v o l 2 6 i s s u e 1 / 1 7 • f e b r u a r y /m a r c h 2 0 1 7 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 ecr special issue: 7-22 • roles: radiographers & radiologists • vascular imaging shifts upward • the carbon hyper-polariser and the brain laboratory/infection 23-28 • virologists: today’s necessity • mass spectrometry advances prostate research • liquid biopsies v. imaging k c o t s r e t t u h s / l a n o i s s e f o r p b s e © forensics identify victims and terrorists ‘i am sorry, the electricity will be cut off because we’re going to simulate an attack, or emergency exercise, this morning,’ explained dr wim develter, when he sud- denly delayed his interview with mélisande rouger of european hospital. they were about to discuss computed tomography, and its role not only in advanced healthcare and other more unexpected areas, such as the arts and forensics, but in recent years as a forensic tool in police investigations into terrorism. during ecr 2017, this leading forensic pathologist, from leuven university hospitals, will describe the procedures and practices within his work. seasoned forensic pathologist dr wim develter has worked on dis- aster victim identification (dvi) in four major catastrophes, including the terror attacks in brussels airport in zaventem, in march 2016. trains at the department of forensic medicine department at leuven in university hospitals, the netherlands, he forensic pathologists. in its di and crime scene the department organises simulations in which an invasive attack or disaster takes place and the personnel must act accordingly. investigation work, wim develter md is a trained clinical pathologist and an expert in corporal damage. as such, he specialises in forensic medicine in the department of forensic medicine at leuven university hospitals. he is also secretary for the royal belgian society of legal medicine. tify them. once this information is gained, the forensic team can track down where he or she received sur- gery or where objects were bought. develter could not speak of the contents of the on-going investiga- tion regarding the brussels attacks at the time of our interview, but he said the identification process of a terrorist or victim is similar. ‘after an attack you have a lot of extra information that can be useful for your investigation. i am one of the leading forensic pathologists in this enquiry, so i cannot say anything about the contents of the investi- gation because of the instruction’s secrecy,’ he said. however, during continued on page 2 www.healthcare-in-europe.com contents news & management 1-4 it & surgery 5-6 radiology – ecr 2017 laboratory/infection 23-28 7-21 k c o t s r e t t u h s / m r c © memorial for the victims of three bomb attacks at brussels airport and a metro station. left: forensic scientists were trained with damaged mannequins and, below, mock cases to identify victims in his latest exercise, develter put mannequins with prostheses in a plane to train staff towards the identification model as well as to test whether leuven’s facilities were big enough and if everyone was sufficiently trained. ‘we also tested the psychological support for the families. shortly after that exercise, the brussels bombings occurred, so we were well prepared,’ he added. the examination of disaster vic- tims and their remains often begins with ct exams, first to rule out dan- ger in the bodies – hidden explo- sives or biohazard – and then to organise the identification process (complete bodies, body fragments or body parts). ct also helps by showing the pathologists whether the victims were wearing jewellery or metallic devices, such as pros- theses, at the time of the disaster, information that can help to iden- chemiluminescence immunoassay focused supplier 120 countries exported 7000 units installed globally infectious disease autoimmune tumor markers thyroid fertility tpa-snibe pepsinogen i pepsinogen ii gastrin-17 h.pylori igg β2-mg hcg/β-hcg calcitonin tg(thyroglobulin) proinsulin *progrp *afp-l3 ferritin afp cea total psa f-psa ca 125 ca 15-3 ca 19-9 pap ca 50 cyfra 21-1 ca 242 ca 72-4 nse s-100 scca tsh(3rd generation) t4t3ft4ft3tg(thyroglobulin) tga(anti-tg) trab tma anti-tpo rev t3 intact pth drug monitoring cyclosporine a tacrolimus, fk 506 digoxin fsh lh hcg/β–hcg prl estradiol free estriol progesterone testosterone free testosterone dhea-s 17-oh progesterone *amh *shbg *androstenedione anemia vitamin b12 ferritin folate immunoglobulin lgm lga lge lgg hepatic fibrosis ha piiip n-p c iv laminin cholyglycine glyco metabolism c-peptide insulin ica iaa(anti insulin) proinsulin gad 65 ia-2 bone metabolism intact pth calcitonin osteocalcin 25-oh vitamin d cardiac ck-mb troponin i myoglobin nt-probnp aldosterone angiotensin i angiotensin ii d-dimer lp-pla2 hs-ctnl hs-crp *direct renin *h-fabp hbsag anti-hbs hbeag anti-hbe anti-hbc anti-hcv syphilis chagas 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news & management 3 down to earth devices on sale now: a novel monitoring patch tried and tested in the international space station. john brosky reports space missions are famous for driving innovation, from mylar blankets to microchips. so when french scien- tists learned one of their compatriots would be aboard the soyuz ms-03 spacecraft to reach the international space station (iss), they gathered cutting edge technologies for him to carry into orbit. on 17 november 2016 the european space agency (esa) astro- naut thomas pesquet was launched into space with nasa astronaut peggy whitson and russian cosmo- naut commander oleg novitsky for the six-month proxima mission. inside pesquet’s space gear were equipment and materials for two assignments, the matiss project designed by the french national centre for space studies (cnes), and the esa’s everywear program. the everywear tablet computer serves as the data platform for two devices from bodycap, a start-up based in caen, france, which col- laborated on a zero-gravity study of wearable technology with the cnes laboratory focusing on microgravity science and the swiss institute for space medicine and physiology. monitoring sensors a sensor in the e-tact patch worn by astronaut pesquet combines activity tracking, skin temperature monitoring and body position detec- tion; data is sent wirelessly in real time or stored on the device for subsequent analysis. the patch can be worn on any body area for some time, monitoring chronic diseases, sleep disorders and overweight peo- ple, for example. ‘as there is no gravity in the iss, the astronaut needs to be attached to the bed to avoid drifting around the capsule, which makes it difficult to sleep. what becomes important the uk will train more doctors beyond is the need for more trained health and social care practitioners, including doctors,’ said the asso- ciation’s chief executive katherine murphy. it’s reassuring to hear the secretary of state recognimse that, at present, the demand is not being met and take action to solve this. ‘the patients association has always heralded the hard work and dedication of all staff that work in the nhs, wherever they trained, or whatever their nationality. but we also recognise the importance of giv- ing opportunities to british students wanting to pursue a career in health, and the unique value this adds to our world-famous, great, british institution that is the nhs.’ k c o t s r e t t u h s / u v r a p n i l a t a c t u n o j © smart surfaces to resist bacterial colonisation inside the spacecraft with an eye on the future. ‘if we are going to send people to mars, we don’t want them to get sick on the way, nor do we want them scrubbing and cleaning all the time,’ said guillaume nonglaton, the project manager for the matiss experiment at the grenoble-based leti research institute. housekeeping in the space station takes up an inordinate amount of the astronauts’ time, which could be better spent performing their scien- tific mission. keen housekeeping is a vital task astronaut pesquet installed four plaques in spots regularly frequent- ed by fellow astronauts, such as the kitchen area. each plaque holds 20 different samples of hydrophobic materials that will be exposed to the air in order to come in contact with water droplets circulating within it, each possibly carrying bacteria. the sample surfaces were each designed to repel the droplets so that they remain in the air and can be filtered, rather than being absorbed on a surface where they may take root. advanced materials developed for the experiment include a fluorinated thin layer, an organic silica and a biocompatible polymer, all chosen for their hydrophobicity, and ability to be manufactured on an industrial scale. the materials also have practical benefits back on earth for germ-free medical device surfaces and even elevator buttons. nonglaton: ‘one never knows where the next good idea for prac- tical applications will come from; perhaps this time it will come down from space.’ a s e / a s a n © is an ability to quantify movement during his sleep, as this is a very good indicator of sleep quality, a measure of whether he is truly sleeping or is restless,’ explained sébastien moussay md, a co-found- er of bodycap. the other device from bodycap is the blood pulse wave sensor finger- worn device to detect changes in the blood pulse of the carotid artery when the astronaut presses his fin- ger against his neck. this tonometer is being used as part of a study of modifications to astronaut pesquet’s cardiovascular system during long- term exposure to microgravity. without the resistance of gravity, finger worn blood pulse wave sensor is a tonometer that checks on modifications to the cardiovascular system moussay said, the heart does not need to force blood flow to the brain and it progressively weakens, requiring a period of therapy for recovery once pesquet returns to earth in may 2017. the pulse wave sensor is a work- in-progress, moussay pointed out, but e-tact is a ce-approved prod- uct with down-to-earth medical applications in programs for the obese and diabetic patients where physical activity is a vital meas- ure, as well as for sleep labs. an example is patient compliance to prescribed physical therapy routines in the period following bariatric surgery. connected watches and other activity trackers popular with con- sumers do not make the grade with clinicians, he said. ‘what’s very important for doctors and medical staff is a measurement of metabolic change linked to activi- ties such as walking and swimming. they are less interested in measur- ing hand movements of someone playing a video game, which is the data provided by connected watch- es,’ moussay explained. the matiss project is a test of join - learn - care the xenios e-learning platform xenios campus offers a large selection of teaching programs on applications, certifications, professional publications and learning assessments, as well as detailed information on our xenios products. but the xenios campus has much more to offer! create your own learning environment with content totally tailored to your needs. contact our xenios mentors for an exciting exchange of experience and opinions. become part of the xenios campus and benefit from the community’s concentrated expert knowledge! www.xenios-campus.com xenios campus community globally present in more than 70 countries s e e rapi h t the therapy leader in lung and heart assist. xenios ag i im zukunftspark 1 i 74076 heilbronn, germany i +49 7131 2706 0 l u n g a nd hea r t www.healthcare-in-europe.com

it 5 cutting into a virtual brain areas to assess curative results computer model simulates epileptic events jan peter heida is partner and consultant of research firm sirm • in december, reporting was offered to hans de boer of vno-ncw. simulation of a patient’s epileptic seizures: seizures started in the right hippocampus (channel b1–2) before spreading to the contralateral hippocampus (channel b′1izu and further spreading in the left temporal lobe (d’après jirsa et al, 2016) kantar tns did an additional study (care monitor), in addition to the sirm study. • 1,430 people (18+), representa- tive of the community, were invited to participate in this study. 943 dutch finally filled in the questionnaire. • 351 healthcare professionals (148 doctors, 58 pharmacists and 145 medical specialists) completed the questionnaire • for this study the cawi (computer assisted web interviewing) method was used. • the average questionnaire com- • the questionnaire for both pletion time was 12 minutes. groups was largely similar. a single question was asked only to healthcare professionals. • the fieldwork ran from 21 february 2016. some results • compared to the past, 70% of healthcare consumers believe that care has become less patient-centred. among caregiv- ers that percentage was 44%. • 45% of consumers see care co-operation worse than before (56% think it better) against 20% of caregivers (80% consider it better now). • both healthcare professionals and healthcare consumers iden- tify the fact that the problem is that healthcare professionals are thinking about too many islands. • more than three quarters of care consumers find it very important, or essential, that something is done to improve collaboration between health- care providers and healthcare professionals. professor david stuckler is research director and professor of political economy and sociology at the university of oxford. his research integrates political economy and public health and he currently focuses on macro-social and economic determinants of health, political economy of global health and development, and comparative social welfare. dr richard horton, editor-in-chief of the lancet, said: it’s time to write a new contract between the uk’s nhs and society. the relationship between government and the medi- cal profession is broken. it’s there- approximately one percent of the world population are epileptic; in france alone, an estimated 600,000 people regularly experience sei- zures. during an epileptic event cor- tical neurons suddenly discharge, forcing their rhythm onto other nerve cells. this unusual and always temporary activity differs from per- son to person: it may manifest itself in a wide range of symptoms, from slight jerking of some muscle groups to serious convulsions and impediments of speech, memory, movement and behaviour. brigitte dinkloh reports in the past, research instruments that could gather knowledge on epilepsy were limited because, in about 50 percent of those affected, neither mri nor electroencephalog- raphy (eeg) show any visible brain anomalies. however, now research- ers at the centre national de la recherche scientifique (cnrs), the national institute of health and med- ical research (inserm), aix-marseille university and the general hospital marseille (ap-hm), have succeeded in creating a virtual brain that not only allows modelling the originat- ing sites and trajectory of abnormal brain activity but which can also optimise the planning of surgical interventions. in 70 percent of epileptic patients the seizures can be managed by medication. ‘when medication is not sufficient, however, surgery has to be considered,’ says dr fabrice bartolomei, medical director of the fore urgent to set out a new, posi- tive vision for health and the health service - a modern nhs that delivers the best care for patients wherever they live, supports world-class sci- entific research, is supported by all sectors of society working to create a healthier nation.’ professor sir robert lechler, president of the academy of medical sciences, said the significant health challenges facing society as a result of an ageing and growing popula- tion, rising obesity levels and envi- ronmental and economic change cannot be ignored. ‘finding ways to keep the popula- tion healthy matters - a healthy soci- ety is also a wealthy and happy one.’ other authors included professor dame sue bailey, chair of the academy of medical royal colleges; professor maureen baker, chair of the royal college of general practitioners; martin mckee, professor of european public health, london school of hygiene and tropical medicine; heather henry, co-chair of the new nhs alliance, department of neurophysiology at hôpital de la timone in marseille, france. ‘in a first step the epilep- togenic area is identified and, in a second step, it is removed or neu- tralised.’ an mri head scan is performed to localise the abnormal brain activ- ity. mri offers both an anatomy snapshot and – helped by the 3-d modelling technique tractography – the reconstruction of the course of larger neural tracts. a second source of information is eeg. ‘brain activity is recorded by electrodes which, under general anaesthetic, were implanted into the brain by the neurosurgeon,’ bartolomei explains. ‘the electrodes are placed in areas the surgeon considers important to understand the origin of an epilep- tic event and its propagation in the brain,’ innovative and less invasive tech- niques are currently being tested, such as magneto-encephalography (meg), which discovers and maps changes in the magnetic fields on the surface of the skull. an entirely new approach is the ‘virtual brain’, which ‘…allows us to personalise a mathematical model for each indi- vidual patient,’ explains dr viktor jirsa, director of neuroscience systems at cnrs, ‘and provides a visualisation that enables individual simulations.’ lord nigel crisp is an independent crossbench member of the house of lords, where he co-chairs the all party parliamentary group on global health. he works and writes extensively on global health. a former chief executive of the national health service (nhs) and permanent secretary of the united kingdom’s department of health, he is a senior fellow at the institute for healthcare improvement and an honorary professor at the london school of hygiene and tropical medicine. a grassroots organisation of 10,000 individuals and organisations work- ing to improve community health; and professor cathy warwick, chief executive of the royal college of midwives. neurologist fabrice bartolomei, specialist in epilepsy, is a professor at the aix-marseille university (http://edu. univ-amu.fr/en or http://edu.univ-amu.fr/ en) in france, leading the neurophysiology service clinic. he is also medical director of the centre saint-paul at the henri gastaut hospital (http://www.hopital- gastaut.com), one of europe‘s oldest hospitals to manage epilepsy, after a few pioneeers established epileptology following wwii. today the hospital treats 3,000 adults and children annually. bartolomei has published numerous epilepsy studies, particularly on the concept of epileptogenic networks and on the relationship between stress, emotions and epilepsy. he has largely contributed to the promotion of eeg/seeg analysis in focal epilepsies and is the co-inventor of the epileptogenicity index, a method to assess epileptogenicity of brain regions. surgery. the model, however, can- not predict any surgical side effects. in marseille, the virtual brain is almost already used to plan inter- ventions. an evaluation of the patients who underwent surgery remains to be done. there is a long way to go for researchers: they need to assess whether the virtual brain indeed provides an accurate picture of the epileptic event. bartolomei estimates another 18 to 24 months before the model can be used in a clinical setting. since, in epilepsy, electrical biomarkers are very specific, transfer of the model to other neurodegenerative diseases will not be easy by visualising brain activity and detecting the origins of an epileptic event and its spread in the brain, the virtual brain technology offers a more precise diagnosis. surgeons can mark the surgery regions of interest and plan and even test the most effective and least invasive sur- gical cuts. thus different scenarios and their effects on the brain can be simulated. bartolomei explains: ‘in a first step the mri and eeg data are transferred to the model. in a second step, electrical impulses are applied to nodes in the model, par- ticularly in the areas that are most likely epileptogenic. thus epileptic events can be triggered and visu- alised in the virtual brain and the source, as well as spread of abnor- mal activity, can be reconstructed.’ in each patient the interaction of nodes in the brain is different. the virtual model allows prediction of the effects of a given surgical intervention at a given node. the surgeon can remove certain areas of the virtual brain and see whether the epileptic events continue to develop, or whether cutting the con- nections, so to speak, has stopped the event. this technology increases plan-ability and efficacy of epilepsy fully automated formalin mixing and dispensing station www.kugel-medical.de km_azg_formalinmischstation_103x133.indd 1 01.02.17 09:13 www.healthcare-in-europe.com

ecr@ w w w. h e a lt h c a r e - i n - e u r o p e . c o m 2017 v i e n n a • a u s t r i a • 1 - 5 m a r c h 2 0 1 7 s p e c i a l i s s u e f o r t h e e u r o p e a n c o n g r e s s o f r a d i o l o g y zika birth deffects decrease, but… microcephaly, cortical malformation, and brain calcification; axial ct image (a) shows many small dystrophic calcifications in the junction between cortical and subcortical white matter (white arrows) and noticeable reduction of the brain parenchyma thickness. sagittal t2 weighted image (b) shows hypogenesis of the corpus callosum (black arrow), enlarged cisterna magna (long white arrow), and pons hypoplasia (white arrow). axial t2 weighted image (c) shows simplified gyral pattern (white arrows), ventriculomegaly (long black arrow) wildly open sylvius fissure as well as enlargement of subarachnoid space (black arrow). coronal t2 weighted image (d) shows pachygyria in frontal lobes (black arrows). note the bilateral cortical thickness in the pachygyric frontal lobe (black arrows), shown on axial and sagittal t2 weighted images (e and f). syndrome decreased throughout 2016. two possible explanations: t the pop- ulation is gradually becoming immune to the virus in north-east brazil and prevention has become more intense, with people knowing how to protect against the aedes aegypti, the mos- quito responsible for zika infections.. ‘the who revealed that, as of 14 december 2016, 75 countries and ter- ritories, especially in latin america, reported evidence of mosquito-borne zika virus transmission. up to then 29 countries, particularly in latin america, had reported microcephaly and other central nervous system malformations; four were without endemic transmission. after brazil, colombia (67) and the usa (37) had most cases.’ observational studies to understand the spectrum of this syndrome ongi- nud. ‘the fact that some children do not present with microcephaly but image alterations raises questions of great importance for public health. perhaps we’ve seen the tip of the ice- berg with the most severe brain dam- age cases associated with microceph- aly.‘ researchers want to know the real size of what is submerged, where minor changes without microcephaly could cause future problems, e.g. epi- lepsy and cognitive impairment.. ‘other groups are trying to evaluate prospectively the risk of developing microcephaly and other abnormalities after zika infection during pregnan- cy. besides congenital microcephaly, neurologic complications have been found in adults.’ according to the who, up to 14 december there was an increase in guillain-barre cases and/or laboratory confirmation of zika virus infection among guillain- barre cases in 20 countries. myelitis and encephalitis have also been iden- tified. ‘as radiologists, we try to help the scientific community to under- stand the pathophysiological process of the disease.’ is there hope of a treatment? ‘there is neither specific treatment nor a vaccine. although vaccination can be developed, a treatment for the lesions caused by the virus is extremely unlikely. this does not mean there is nothing to do. once the disease is recognised, rehabilitation must begin immediately, especially in less severe cases, to provide the chance of better neuro-psychomotor development for the children and support for their families. ‘treatment and support must also be directed towards other disease manifestations, – seizure, ophthal- mologic and auditory deficits, arthro- gryposis and possible complications, e.g. hydrocephaly.’ as it is highly suggestive of congenital zika syndrome. ecr 2017 guest lecturer maria de fatima vasco aragao, a radiologist from pernambuco state, brazil, has been tracking the zika virus ever since it broke out in her country in 2015. she will highlight how ct and mri can help reach diagnosis, especially in the absence of microcephaly. in an exclusive interview with european hospital correspondent mélisande rouger, the radiologist warned there might be more to come regarding the spectrum of zika syndrome, with possible outcomes such as epilepsy and cognitive impairment. ‘we do not follow patients routinely in order to prevent sedation of infants and ionising radiation. control studies are only indicated after identification of clinical signs of a complication, for instance hydrocephalus and seizures. ‘microcephaly and brain malforma- tions can be diagnosed with ultra- sound during pregnancy.’ ‘when a baby is born with micro- cephaly in an epidemic area, the paediatrician and neuropaediatrician usually suspect congenital zika syn- drome, whether or not the moth- er recalls a rash during pregnancy. but we are beginning to see cases in which neuropaediatricians don’t suspect congenital zika syndrome, because the babies don’t have micro- cephaly, but have.normal-size heads.’ they undergo mri examination due to unspecific neurological signs, e.g. delayed neuropsychomotor develop- ment and motor deficits. here, radiol- ogists must be alert, as the indication is not zika virus or microcephaly, and microcalcifications may be subtle, so could be missed. ‘not only the pres- ence of calcification, but also its loca- tion at the cortical subcortical white matter junction needs to be identified, ‘another suggestive finding is mal- formation of cortical development pre- dominant in the frontal lobes. in addi- tion, these children are around one year and, therefore, specific igm test for zika virus can be negative, even if the child has the disease. therefore, the radiologist’s responsibility is even more important in case of congenital zika syndrome without microceph- aly, to suggest the diagnosis to the paediatrician and neuropaediatrician. in these cases, radiology is the only tool we have to make the diagnosis. so radiologists must be alert. ‘ ‘imaging is important, especially in less severe cases, for early detection of congenital zika syndrome, allow- ing rehabilitation to start quickly, to help improve their development. if microcephaly is absent and clinical signs appear when infants are several months old, the most important way to diagnose the syndrome is through imaging studies, so radiologists need to detect microcalcifications at the cortical subcortical white matter junc- tion, which can be difficult on mri, and malformations of cortical devel- radiologist maria de fátima viana vasco aragão is president of pernambuco radiology society, professor of radiology at the maurício de nassau university and scientific director of the multimagem diagnostic centre in recife. ‘imaging is also important in iden- tifying complications of the disease, such as hydrocephalus, in which the indication for surgery for ventricular derivation is important, to prevent neurological deterioration.’ opment, predominant in the frontal lobes. how many cases are there? ‘since its peak in october/november 2015, new cases of congenital zika demands for high quality education ecr focuses on youth ‘youth’ is the central theme of this year’s ecr. more than 25,000 delegates from over 100 countries are expected for the 29th conference at the vienna’s austria centre to take part in the annual meeting that promotes science and innovation., the youth focus is reflected throughout the 2017 program, to which end the planners considered the demands of a young generation of radiologists for high-quality education, delivered in an efficient and customer-friendly way. the more interactive session will attract junior radiologists. professor paul m parizel is the first person to occupy the new role of a combined esr and ecr presidency. the participants expect a varied program. there will be three state-of-the-art symposia, 10 professional challenges sessions, 19 special focus sessions, more neurologist professor paul m parizel, who leads antwerp university hospital’s radiology department, has been appointed the first esr/ ecr president than 70 refresher courses and four multidisciplinary sessions, which feature radiologists, oncologists, gynaecologists and surgeons involved in the interdisciplinary treatment of patients. the good relationship between the esr and the european federation of radiographer societies (efsr) also has a strong impact on the program. ‘the quality of our performance depends on the strength of the entire team,’ parizel observed. ‘i am so happy that the ecr collaborates closely with radiographers, and the scientific program for 2017 will reflect this growing symbiotic relationship.’ color displaymegapixelwww.healthcare-in-europe.com

9 is also head of the radiology section of the german society for ultrasound in medicine. as course director and president, clevert organises numerous national and international ultrasound courses and congresses. on the 80th anniversary of the founding of the medical faculty at tbilisi state medical university, the professor, as head of the interdisciplinary ultrasound centre, received an honorary doctorate. new elastq imaging, real-time shear wave elastography, completes philips solution for liver assessment 3-d simulation includes haemodynamics ‘another special feature is the ability to acquire more data within the field of view during post-pro- cessing, in addition to the data sets already stored. this means that specific smaller, partial segments of interest, within a larger field of view, can be evaluated and documented later on. ‘the system also makes a so- called confidence map available during the examination, which indi- cates the quality of the signal by colour: green means high, yellow means moderate and red means low. it’s therefore always possible to get the best out of the images.’ professor dirk-andré clevert md heads the interdisciplinary ultrasound centre at munich university hospital (founded in 2004), where all ultrasound activities in the hospital converge. he ‘the platform offers a large range of transducers, with three different transducers available for abdomi- nal scanning alone. this choice of transducers makes it possible to utilise the technology developed for the liver for other applications and organs as well. for patients with acute stroke, ct and ultra- sound data can be fused to check for any severe brain damage, and for patients with prostate cancer it facilitates precise positioning of lesions detected on the mri scan to help carry out biopsies. ‘this means that the technology promotes the interdisciplinary utili- sation of image data that would oth- erwise go to waste. instead, doctors can feed radiological image data into their systems and use it for pro- gress monitoring. viewing a ct or mri scan next to an ultrasound scan makes it possible to track whether a lesion has become smaller, larger or has remained the same over longer periods of time.’ which trump cards does the new shear wave elastography offer? ‘this technology is primarily used on the curved array transducer. the large measurement window makes it possible not only to view and measure partial liver segments but also larger areas of the parenchyma. ‘along with colour coding, which indicates whether tissue is hard or soft, a mean numerical value can also be determined. this can be used to monitor treatment and see whether the values are chang- ing. the system edits the data and converts it directly into a structured patient report, which simply needs to be printed. josé ignacio bilbao jaureguizar is professor of radiology, head of interventional radiology and consultant radiologist at university clinic of navarre (ucn) in pamplona, spain. he is also former chairman of ucn radiology department. he gained a medical degree at navarre university’s medical faculty. training followed in interventional radiology at md anderson cancer centre, houston, usa and he received his phd, cum laude, at navarre university. his research interests are percutaneous treatment of tumours including chemotherapy and embolisation, especially in liver tumours. involved in function and find out more about fluid dynamics.’ in the future, 3-d simulation models should be tailored to every patient. this would prove of tre- mendous help in brain cancer sur- gery for instance, bilbao added. ’we still have a lot of work ahead. developing a simulation model takes thousands of hours on a super computer. it’s not only about money, but also techniques. it could take years, but things go so fast now, so who knows? ad mh wb mit 210x286 1016.indd 104/10/16 15:25eh @ ecrwww.healthcare-in-europe.com

mobile x-ray around the globe 11 tions for mobile, stationary and ret- rofit applications. ‘and,’ the compa- ny adds, ‘due to the equipped wire- less file transfer and the automatic exposure detection (aed), the user can work in a most comfortable way without any disturbing cables.’ details: www.medical-econet.com medical econet radiography solutions are equipped with a worldwide unique hybrid-powered technology since launching mex+ dr solutions in 2009 the imaging and x-ray solu- tions producer medical econet has installed the range internation- ally. physicians in diverse areas and fields of expertise, medical crews on ships and oil-rigs, paramed- ics in military ambulances, as well as disaster relief forces in conflict areas, report satisfaction regarding the lightweight and flexible mex+ x-ray devices in their daily work, the manufacturer reports. ‘a highly beneficial factor is the user-friend- ly handling of the self-explanatory mex+ image acquisition software, which contains a full integrated positioning guide and proposals for adequate dose values.’ with a specific focus on mobil- ity and flexibility, medical econet explains it ‘supplies radiography solutions that are equipped with a worldwide unique hybrid-powered technology. this smart technology allows operation of the mex+ porta- ble x-ray generators by the integrat- ed battery, or by an external power supply, while charging the battery. these durable lithium-ion batteries can produce over 500 exposures, with only one full charge, and gen- erate clean diagnostic images by high frequency technology.’ in addition, the firm’s range of wired and wireless digital radiogra- phy detectors come in three imaging sizes (10x12, 14x17, 17x17 inch) and can be provided as customised solu- professor emanuele neri chairs the ehealth and informatics committee of the european society of radiology (esr), and the esr eurosafe ct dose repository, he is also a delegate for imaging biobanks of esr research committee and member of the rsna radiology informatics committee. at the university of pisa, neri is associate professor of radiology, devoting most of his research focus on gastrointestinal and oncologic imaging and imaging informatics, with special interests in structured reporting, imaging biomarkers and biobanks. reason in parallel with development of standardised reports is an effort to arrive at standard terminology, a lexicon,’ neri said. ‘radlex, devel- oped at rsna, will probably be the example to follow,’ finally, reports are not just a mat- ter of text but also convey a wealth of quantitative information, such as measurements of volume, length, density, or contrast uptake. some of this data may be captured and reported automatically where soft- ware vendors can reliably transfer the measures into the report. ‘but,’ he added, ‘this will not always be the case.’ elastq imagingpurewavecontrast enhancementfusion and navigationdiscover evolution 3.0 at www.philips.com/epiqnow epiq with evolution 3.0 brings a suite of de(cid:3) nitive features and capabilities that o(cid:1) er a comprehensive ultrasound solution for liver disease assessment, treatment planning and monitoring. elastq imaging, real-time shear wave elastography for de(cid:129) nitive tissue sti(cid:141) ness datapurewave transducer technology for exceptional liver imaging even on challenging patientscontrast enhanced ultrasound for superb liver tissue (cid:160) ow analysisimage fusion and navigation for fast clinical decisions and advanced treatment planningepiq evolution 3.0: the ultimate ultrasound solution for liver assessmenteh @ ecrwww.healthcare-in-europe.com

12-year population imaging study produces provocative insights professor of radiology gabriel p krestin chairs the radiology and nuclear medicine department at erasmus mc, university medical centre in rotterdam, the netherlands. a graduate of the university of cologne, germany, his residency in radiology was completed in 1988. he was later appointed radiologist and head of the mri centre in zürich university hospital, switzerland, where he became associate professor of radiology and head of the clinical radiology service, before moving to his present position. the human brain is decreasing with age. yet, when we were looking at volumes of brain structures, meas- uring grey and white matter, what we saw was that, with increasing age, the grey matter is not chang- ing in volume. it’s the white matter that changes in volume. if we look deeper we find that it is not the grey matter that atrophies so much as the white matter.’ ‘another process that we relate to age is the formation of white mat- ter lesions. with some sequences in mri we can identify those small, high-signal intensities, even if we don’t know exactly the histopathol- ogy and pathophysiology of these lesions. ‘we assume that these white mat- ter lesions are related to degenera- tion, and at the same time, we know that the number and the load of white matter lesions increase with age. ‘from population imaging studies we learned that white matter lesions are associated with a certain number of risk factors. for instance cardio- vascular risk factors, like smoking, hypertension, or diabetes, lead to an increased white matter lesion load. and, finally, we also learned that these white matter lesions are also to select can be overwhelming. the promri configurator relieves con- cerns by channelling mr-conditional systems and devices into a single online platform with an easy-to-use interface. in a step-by-step process doctors are directed to possible car- diac implantation combinations for their patients’ mri needs. the promri configurator marks the second offering of the promri check online platform that the manufacturer offers physicians. ‘the first tool, the promri systemcheck, was launched in 2014 and helps physicians to determine whether an implanted biotronik system is mr-conditional.’ this is a ‘retrospective tool’, the firm points out. ‘the promri configurator enables physicians to be proactive in their approach – to determine beforehand the best sys- tem or device to implant based on the physical needs of the patient.’ as manuel ortega, the company’s senior vice president, confirmed: ‘we are determined to maximise patient accessibility to mri scans as far as possible.’ details: www.promricheck.com 13 predictors of certain outcomes, of dementia, but also of stroke. ‘still, all of this is only the tip of the iceberg. there’s a lot more that we cannot see with our eyes that are under the water line, let’s say. today we can measure with sensitive tools such as diffusion weighted mri, the microstructural integrity or dam- age of the white matter. with these measures, what we find in longitudi- nal population studies is that even in the non-affected white matter, which appears to be completely normal on conventional mri images, a change in these diffusion metrics appears long before the white matter lesion becomes visible – years later. on the other hand the microstructure of the white matter is linked to cogni- tion, and damage is associated with impairment of cognition. ‘we have also done functional connectivity studies and we can see these white matter damages that we attributed to aging are quite exten- sive. yet they have nothing to do with age. when we correct for all the risk factors, and a lot of other factors that can play a role, we see that there’s not much remaining. instead of a change with age these aging people are increasingly affect- ed by other diseases or impairments related to cardiovascular risk factors, diabetes, decrease of brain perfusion or impaired microvasculature. ‘again, my message is that what we relate to age is not, in fact, due to the so-called normal aging process but is part of a process that has to do with some disease pathophysiology. ‘the reason that assessment of such imaging alterations becomes important is that these measures are biomarkers that can predict certain outcomes. people who have dam- age to the microstructure of the white matter, or show a high level of atrophy, or white matter lesions, will have a higher risk to develop dementia or stroke. ‘over the past fifty, years we have increased life expectancy due to the fact that today we have a much better understanding of these risk factors and thus a better prevention, by decreasing the number of predis- posing or external factors.’ experience and explore this new generation ultrasound system join us at ecr 2017, march 2nd, 15:30 at booth x2/17 for the unveiling of our new premium arietta family member hitachi medical systems europe holding ag www.hitachi-medical-systems.com eh @ ecrwww.healthcare-in-europe.com

neuro-imaging: what radiologists can do today – and not yet new digital mobile x-ray systems for higher operator satisfaction world have a carbon hyper-polariser because it costs something north of a million dollars, and then it has to be placed beside the scanner because the tracers have very short half-life.’ following the lecture a discus- sion of developments fell into the category of automated image analy- sis, big data and machine learning, he said. ‘there is work being done on very interesting concepts based on automated image analysis and machine learning. when we humans look at an image, we see patterns that are based on the spatial location of dots, their grayscale or colour, and shapes. but digital images can yield additional information already embedded in them, based spatial frequencies and similar features, that can only be extracted by various mathematical operations and trans- forms, and not appreciated by the human eye,’ he explained. ‘when we analyse this scatter image we can’t say whether it’s a picture of a human brain or a giraffe. but, with appropriate software, a computer can recognise patterns that we cannot, potentially finding unique patterns that may ultimately prove diagnostic of certain diseases. by analysing sufficiently large sets of such image data, perhaps soon automated analysis will enable us to distinguish between various types of brain tumours, grade them, and pos- sibly even inform us of their genetic makeup,’ looking ahead, kucharczyk said he hopes that radiologists, like the team of the neonatal care unit, portsmouth hospital nhs trust with the mobile digital x-ray systems larger image display monitor and convenient storage space,’ shimadzu adds. scatter correction software ‘the scatter correction software enables more efficient work, due to the elimination of grid misalign- ments,’ the firm points out. ‘whereas a grid physically reduces scatter and increases image contrast, the soft- ware mimics this process virtually. it generates a scatter model, which is subsequently subtracted from the image. the result is an image with reduced scatter and increased con- trast.’ finally, shimadzu adds that the state-of-the-art control software incorporates new functions and optimises the pre- and post-pro- cessing workflow. ‘the anatomical programs (aprs) can be selected easily via a body mask to per- form radio- graphic examinations.’ further information: shimadzu europa, www.shimadzu-medical.eu recommended the 15 machines, can learn from the detailed correlative analysis of clinical infor- mation, images, and pathology stud- ies to deliver findings that increas- ingly correlate with the ultimate pathology report. ‘as radiologists, we are quite accurate in macroscopic diagnosis. we can see many things about a brain tumour that a patholo- gist does not: the extent of a tumour, european hospital its size, and whether there is more trim: 210mm x 297mm than one tumour. and we can pro- no bleed vide a fair estimate of the grade and histopathology of the tumour. ‘today, the pathologist has the final say in brain tumour diagnosis and, by definition, has the definitive opinion on grade, mitotic rate, histo- pathology and genetic profile, with terms such as: 1p19q co-deletion to determine the chromosomal type, idh 1 and 2 mutation [isocitrate dehydrogenase], and the mgmt pro- moter methylation status,’ he said. ‘these are all important in determin- ing diagnosis, prognosis, and prob- ability of treatment response.’ then, he speculated: ‘wouldn’t it be cool if we could actually deter- mine the same findings from the images as the pathologist does from the microscopy?’ continuing: ‘ultimately our objec- tive should be to be able to do eve- rything the pathologist does, but to do it in vivo, by extracting that infor- mation from images. our objectives should be to determine all features of the diagnosis and prognosis with- out having to operate on the patient, without having to extract tissue. are we there yet? no way. will we ever get there? probably not completely, but we are moving in that direction,’ kucharczyk concluded. walter kucharczyk, md, frcpc is the director for research at the joint department of medical imaging of the university of toronto and a hands-on neuroradiologist there, as well as a professor of medical imaging and neurosurgery.. meet your goals for fast, accurate diagnoses with weight-bearing 3d imaging exams. experience the power of an on-site ct system. a world leader in diagnostic x-ray introduces a revolution in cone-beam ct imaging. the carestream onsight 3d extremity system is designed to meet your most critical imaging needs – supporting rapid, affordable exams for accurate diagnoses and accelerated productivity. so get ready for onsight to lead the (cid:31)eld in cbct imaging. learn more at carestream.com/ecr. onsight 3d extremity system onsight 3d extremity system onsight 3d extremity system ontrack. ontarget. onbudget. . h t l a e h m a e r t s e r a c f o k r a m e d a r t a s i m a e r t s e r a c . 7 1 0 2 , . c n i , h t l a e h m a e r t s e r a c © shimadzu is at ecr 2017 expo x2. stand 19 carestream.com eh @ ecrwww.healthcare-in-europe.com

closing gaps in the hygiene chain of medical devices 17 trusted cable systems to give plastic surfaces an antimicrobial effect, leoni adds a metal oxide to the polymer during the extrusion or moulding process, which then lowers the ph level on the surface as a result of escaping acid ions. a basic principle for wiring is to route hardwearing cables close to the motion sequence. thorough system solutions for dynamically durable wiring of imaging devices can involve drag chain structures, abrasion-proof bulkhead receptacles, cable reservoir modules or spring return systems antimicrobial cables and systems can help to enhance the hygiene of imag- ing procedures and patient safety. the integration of only a small quantity of a metal oxide to the sheath material significantly reduces contamination to >99.99% on the surface. similar to the skin’s protective shield of acids, germs, bacteria, viruses and fungi are killed at a ph level of <4. ‘during nor- mal handling (involving contact with sweat and proteins), the antimicrobial effect is retained well, throughout a range of times and concentrations,’ leoni continues. ‘this is an important difference compared to conventional methods using silver or copper.’ at ecr 2017 leoni’s business unit healthcare hall x5. stand 26. ever more imaging devices are charac- terised by very extensive movement sequences while simultaneously being compact. both device manufacturers and suppliers must consider mounting dynamic requirements when develop- ing their products and ensure their long-term system integrity. furthermore, antimicrobial prod- ucts are of interest not only for mini- mally invasive or invasive applications because of the increasingly discussed risk of nosocomial infections, but can also close unwanted gaps in the hygiene chain of medical devices. systems supplier leoni reports that it supports customers ‘…as early as the development phase of their medical devices with cable routing, specifi- cation, design and manufacture of complex cable systems and ready-to- install subsystems. these solutions for imaging processes decrease installa- tion time while supporting the device properties in providing maximum patient safety, excellent image quality and long-lasting dynamic operation.’ incorporated components conform to either national or international standards, the firm adds, with proven reliability in numerous tests. leoni adds that the firm itself executes verifi- cation and documentation in standard and increasingly complex customised testing procedures as an add-on ser- vice for its customers. comprehensive testing proves reliability in addition to transferring a grow- ing bandwidth, cables and cable sys- tems for imaging devices nowadays must cope with an increasing range of movement. ‘devices are becoming more mobile; horizontally, vertically and orbitally,’ leoni points out. ‘cable breakage and consequently required service calls are as unwanted as ever. ‘the best preparation for durable wiring is optimum routing, as well as the corresponding specification of individual components and the whole system. involving a solution provider like leoni in the development phase of an x-ray machine can minimise the interference on the wiring at an early stage.’ as a systems provider, the firm reports that it scrutinises the long- term manoeuvrability of its solutions in extensive tests. ‘alongside using standard set-ups in compliance with national and international standards (such as ul), leoni will, on customer request, simulate non-standard move- ment sequences with prototypes or device models designed in-house. a leoni add-on service – basic or com- plex test set-ups can be established in 2-d or 3-d, and individual com- ponents can be rapidly produced by means of 3-d printing. leoni is there- by able to document and verify the system integrity of its solutions when subjected to customised movement sequences in long-terms tests.’ leoni’s tobias höft is team leader sales of leoni’s business unit healthcare telephone: +49 4491 291 124 mobile: +49 160-90192902 e-mail: tobias.hoeft@leoni.com eh @ ecrwww.healthcare-in-europe.com

19 charles mccollum is professor of surgery at the university of manchester and an honorary consultant surgeon at university hospital of south manchester, with a tertiary referral practice in carotid artery disease, cerebral perfusion, complex aneurysms and venous disease. leading a research team of lecturers, fellows, scientists and technicians, his collaborations are with various disciplines including epidemiology, neuro-imaging, dementia services, stroke medicine, cardiology, mathematics, engineering and industry. he has published over 450 papers including 350 on original research. phy,’ rogers said. ‘finding an imaging modality that allows us to make sur- gical decisions, that does not involve radiation and nephrotoxic contrast media, is of the utmost importance to the european market and would save the european economic area a sig- nificant amount of money each year. ‘that’s what we are trying to achieve with the resona 7 tomographic ultra- sound solution. effectively, it will use both devices to replace angiography as the next step in vascular surgical planning.’ being able to view the vas- cular system in the 3-d, he pointed out, opens up new ways of measur- ing, monitoring and assessing a range of diseases. delivering a new dimension to vascular imaging way forward: 3-d tomographic ultrasound have confidence in when making surgical decisions. the greatest impact, he believes, will be in stroke intervention due to evidence suggesting that emboli (ele- ments of thrombus or atherosclerotic material discharged from the plaque and blocking arteries in the brain) are more important in the causation of stroke than stenosis. ‘we’ve found that the volume of plaque is a very important association with stroke symptoms,’ he said. ‘if the risk of stroke is over 5% then, to detect peo- ple with carotid plaques, population screening becomes worthwhile. we can use the resona 7 tomographic ultrasound solution to measure the volume of the plaque.’ this is now a major focus for mccollum and team; he also believes that the same combination could increase accuracy in aneurysm screening. resona 7 incorporates a novel ultrasound-based technology called v-flow which can visualise blood flow and, rather than a series of static images, the fluidity will be displayed with dynamic arrows indicating the flow process. mccollum said it is par- ticularly suited to this latest research, especially with high quality images and mindray’s flexibility in respond- ing to clinicians’ needs in develop- ing the equipment and associated techniques. in addition, with ivs performing more than 80,000 vascular ultrasound investigations a year, there is demand for robust and reliable equipment to achieve such high volume. ‘it needs to have excellent image quality and a very good user inter- face; that’s why we chose mindray resona 7,’ explained steven rogers, an academic clinician with ivs. piur imaging provides the tomographic ultrasound device that couples to the resona 7 to produce the tomographic ultrasound images.’ there are four key research areas the team aims to advance tomo- graphic ultrasound use in the vas- cular surgical market in addition to aortic aneurysms: carotid plaque vol- ume for plaque vulnerability in the prevention of stroke; arteriovenous fistula for haemodialysis access; vein mapping for cardiac and vascular bypass; tomographic ultrasound angi- ography to produce angiogram-like images for planning peripheral arte- rial disease surgery. ‘for certain aspects at present, previous ultrasound was not good enough to make a surgical decision, which means surgeons have to rely on traditional forms of angiography, whether ct, mr or catheter angiogra- steven rogers is an academic clinician, providing clinical services for ivs and conducting 3-d ultrasound research using piur imaging equipment and mindray’s resona 7. as a senior clinical vascular scientist and research associate, his research interests include 3-d ultrasound within vascular surgery focus on carotid disease, aortic aneurysms, peripheral arterial disease and venous disease. at the vascular societies’ annual scientific meeting 2016, rogers was awarded the ann donald scientist of the year award and a prize for best proffered paper for his presentation on tomographic 3-d ultrasound on peripheral arterial disease. be achieved, avoiding a transient state, enabling continuous filtering for removing clutter. to derive the direction of flow velocity, multi- directional transmissions and receptions are employed. a true velocity with accurate direction calculated via angle-compounding technology, shows an example where compounding and regression analysis of two angles is applied giving more angles. this is supported by innovative display technology with colour arrows. clinical results have already shown that this new method gives much more detail with different types of flow in the carotid artery, compared to conventional ultrasound colour flow mapping (cfm). eh @ ecrwww.healthcare-in-europe.com

patient management and care alongside technical ability r a dio g r 21 aphers’ special the role of a radiography assistant ‘breathe in. hold your breath. then we press the button’ – the times when this brief summation could be made about a radiography depart- ment assistant’s (rda) work are long gone. as an imaging support worker, the radiology assistant helps qualified radiographers with pro- cedures such as biopsies, and also performs clerical tasks, such as handling appointments. with rapid technological and innovative advances in radiology, plus transformation of the field, this assisting role has developed increasing importance and is now an essential part of the smooth operation of radiology, nuclear medicine, radiotherapy and medical physics. responsibilities in radiol- ogy are manifold, needing a multi- talented approach. an rda’s tasks fall into three main areas: logistics, management and examination. they manage patients from admission to discharge, acting as a constant contact for reassurance and information during radiology department visits, as well as trans- porting patients between wards and departments. radiology assistants also help to maintain image processing systems reviewer workshop interested in publishing your work or reviewing for a journal? attending ecr in vienna this march? join the radiography editorial team for an interactive and informative author or reviewer workshop. saturday 4th of march, 16:30 - 17:30 topics covered will include; • chairman’s introduction: establishing the evidence base in radiology and radiography graciano paulo; portugal/pt • why publish your work? • journal selection: aims and francis zarb; msida/mt scope, audience and metrics julie nightingale; salford/uk • ethics of publishing • things to consider: the review- jonathan mcnulty; dublin/ie er’s perspective andrew england; salford/uk • editor’s ten top tips for publish- ing success julie nightingale; salford/uk • panel discussion: what are the barriers to publishing your research or becoming a reviewer and how can they be overcome? printed by: wvd, mörfelden-walldorf, germany publication frequency: bi-monthly representatives china & hongkong: gavin hua, sun china media co, ltd. phone: +86-0755-81 324 036 e-mail: gavin_hua@163.com germany, austria, switzerland: ralf mateblowski phone: +49 6735 912 993, e-mail: rm@european-hospital.com france, italy, spain: eric jund phone: +33 493 58 77 43, e-mail: ej@european-hospital.com gb, scandinavia, benelux: simon kramer phone/fax: +31 180 6200 20 e-mail: sk@european-hospital.com israel: hannah wizer, international media dep. of el-ron adv. & pr co., ltd., phone: +972-3-6 955 367 e-mail: hw@european-hospital.com south korea: ch park, mci phone: +82 2 730 1234, e-mail: mci@unitel.co.kr usa & canada: hanna politis, media international phone: +1 301 869 66 10, e-mail: hanna@media-intl.com all company, brand and product names in this publication are the property of their respec- tive holders. users must obtain permission from those holders before copying or using the owner’s trademarks, product and company names or logos. editor-in-chief: brenda marsh art director: olaf skrober managing editor: sylvia schulz editorial team: sascha keutel, marcel rasch senior writer: john brosky executive director: daniela zimmermann founded by heinz-jürgen witzke issn 0942-9085 correspondents austria: michael kraßnitzer, christian pruszinsky. china: nat whitney france: jane macdougall. germany: anja behringer, annette bus, walter depner, cornelia wels-maug, holger zorn. great britain: brenda marsh, mark nicholls. malta: moira mizzi. spain: mélisande rouger, eduardo de la sota. the netherlands: madeleine van de wouw. usa: cynthia e. keen, i.t. communications, lisa chamoff. subscriptions liane kaiser, theodor-althoff-str. 45, 45133 essen, germany subscription rate 6 issues: 42 euro, single copy: 7 euro. send order and cheque to: european hospital subscription dept and accessory equipment and report on faulty equipment. they assist the radiographer in logistics, such as the management of materials needed for the radio- logical process. some have a huge degree of responsibility being, for example, authorised to order materi- als costing as much as a luxury car. an rda also needs concentration and precision to help perform the rising numbers of complex examina- tions and interventional procedures. incorrect or incorrectly processed images lead to wrong diagnoses, or more work if the formatting must be redone – losing time and costing more. in other words, the quality of a radiography assistant’s work can underpin fast, precise diagnosis. last but not least, good teamwork is a vital prerequisite for any suc- cessful radiography assistant, by relating well with radiology depart- ment colleagues, physicians, nurses, auxiliaries, porters and all others involved in patients’ welfare. claus becker qualified as a radiography assistant at the training college for radiography assistants in grosshadern, munich in 1997 and launched his career in the radiology department a regensburg university hospital. in 2011-12 he completed further training in esslingen, qualifying him to teach prospective radiography assistants. in 2006 becker was appointed senior radiography assistant at regensburg. he has also chaired the board at the association for the medical technical professions (vmtb), since may 2015. save the date 8th efrs educational wing annual meeting & the seminar “educational developments in radiography” on wednesday 1st march efrs radiography student meeting “the future is in our hands: stay involved, make a differ- ence” on thursday 2nd march www.leoni-healthcare.com your partner for medical devices european congress of radiology vienna · march 1–5 booth x5 26 as a system provider, leoni works to support development and supplies innovative cable solutions for medical devices: antimicrobial cables and systems tailor-made cable systems with ul/csa approval system solutions with add-on services like engineering or testing business unit healthcare · healthcare@leoni.com michaela rosenblattl m.ed heads the radiology degree course program at the university of applied sciences in wiener neustadt, vienna, and is president of the austrian society of radiological technologists (rtaustria). welcome. as mentioned, rtaustria is a founder member of the european federation of radiographer societies (efrs). the efrs represents more than 100,000 radiographers in mem- ber organisations across europe and supports the ecr, which hosts the educational wing annual meeting with an integrated program for stu- dents of radiography. ‘the ecr is important for exchange amongst our members,’ rosenblattl points out. ‘we are pleased that the program for radiographers has been significantly expanded this year.’ patrick doherty is regional business manager western europe and africa at the advanced therapies department at siemens healthineers in forchheim, germany. he gained his radiography undergraduate and master’s degrees at university of dublin school of medicine, ireland is trying to do for our patients to make clinical decisions faster, easier and more comprehensive. having been on the clinical side i can appre- ciate quicker what already has been achieved by the industry. you cannot compare the clinical to the industrial environment. this is like comparing an apple with an orange. ‘my personal message about the advantages and disadvantages of working in the industry is a very real- istic one. there exists a perception in the clinical environment that people in industry have a good life, because they may receive benefits like a com- pany car, bonuses, and the company supports you very well. yes, that’s right. however, the industry is, in fact, a tough environment; it’s chal- lenging. for example you might not have to work a night on call but the working days are typically longer than those in the clinical world ‘the step to change from a clini- cal environment to industry should not be undertaken just because you want a company car. it sounds great to travel the world, go to conferences and events, and those are elements of the job that you can have. but, i would encourage the thinking that these are the primary benefits of working in the industry. ‘there is a high application rate of clinical based people who want to go into industry, with the majority stay- ing in their original position for only about three years, before they either return to the clinical environment or move within the company. that’s what i have seen personally.” eh_ecr special_01.2017_103x133.indd 1 02.02.17 13:25 eh @ ecrwww.healthcare-in-europe.com

laboratory 23 no standardisation of delivery, regulation and accreditation lab medicine in norway, serbia and france laboratory medicine delivery, regulation and accreditation vary between countries, e.g. norway, serbia and france recently aired at film 2017. leading figures explained the shape, scope and funding of healthcare and lab services and roles played by different profes- sionals and challenges they face, mark nicholls reports. norway – professor sverre sandberg spoke about this sparsely populated country of five million people, with healthcare systems arranged to meet those needs. laboratory medicine is funded and shaped with services to meet the demands of 80 hospitals, four medical universities, 4,000-5,000 general practitioners (gps), four health regions, care homes and nursing homes, military installations and oil platforms. sandberg, who directs noklus (see profile) and is a university of bergen professor, said the gov- ernment funds the healthcare sys- tems and laboratory medicine but norwegians increasingly have health insurance. in terms of lab services, most hospitals have laboratories, and also take samples from gps and nursing homes. public laboratories receive a basic reimbursement from hospitals and some have an internal reimburse- ment system paid by clinical depart- ments. the government reimburses ser- vices for gps; negotiations continue for reimbursement for tests in hos- pitals. the government reimburses one major private lab, depending on whether it’s a simple or complicated analysis. gp surgeries perform a basic rep- ertoire of tests (hb glucose, urine strips, hcg), with specific reim- bursement negotiated annually; lab med participates in the negotiations. sandberg said all data is closely monitored, with evidence collected on numbers of samples, though var- iation exists between health regions. key to this, and monitoring costs, is an open dialogue with clinicians, he said. ‘we want to maintain that close contact, regular discussions over the number and type of tests, so we can provide evidence about laboratory testing.’ with demands to cut the budget, he said services must become more effective and, ‘the best way to cut down requesting by clinicians is by talking to them regularly’. norway’s laboratory medicine as a counsellor for public health at the fédération hospitalière de france (fhf), bernard gouget monitors national public hospital programmes involving, for example, health and safety. he was assistant professor at university hospital, paris-descartes, a member of the steering committee overseeing medical laboratories reform and is a medical biology expert for the eu. snezana jovicic heads the clinical laboratory for cardiac, vascular and endovascular surgery, cardiology and pacemakers, at the centre for medical biochemistry, clinical centre of serbia. she teaches at the medical biochemistry department, in the pharmacy faculty, university of belgrade and is an executive board member for serbia’s society of medical biochemists. involves microbiology, immunol- ogy, genetics, pathology and medi- cal biochemistry with 300-400 lab specialists, 4000-5000 medical tech- nologists, it staff and a small num- ber of biochemists and scientists. ‘twenty years ago, medical doctors led hospital laboratories; now all but one has a medical technologist as director.’ while they have logistics and technical skills, the biggest chal- lenge is professional knowledge to lead the sector effectively in the future, he added. poc testing is a key element of norway’s laboratory medicine, with noklus established for deliv- ery and monitoring by advising what should be analysed and where, ensuring correct results, supporting, advising on problems, equipment, education and e-learning courses. noklus has 2,990 participants in gp offices and nursing homes, is expanding to homecare, and covers 21 military installations and 50 oil this is the era when tests must have proven consequences facing up to many new challenges medical laboratories must be pro-active if they are to meet the new chal- lenges being presented to the sector globally, according to dr william morice from the renowned mayo clinic in america. report: mark nicholls with clinical laboratory medicine pro- viders facing a number of challenges across various health systems and countries, morice offered a usa per- spective from his role as professor and chair of the department of laboratory medicine and pathology at the mayo clinic and president of mayo medical laboratories. in his presentation – leadership challenges for laboratory medicine – delivered during the frontiers in laboratory medicine conference film 2017, held in birmingham, uk, he suggested laboratories need to reach out to partners, offering their knowledge to a wider sphere, and also seek to exert influence if they are to take a leadership, rather than a ‘back-office’, role. he was speaking as clinical labora- tory medicine service providers face ‘interesting and challenging’ times ahead, against a backdrop of ris- ing demand, falling reimbursement, technological innovation, enhanced quality and governance, and the need to recruit and retain a skilled workforce. he looked at how the changing usa’s healthcare environment was impacting on the mayo clinic and mayo medical laboratories. laboratories have seen rapid growth, but there have been utili- sation issues, a drive to decrease spending and then a need to look at the consolidation of lab activity in the united states. further uncertainties loom with the fda proposing a ‘risk-based’ classification system for laborato- ry-developed tests and the as yet unknown changes that might arrive under the very new presidency of donald trump. morice told delegates that, within the laboratory medicine sector glob- ally, there was often not enough money available to pay for health- care – even in countries such as china – at a time that the profession faces market disruption. earlier, the film 2017 delegates had heard from senior figures in the uk’s pathology, biomedical sci- ences and clinical biochemistry sec- tors about changing demands on services within the national health service (nhs) against a continuing backdrop of needing to reduce costs and make financial saving through service reconfiguration. mayo clinic’s department of laboratory medicine is part of an integrated practice with 10 divisions and 63 labs, providing the full gam- bit of care for patients, with some 24 million tests performed last year by mayo’s labs. one of the biggest challenges, he said, lay in the sector looking to exert its influence and leadership at a time that some were viewing it as a ‘back-office’ function. ‘when i took the job, we were not seen as an integral part of our practice care activities, although laboratory test- ing,’ he said, ‘provides a significant proportion of mayo clinic’s top line platforms, visiting 50-60% of them annually. with 22 norwegian loca- tions and main centre in bergen, it is important to norway’s lab services, given the country’s demo- graphics. healthcare takes 9.6% of the gross national budget. serbia has a seven million popula- tion, 161 community health centres, 41 general hospitals and 35 special- ist hospitals, 37,500 hospital beds, 10% of gdp spent on healthcare – funded via citizens’ contributions to mandatory health insurance, along- side state financing for those not in the mandatory system, such as the unemployed, refugees, and welfare recipients. dr snezana jovicic, head of the clinical laboratory for cardiac, vascular and endovascular surgery, cardiology clinics and pacemakers, in the serbian centre for medical biochemistry, explained that labora- tory medicine covers biochemistry, laboratory haematology, microbiol- ogy, immunology, immunohaema- tology, toxicology, cytogenetics and molecular genetics, tissue typing and histopathology. clear guidelines and strong edu- cation cover the sector, e.g. through the medical biochemistry unit at the pharmacy faculty, university of belgrade. serbia has many medical bio- chemistry labs, including 261 state laboratories and 193 private labo- ratories, with 295 medical biochem- ists, 227 medical biochemistry spe- cialists and 276 clinical biochemis- try specialists. ‘medical biochemistry laboratories are organised according to the healthcare level – primary, secondary and tertiary – and accord- ing to the guidelines for providing healthcare,’ jovicic said. the serbian society also aims to unite its specialists to promote and develop all branches of medical bio- and bottom line revenue.’ morice acknowledged that mayo clinic has been seen as ‘unique and singular’ in the past, in terms of us healthcare provision. ‘but the way we responded, and to survive,’ he explained, ‘is that we have built bridges and collaborations; we have started to work with the diagnos- tic and insurance companies – we strive to become part of the solution process.’ the big change, he pointed out, is in shifting away from the fee-for- service environment towards value- based healthcare and that labs were now in the era where tests must have proven consequences – if they are to be paid for – with consumer choice of laboratories driven by cost transparency. however, he added: ‘we also know that, at times, the cost of not doing the test is more than the cost of doing the test in terms of the overall care cost for patients.’ morice emphasised how lab man- agers can use data to shape patient care and drive down costs. ‘if we make the right test, we will deflect away from other tests and save money – by using lab data correctly to drive patient care,’ he added. mayo labs are engaging with part- ners – particularly in it and other areas of healthcare areas - apply- ing knowledge into the systems of partner organisations, and bringing money back into the already finan- sverre sandberg directs the norwegian quality improvement of primary care laboratories (noklus) and the norwegian porphyria centre (napos) and is a university of bergen professor. he has chaired the committee on evidence-based laboratory medicine; published 240+ peer reviewed papers and is president of the european federation of clinical chemistry and laboratory medicine. chemistry in healthcare provision. ‘it aims to achieve uniform work stand- ards in clinical biochemistry labora- tories and provide continuous edu- cation for all medical biochemists at all academic levels. professional interests are ensured through the chamber of biochemists of serbia,’ jovicic said. laboratories and services activi- ties are clearly defined, with all stages of work subject to standardi- sation by the implementation of a total quality management system (tqm) – plus external quality con- trol – and an accreditation body. as with other countries, pressure to save money continues, with ser- vice users cutting budgets yet want- ing the same levels of service and numbers of tests, she said. france – over recent years, medical biology has been reformed, aiming to enhance ‘medicalisation’ of the profession; harmonising public/pri- vate practice, and to ensure medical biology tests quality by implement- ing mandatory accreditation. the country has 10,442 medi- cal biologists (2,975 medical doc- tors and 7,467 pharmacists) medical continued on page 24 dr william morice is chair of the department of laboratory medicine and pathology at the mayo clinic, rochester, usa, and president of mayo medical laboratories. a graduate of mayo medical school (1987-1994), he was previously chair of the division of haematopathology at mayo. his research interests include lymphoproliferative disorders of cytotoxic t-cells and natural killer (nk) cells and the laboratory evaluation and diagnosis of plasma cell proliferative disorders and b-cell disorders with plasmacytic differentiation. cially-strong department, which uses its returns to support the research and education mission of mayo clinic, a non-profit entity. ‘we have moved to a period of fre- quent change, particularly with next generation sequencing, and we have to be much more proactive about understanding what is happening in our environment and then participat- ing in it from a leadership perspec- tive,’ morice concluded. ‘we have to get people engaged so we feel we are driving some of the change, rather than just responding to it.’ www.healthcare-in-europe.com

laboratory 25 ascertaining the value of microrna small molecules of genetic material can help choose therapy chemotherapy is aimed at caus- ing maximum damage to, or death of, the tumour tissue. the question was therefore whether micrornas from the tissue samples removed and examined for diagnosis also remain significant for the prognosis of the expected disease progression after chemotherapy (and after surgery). the analysis showed that, although chemotherapy changed some of the micro-rnas in the mir-score, two of them (mir-30e and mir-221) were basically resistant. ‘if they can be detected in the diagnostic tissue sample, this can very likely be used to help assess a patient’s prognosis,’ kirschner reports. the next objec- tive is to determine how the admin- istration of different cancer drugs (cisplatin, pemetrexed, gemcitabine) affects micro-rnas because different chemotherapeutic agents have dif- ferent effects on the malignant cells. between 15 and 20 cases (depend- ent on country statistics) of mesothe- lioma per million are diagnosed in europe annually. compared to non- small cell lung cancer, for example, this type of cancer is rare but, due to is aggressiveness, is one of the lung cancers with the worst prognosis. it has been clearly documented that exposure to asbestos fibre is the cause of most cases of pleural meso- thelioma. michael krassnitzer reports on a new approach in molecular diagnos- tics introduced during the iaslc world conference in vienna den prior to surgery. these conditions the mir-score was determined under through examination of the microrna from 34 tissue samples obtained during diagnostic examinations (i.e. prior to chemotherapy) and 34 tissue sam- ples obtained during surgery – i.e. after induction chemotherapy. ‘molecular diagnostics is the basis of increasingly individualised, and therefore more effective treatment for lung cancer,’ explained professor robert pirker md, president of the 17th world conference in december organised by international association for the study of lung cancer iaslc. the one of the objectives of molecular diagnostics is to detect certain muta- tions in tumour dna, which can be used to predict whether particular types of treatment will be successful. a study presented at the confer- ence demonstrated that the analysis of dna is not the only procedure that molecular diagnostics needs to rely on. in the case of pleural meso- thelioma, a rare but dangerous type of cancer, microrna can be used to help select the best treatment strate- gies. micrornas are small molecules of genetic material that serve as important regulation mechanisms for gene activity, specifically for switch- ing genes off. swiss and australian researchers have succeeded in the development of a score based on six micrornas that could be used as a decision aid in the treatment of mesothelioma. pleural mesothelioma develops in the layers of tissue that wrap the lungs. among patients, there is one group with a markedly longer sur- vival rate than others. dr michaela b kirschner, at the department of thoracic surgery, university hospital zurich and colleagues at the asbestos diseases research institute, in sydney, have introduced the mir- score, a prognosis marker for meso- thelioma that can be used to identify these patients. the researchers examined and analysed the mir-score of pleural mesothelioma patients prior to, and after chemotherapy, using tissue samples obtained either for the pur- pose of diagnosis or during tumour surgery – i.e. radical removal of the pleura, lung, pericardium and parts of the diaphragm. radical tumour surgery can increase the rate of sur- vival, with induction chemotherapy aimed at reducing the tumour bur- michaela barbara kirschner is a postdoctoral research fellow at the division of thoracic surgery, university hospital zurich, switzerland. as a molecular biologist she has a strong background in microrna and mesothelioma research. dr kirschner trained at the university of heidelberg, germany, and the german cancer research centre. as part of her biomarker- focused research, she has developed robust methods to detect micrornas in the circulation; her research also led to the discovery of novel potential blood- based microrna biomarkers. in the last six years she has published 19 papers, seven of these as first author, presented regularly at national and international conferences, and has received a number of travel grants. www.gbo.com/preanalyticsgreiner bio-one gmbh | bad haller straße 32 | a-4550 kremsmünsterphone: (+43) 75 83 67 91-0 | fax: (+43) 75 83 63 18 | e-mail: office@at.gbo.com• simple sampling for different patient groups• easy sample transfer with integrated blood collection scoop• no accessories necessary, such as capillaries or funnels• leakproof caps for safe transport• tubes with fill volume ranges for more flexibilityevery drop countsminicollect® capillary blood collection systemsystem is currently not available in the usawww.healthcare-in-europe.com

infection control 27 travel transports viral trouble virologists are today’s universal necessities globalisation has been a defining term in this 21st century: with almost anybody able to visit any place at any time, diseases, viruses and bacteria can be travel companions. thus virology is gaining increased attention. walter depner interviewed professor barbara gärtner, president of the german association of virology, about the issues and challenges arising from this development. virology, as an independent dis- cipline, is not necessarily in the public eye, but is increasingly important – is this the case and where would you position your discipline today? prof. gärtner: ‘i think it’s an accu- rate observation that virology is gaining importance, primarily due to so-called epidemics. whilst, a few years ago, hiv dominated the headlines, today people are more interested in influenza or tropical viruses such as zika or ebola, which in turn are covered more widely and frequently in the non-medical media. think of the situation in the run-up to the olympic games in rio de janeiro 2016 when the zika virus was a big issue in the media.’ germany has two professional associations – the dvv, of which you are president, and the society of virology, gfv, with the latter representing virologists not only in germany itself but also in all german-speaking countries. what are the tasks of the dvv compared with gfv and where do they cooperate? ‘dvv supports public health services with a focus on influenza. thus we organise an international influenza congress every three years. other important issues are viral disinfec- tion, infections during pregnancy, virus safety and noroviruses as well as vaccination and antiviral therapy. ‘since we primarily represent the public health services sector, private individuals cannot become members of dvv. our members are, inter alia, the german federal ministry of health and almost all state ministries of health. dvv aims to support the public health services sector in fighting viral diseases. thus, the organisation clearly focus- es on applied research. by contrast gfv is a medical professional society, an association of individual researchers and scien- tists in the area of virus infections. obviously these two organisations share many interests and tasks. all virologists working for dvv are members of gfv and there are a number of joint working groups – this leads to very tight cooperation.’ would you describe the increas- ing importance of virology over the past 10-20 years and where is the discipline heading? ‘firstly, the increasing importance of virology is clearly linked to the fact that we know more and more virus- es, understand their links to certain diseases better and that epidemiol- ogy looks at certain viral infections k c o t s r e t t u h s / l a n o i s s e f o r p b s e © in new ways: all of a sudden we recognise viruses where we did not see them before. ‘a case in point: zika virus diseas- es, or the spread of the chikungunya virus, which, over the past few years has been conquering many new areas. however, at the same time as the viruses were spreading, our diagnostic capabilities were expand- ing immensely and viral therapy has seen groundbreaking progress. take, for example, modern hepatitis c therapies with antiviral medica- tion – they have all but revolu- tionised conventional therapies that were fraught with side effects. ‘with the on-going globalisation virus infections will continue to spread. treating the triggers and diagnostics will become more important – for all intents and pur- poses that will no doubt hold true for the entire discipline of virology.’ new insights, as well as external influences, are already forcing virologists to become specialised. going forward, does a virologist have to be even more of a special- ist and what does that mean for interdisciplinary work? ‘as far as basic research is con- cerned, specialisation is doubtless the name of the game. however, when it comes to clinical virology a broader approach is still possible. having said that, i should add that new developments in antiviral sub- stances are highly demanding. while in bacteriology, the microbiology specialist physician routinely pro- vides treatment recommendations, in virology the clinical specialists who frequently treat viral infections such as hiv, hepatitis c or cmv in immunosuppressed patients, decide on the therapy. ‘virology should aim to move beyond diagnostics and be more directly involved with the patients. professor barbara gärtner, president of the german association of virology (dvv) is interim director of the institute of microbiology and hygiene at university hospital in saarland, germany. the professor is also in charge of microbiology at the saarland public health consulting service. close cooperation with other dis- ciplines, such as microbiology, hygiene and other clinical fields seems to be vital.’ with people being ever more mobile, viruses and diseases also travel. what does that mean for national medical societies? ‘the pathogens will spread as human mobility increases and vec- tor-borne diseases will definitely spread, too. another issue to deal with in the future is close contact between humans and animals. many diseases that turn into epidemics are originally zoonoses, meaning they developed in animals, for exam- ple, influenza and ebola. large- scale – industrial – livestock farming increasingly happens in so-called developing countries. we import those products, which exacerbates the problem. ‘thus international cooperation to fight epidemics is imperative. nevertheless national profession- al societies will remain important because many aspects have to be implemented nationally. and, in the end, international organisations are made up of national member coun- tries.’ disheartening patients organisation study results hepatitis control must be accelerated report: sylvia schulz last year the who launched a global strategy on viral hepatitis aiming to eliminate hepatitis b (hbv) and c (hcv) as public health threats by 2030. among the goals: a 90% drop in the number of chronically infected people and a 65% mortality rate reduction, as untreated chronic viral hepatitis can cause irreversible liver damage leading to cirrhosis or cancer. the global health organisation, clearly demonstrating that hepatitis is not only a problem among third world countries but is also a current european issue, set up an action plan last september. europe records around 57,000 newly diagnosed acute and chronic cases of hepatitis b and c annually. on top of that, an estimated 10 million europeans are believed to have chronic hepatitis b and c infections without knowing it or being treated. as the monitoring and evaluation framework of the who hepatitis strategy is not expected to become operational until 2018, the european liver patients organisation (elpa) surges ahead, compiling facts about state of the art care concerning this disease. it commissioned a broadly based, the hep-core study, to shed light on the policy response to hep- atitis b and c engaging with elpa member organisations. based at the university of barcelona and copenhagen, the research team carried out the sur- vey, with data collected from local specialists in each country. the researchers asked one patient group in each of elpa’s 27 member-coun- tries to complete a 39-item sur- vey about various aspects relating to hbv and hcv: overall national response, public awareness and engagement, disease monitoring and data collection, prevention, test- ing and diagnosis, clinical assess- ment, and treatment. the plan is to repeat the patient-led monitoring tool on a regular basis, to com- pare results between countries and follow individual country progress over time. in brief, the study reveals seri- ous gaps in policies concerning hepatitis control. 52 per cent of the 27 european countries surveyed lack national strategies to address viral hepatitis b or c despite the who’s assembly resolution calling on all countries to have one. only three of those countries have access to the new, highly effective medi- cines (direct-acting antivirals) for hepatitis c without restrictions. the director of studies, professor jeffrey v lazarus, from the university of barcelona, said: ‘these hep-core results serve as an unprecedented analysis of regional and national gaps, clearly showing where there are deficient policies and, by default, what action needs to be taken.’ no national register for example, despite an urgent need for broad monitoring and disease surveillance, this study found that 17 countries (63%) have no national hepatitis b virus (hbv) register and 15 countries (56%) have no national hepatitis c virus (hcv) register. basic access to testing and screen- ing facilities is vital for patients, especially from high-risk groups, such as people who inject drugs, or prisoners. those despite this, patient groups from 10 countries (37%) reported that there are no hcv testing or screen- ing sites outside of hospitals for the general population in their coun- tries. even more alarming, patient groups from 12 of the countries (44%) reported that there are no such sites outside of hospitals that provide testing or screening services for high-risk populations. another section of the survey asked a set of questions oriented towards understanding hepatitis prevention in each country. this section focused on the availability of harm reduction – services that target the reduction of negative health consequences associated with drug use, such as the spread of viral hepatitis. it was reported that clean needle and syringe programmes are avail- able in at least one area of a patient group’s country in 22 cases (81%), that opioid substitution therapy is available in at least one area of a patient group’s country in 24 cases (89%), and that drug consumption rooms are available in only five cases (19%). the study shows that significant gaps in harm reduction regarding reported coverage and availability remain. lazarus concludes: ‘the 2016 hep-core report findings are a resource that can aid the efforts of all those working to eliminate hbv and hcv as public health threats in europe, and beyond, in line with who’s global strategy. we now have a starting point from which we can systematically scale up hepatitis pre- vention, treatment, and care – and monitor the much-needed progress. viral hepatitis must be combated on a large scale and this requires individual country and concerted pan-european action.’ www.healthcare-in-europe.com