more difficult to ensure that someone actually talks to the patient. Present law makes that someone the surgeon. The role of the perioperative nurse includes informing the surgeon if the patient's informed consent has not been documented in accordance with agency policy, documenting having done so, and taking any additional actions required by agency policy. Perioperative nurses who suspect overreaching by surgeons should inform their administrators. The perioperative nurse should not unilaterally get involved in the physician-patient relationship. The patient has sought the services of the surgeon, not the nurse.

Documentation↗

[Telemedicine collaboration between the Rikshospitalet and the Ulleval hospital].

BACKGROUND: During the last two years the Intervention Centre at the Nation Hospital of Norway and Ullevål Hospital have pursued a research programme in telemedicine aimed at exploring the potential of inter-hospital collaboration. MATERIAL AND METHODS: Both hospitals established a communication network between operating rooms and lecture halls. Sound and video from minimally invasive surgical and radiology procedures were transmitted on a wide bandwidth ATM network (34 Mbits/s) to gain experience with the use of telemedicine for educational purposes and the treatment of patients. RESULTS: Evaluations of technical off-line and clinical line transmissions have given us helpful information about the potential of telemedicine and what it will take to utilise this potential. With the MPEG2 standard, a wide bandwidth network yields sufficient sound and image quality for educational and clinical collaboration. However, multimedia communication requires changes in the organisation to secure quality of service in relation to technical management and telemedical production. INTERPRETATION: Inter-hospital collaboration on telemedicine may be a resource in clinical practice, facilitating professional enhancements, particularly in surgery, radiology and internal medicine. Changes in the organisation are needed, but they are feasible.

Computer Communication Networks↗

Does off-pump total arterial grafting increase the incidence of intraoperative graft failure?

BACKGROUND: Early graft failure is a common cause of cardiac mortality and morbidity after coronary artery bypass grafting, but there is little information on its natural incidence. Furthermore, there is particular concern about graft patency in off-pump coronary artery bypass grafting and total arterial grafting. METHODS: We performed a prospective observational study to assess intraoperative graft patency in patients undergoing off-pump and on-pump coronary artery bypass grafting, who also underwent total arterial grafting. We used an intraoperative imaging system, SPY (Novadaq Technologies Inc), based on the fluorescent properties of indocyanine green dye. RESULTS: We assessed the intraoperative graft patency of 533 conduits in 200 patients. The mean number of grafts was 2.7 per patient. Of these patients, 155 (78%) had off-pump coronary artery bypass grafting, and 45 (22%) had on-pump coronary artery bypass grafting. Overall, 161 (80%) had total arterial grafting, with composite arterial grafting performed in 120 (60%) patients. Fluorescence, confirming graft patency, was observed in all but 8 (1.5%) conduits in 8 (4%) patients, necessitating graft revision. Six (3.9%) and 2 (4.4%) of these patients, respectively, had off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting. CONCLUSION: Intraoperative fluorescence imaging demonstrated a low (1.5%) but well-defined incidence of intraoperative graft failure, which affects around 4% of patients. This emphasizes the need for routine assessment of graft patency. Intraoperative fluorescence imaging permits detection and revision of failed grafts in the operating room. We found no difference in the incidence of failed grafts when comparing on-pump and off-pump total arterial grafting.

Aged↗

Pediatric ambulance utilization in a large American city: a systems analysis approach.

BACKGROUND: Research on utilization of ambulances by pediatric patients lacks an objective, reproducible tool for the evaluation of patterns of ambulance use by both the providers and the users of this resource. OBJECTIVES: 1) To develop an objective, diagnosis-based measure of appropriateness of ambulance utilization. 2) To use the measure to evaluate whether Municipal Ambulance Service dispatchers assign ambulances appropriately, and whether parents/caretakers request ambulances appropriately. STUDY DESIGN: 1) Development of the pediatric ambulance need evaluation (PANE) tool: The consensus of an expert panel was used to assign patients arriving by ambulance to three levels of prehospital transport need based upon their ultimate hospital discharge diagnoses, and were as follows: required advanced life support ambulance (ALS); required basic life support ambulance (BLS); required a less acute mode of transport (LAT). 2) Assessment of appropriateness of ambulance assignments by EMS call-receiving operators (CRO) and of ambulance requests by parents/caretakers: Comparison of actual type of ambulance assigned and of need for ambulance, using the PANE tool and hospital admission rates as gold standards. DATA COLLECTION: Level of prehospital transport provided (ALS vs BLS), ultimate ED diagnosis, and ED disposition (admission vs discharge) was collected for each patient from information abstracted from the prehospital and ED records. SETTING: Bellevue Hospital Center and Harlem Hospital Center, two level I trauma centers in New York City, both with Pediatric Emergency Departments staffed 24 hours a day by attending physicians and residents. PATIENT SELECTION: Consecutive sample of 2633 patients, birth to 18 years of age, who arrived to either hospital by ambulance as primary transports from the field over a one-year period. RESULTS: 1) Development of PANE tool: At Bellevue Hospital, 7% of ED visits arrived by ambulance; at Harlem Hospital, 5% arrived by ambulance. Using these ambulance arrivals, 215 diagnoses were identified for inclusion in the PANE tool. An expert panel categorized each diagnosis as requiring ALS, BLS, or LAT, with a high level of interobserver agreement (weighted kappa = 0.793). As a measure of external validity of the PANE, admission rates were highest in the ALS group, next highest in the BLS group, and lowest in the LAT group (chi2 for trend, P < 0.05). 2) Assessment of ambulance assignments and requests: According to the PANE tool, the sensitivity of dispatcher assignment of ALS ambulances was 72 %. Therefore, 28 % of patients who required an ALS ambulance received BLS care. 50% of patients assigned to an ALS ambulance did not require that level of care, and 1/3 of these were categorized by the PANE as not requiring an ambulance at all. CONCLUSIONS: The PANE tool compared favorably to admission rates as a measure of the severity of illness of patients arriving by ambulance. Applying the PANE tool, we conclude that the majority of requests for ambulances are appropriate, and that the majority of the time dispatchers were able to dispatch the appropriate level of care. However, there is room for significant improvement in utilization of ambulances, and tools like the PANE will be useful in achieving this goal.

Adolescent↗

Safety and complexity: inter-departmental relationships as a threat to patient safety in the operating department.

PURPOSE: Current thinking about "patient safety" emphasises the causal relationship between the work environment and the delivery of clinical care. This research draws on the theory of normal accidents to extend this analysis and better understand the "organisational factors" that threaten safety. DESIGN/METHODOLOGY/APPROACH: Ethnographic research methods were used, with observations of the operating department setting for 18 month and interviews with 80 members of hospital staff. The setting for the study was the Operating Department of a large teaching hospital in the North-West of England. FINDINGS: The work of the operating department is determined by inter-dependant, "tightly coupled" organisational relationships between hospital departments based upon the timely exchange of information, services and resources required for the delivery of care. Failures within these processes, manifest as "breakdowns" within inter-departmental relationships lead to situations of constraint, rapid change and uncertainty in the work of the operating department that require staff to break with established routines and work with increased time and emotional pressures. This means that staff focus on working quickly, as opposed to working safely. ORIGINALITY VALUE: Analysis of safety needs to move beyond a focus on the immediate work environment and individual practice, to consider the more complex and deeply structured organisational systems of hospital activity. For departmental managers the scope for service planning to control for safety may be limited as the structured "real world" situation of service delivery is shaped by inter-department and organisational factors that are perhaps beyond the scope of departmental management.

Central Supply, Hospital↗

History of cardiovascular imaging procedures (as developed and/or applied in German cardiology).

The value of the four main imaging tools: radiology, magnetic resonance imaging, echocardiography and nuclear cardiology depends in the first place on physical properties which determine the spatial, temporal and density resolution and second on the conditions under which the relevant information can be obtained with respect to the diagnostic or therapeutic problem, the comfort of the investigation, the degree of invasivity and the expenses. For several decades radiology was the only available method that allowed a look into the body. Thereby, all relevant information about diseases amenable to any surgical or conservative therapy could be attained. Parallel to the progress of cardiovascular surgery, angiocardiography could provide the anatomic and functional characteristics of congenital and acquired heart diseases. The basic principles for the measurement of total heart size, volume and shape were established already before contrast injection--initially by hand--showed the internal architecture of the heart cavities and the circulatory system. With the invention of film changers, the fundamental knowledge about all kinds of malformations of the heart and vessels was gained. Further technical progress made the procedures faster by cineangiocardiography, more comfortable by simultaneous biplane operation and easier to handle by videotechniques, allowing electronic data processing, storage and retrieval in bright operating theaters. Computer technology favored flexible image processing which, like digital subtraction and functional angiocardiography, could reduce the amount of contrast material to be injected and thereby improve the compatibility, due to better nonionic contrast material and shorter study times. Finally, computer tomography with cross sectional, or spiral data collection enabled a dynamic three-dimensional reconstruction and visualization of the beating heart and to display selected information in 'measures and numbers'. Inspite all these successes, the 'stain' of invasivity remains. Strong competition arose first in echocardiography, which--after some pioneering activities in Germany in the late 1950s--flourished in the 1970s, after being reimported from the US. Most of the rapidly increasing number of ultrasound technologies--from M-mode, via various 2D linear and sector scanning procedures in combination with continuous, pulsed and/or color Doppler methods, new contrast-echo modalities and finally 3D volume scanning procedures--can be applied without any harm in all age groups and from each competent practitioner with comparably small and cheap equipment. Only oesophageal and intravascular approaches retain a touch of invasivity. Consequently not much room remains for other techniques except those, like MRI, which can differentiate tissue properties better and with higher resolution and give unlimited access to all intrathoracic organs noninvasively. Under these conditions the indications for nuclear cardiology are restricted to the small field of myocardial perfusion and metabolic studies, whereas transit time measurements and radionuclide ventriculography are practically obsolete.

Cardiology↗

New IEEE standard enables data collection for medical applications.

The IEEE has gone to ballot on a "Standard for Medical Device Communications", IEEE P1073. The lower layer, hardware portions of the standard are expected to be approved by the IEEE Standards Board at their December 11-13, 1994 meeting. Other portions of the standard are in the initial stages of the IEEE ballot process. The intent of the standard is to allow hospitals and other users to interface medical electronic devices to host computer systems in a standard, interchangeable manner. The standard is optimized for acute care environments such as ICU's, operating rooms, and emergency rooms. [1] IEEE General Committee and Subcommittee work has been on-going since 1984. Significant amounts of work have been done to discover and meet the needs of the patient care setting. Surveys performed in 1989 identified the following four key user requirements for medical device communications: 1) Frequent reconfiguration of the network. 2) Allow "plug and play" operation by users. 3) Associate devices with a specific bed and patient. 4) Support a wide range of hospital computer system topologies. Additionally, the most critical difference in the acute care setting is patient safety, which has an overall effect on the standard. The standard that went to ballot meets these requirements. The standard is based on existing ISO standards. P1073 is compliant with the OSI seven layer model. P1073 specifies the entire communication stack, from object-oriented software to hospital unique connectors. The standard will be able to be put forward as a true international standard, much in the way that the IEEE 802.x family of standards (like Ethernet) were presented as draft ISO standards.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer Communication Networks↗

Influence of CRT workstation on observer's performance.

The effects of the operability of the prototype CRT workstation and room illumination upon observer's performance were studied. In the experiment of reading CT images as a routine daily work at the CRT workstation, the average time required to analyse one CT image under a room illuminance of 100 lux was longer than that on the film viewbox. Prolongation occurred due mainly to the longer time required to retrieve and to arrange images as observers desired, and the limitation to the number of images simultaneously displayed on two CRT monitors. In the ROC studies to detect small pulmonary nodules on CRT images of computed radiography with imaging plate, illuminance around 170 lux showed the best result and a statistically significant difference (P less than 0.05) as compared with that of 480 lux. In addition to the radiologist's visual performance, room illumination must also be taken into consideration as it influences the observer's performance and diagnostic efficiency.

Computer Systems↗

The use of an anesthesia information management system for prediction of antiemetic rescue treatment at the postanesthesia care unit.

UNLABELLED: We used an anesthesia information management system (AIMS) to devise a score for predicting antiemetic rescue treatment as an indicator for postoperative nausea and vomiting (PONV) in the postanesthesia care unit (PACU). Furthermore, we wanted to investigate whether data collected with an AIMS are suitable for comparable clinical investigations. Over a 3-yr period (January 1, 1997, to December 31, 1999), data sets of 27,626 patients who were admitted postoperatively to the PACU were recorded online by using the automated anesthesia record keeping system NarkoData(R) (IMESO GmbH, Hüttenberg, Germany). Ten patient-related, 5 operative, 15 anesthesia-related, and 4 postoperative variables were studied by using forward stepwise logistic regression. Not only can the probability of having PONV in the PACU be estimated from the 3 previously described patient-related (female gender, odds ratio [OR] = 2.45; smoker, OR = 0.53; and age, OR = 0.995) and one operative variables (duration of surgery, OR = 1.005), but 3 anesthesia-related variables (intraoperative use of opioids, OR = 4.18; use of N(2)O, OR = 2.24; and IV anesthesia with propofol, OR = 0.40) are predictive. In implementing an equation for risk calculation into the AIMS, the individual risk of PONV can be calculated automatically. IMPLICATIONS: The aim of this study was to investigate predictors for postoperative nausea and vomiting by using online anesthesia records. With the help of computerized data evaluation, 7 of 34 variables could be detected as risk factors. By implementing an automatic score into the record keeping system, an individual risk calculation could be made possible.

Adult↗