G. Weisser

Correlation of degree of aortic valve stenosis by Doppler echocardiogram to quantity of calcium in the valve by electron beam tomography

The present study shows that in calcific AS, the quantification of valvular calcium by EBT is possible with a low intraobserver variability. The extent of valvular calcium is inversely correlated with aortic valve area. Correction for background scatter does not further improve this correlation. The present data suggest that the progression of calcific AS severity by echocardiography is closely linked to a progression in aortic valve calcium. Given these findings and the low interscan variability described by other groups, 3,4 EBT may be a useful imaging modality for noninvasive monitoring of the course of calcific AS by quantification of aortic valve calcium.

Teleradiology requirements and aims in Germany and Europe: status at the beginning of 2000.

Abstract. Specific radiological requirements have to be considered for realization of telemedicine. In this article the goals and requirements for an extensive implementation of teleradiology are defined from the radiological users point of view. Necessary medical, legal and professional prerequisites for teleradiology are presented. Superior requirements, such as data security and privacy or standardization of communication, must be realized. Application specific requirements, e. g. quality and extent of teleradiological functions as well as technological alternatives, are discussed. Each project must be carefully planned in relation to ones own needs, extent of functions and system selection. Topics like legal acceptance of electronic documentation, reimbursement of teleradiology and liability must be clarified in the future.

Standardization of teleradiology using Dicom e-mail: recommendations of the German Radiology Society

Until recently there has been no standard for an interoperable and manufacturer-independent protocol for secure teleradiology connections. This was one of the main reasons for the limited use of teleradiology in Germany. Various teleradiology solutions have been developed in the past, but the vast majority have not been interoperable. Therefore an ad hoc teleradiology connection was impossible even between partners who were already equipped with teleradiology workstations. Based on the evaluation of vendor-independent protocols in recent years the IT Working Group (AGIT) of the German Radiology Society set up an initiative to standardize basic teleradiology. An e-mail based solution using the Dicom standard for e-mail attachments with additional encryption according to the OpenPGP standard was found to be the common denominator. This protocol is easy to implement and safe for personalized patient data and fulfills the legal requirements for teleradiology in Germany and other countries. The first version of the recommendation was presented at the 85th German Radiology Convention in 2004. Eight commercial and three open-source implementations of the protocol are currently available; the protocol is in daily use in over 50 hospitals and institutions.

Patientenbezogenes Bild- und Datenmanagement in der Radioonkologie

BACKGROUND : Recent changes in the radiotherapy (RT) workflow through the introduction of complex treatment paradigms such as intensity-modulated radiotherapy (IMRT) and, recently, image-guided radiotherapy (IGRT) with their increase in data traffic for different data classes have mandated efforts to further integrate electronic data management for RT departments in a patient- and treatment-course-centered fashion. METHODS : Workflow in an RT department is multidimensional and multidirectional and consists of at least five different data classes (RT/machine data, patient-related documents such as reports and letters, progress notes, DICOM [Digital Imaging and Communications in Medicine] image data, and non-DICOM image data). Data has to be handled in the framework of adaptive feedback loops with increasing frequency. This is in contrast to a radiology department where mainly DICOM image data and reports have to be widely accessible but are dealt with in a mainly unidirectional manner. When compared to a diagnostic Radiology Information System (RIS)/Picture Archiving and Communication System (PACS), additional legal requirements have to be conformed to when an integrated electronic RT data management system is installed. Among these are extended storage periods, documentation of treatment plan approval by physicians and physicist, documentation of informed consent, etc. CONCLUSION : Since the transition to a paper- and filmless environment in medicine and especially in radiation oncology is unavoidable, this review discusses these issues and suggests a possible hardware and organizational architecture of an RT department information system under control of a Hospital Information System (HIS), based on combined features of genuine RT Record and Verify (R&V) Systems, PACS, and Electronic Medical Records (EMR).Hintergrund:Der Arbeitsablauf (Workflow) in der Radiotherapie (RT) ist gegenwärtig durch neue Techniken und Behandlungsparadigmen wie intensitätsmodulierte Radiotherapie (IMRT) und zunehmende bildgestützte Radiotherapie (IGRT [„image-guided radiotherapy“]) im Umbruch. Daraus resultiert eine starke Zunahme von Daten verschiedener Datenklassen. Dies erfordert für die Steuerbarkeit einer Abteilung eine zunehmende patienten- und behandlungsserienzentrierte Integration verschiedener Systeme.Methodik:Der Workflow in einer RT-Abteilung ist multidimensional und multidirektional und umfasst mindestens fünf Datenklassen (RT-/Bestrahlungsdaten, patientenbezogene Dokumente wie z.B. Befunde und Arztbriefe, ärztliche Akteneinträge, Bilddaten im DICOM-Format [Digital Imaging and Communications in Medicine] sowie Non-DICOM-Bilddaten). Diese Daten müssen sequentiell, u.U. auch im Rahmen von adaptiven Feedbackschleifen in die Patientenhistorie eingebunden werden. Dieses Vorgehen kontrastiert stark mit einer diagnostischen Radiologieabteilung, in der im Wesentlichen DICOM-Bilddaten und Befunde erzeugt werden und im Zugriff bleiben. Diese Daten müssen nach Abschluss des Prozesses kaum noch manipuliert werden. Es handelt sich also um einen überwiegend unidirektionalen Prozess. Im Gegensatz zu dieser innerhalb der diagnostischen Radiologie etablierten Standardkombination aus Radiologie-Informationssystem (RIS) und Picture Archiving and Communication System (PACS) muss ein integriertes elektronisches Radio-Onkologie-Klinik-Informationssystem (ROKIS) mit Möglichkeiten zur Speicherung/Administration von Bilddaten zusätzliche gesetzliche Rahmenbedingungen berücksichtigen (längere Speicherfristen, prozesssichere Dokumentation von wesentlichen Therapieentscheidungen sowie Abzeichnen von Bestrahlungsplänen und Dosisverschreibungen, komplexe Patienteneinverständnisse etc.).Schlussfolgerung:Der Übergang zu einer papier- und filmlosen Arbeitsumgebung in der Medizin, insbesondere in der Strahlentherapie, ist vor dem Hintergrund notwendiger Effizienzsteigerungen und steigender Archivierungskosten unausweichlich. Die vorliegende Übersichtsarbeit stellt eine mögliche apparative und organisatorische Struktur für ein ROKIS unter Führung eines Krankenhaus-Informationssystems (KIS) vor. Ein solches System vereinigt in einer Kombination und Erweiterung der originären Merkmale eines Record-and-Verify-(R&V-)Systems Merkmale einer elektronischen Patienten-/Fallakte (ePA) und integriertes Bildmanagement mit einem PACS.Background:Recent changes in the radiotherapy (RT) workflow through the introduction of complex treatment paradigms such as intensity-modulated radiotherapy (IMRT) and, recently, image-guided radiotherapy (IGRT) with their increase in data traffic for different data classes have mandated efforts to further integrate electronic data management for RT departments in a patient- and treatment-course-centered fashion.Methods:Workflow in an RT department is multidimensional and multidirectional and consists of at least five different data classes (RT/machine data, patient-related documents such as reports and letters, progress notes, DICOM [Digital Imaging and Communications in Medicine] image data, and non-DICOM image data). Data has to be handled in the framework of adaptive feedback loops with increasing frequency. This is in contrast to a radiology department where mainly DICOM image data and reports have to be widely accessible but are dealt with in a mainly unidirectional manner. When compared to a diagnostic Radiology Information System (RIS)/Picture Archiving and Communication System (PACS), additional legal requirements have to be conformed to when an integrated electronic RT data management system is installed. Among these are extended storage periods, documentation of treatment plan approval by physicians and physicist, documentation of informed consent, etc.Conclusion:Since the transition to a paper- and filmless environment in medicine and especially in radiation oncology is unavoidable, this review discusses these issues and suggests a possible hardware and organizational architecture of an RT department information system under control of a Hospital Information System (HIS), based on combined features of genuine RT Record and Verify (R&V) Systems, PACS, and Electronic Medical Records (EMR).

[Patient-centered image and data management in radiation oncology].

BACKGROUND : Recent changes in the radiotherapy (RT) workflow through the introduction of complex treatment paradigms such as intensity-modulated radiotherapy (IMRT) and, recently, image-guided radiotherapy (IGRT) with their increase in data traffic for different data classes have mandated efforts to further integrate electronic data management for RT departments in a patient- and treatment-course-centered fashion. METHODS : Workflow in an RT department is multidimensional and multidirectional and consists of at least five different data classes (RT/machine data, patient-related documents such as reports and letters, progress notes, DICOM [Digital Imaging and Communications in Medicine] image data, and non-DICOM image data). Data has to be handled in the framework of adaptive feedback loops with increasing frequency. This is in contrast to a radiology department where mainly DICOM image data and reports have to be widely accessible but are dealt with in a mainly unidirectional manner. When compared to a diagnostic Radiology Information System (RIS)/Picture Archiving and Communication System (PACS), additional legal requirements have to be conformed to when an integrated electronic RT data management system is installed. Among these are extended storage periods, documentation of treatment plan approval by physicians and physicist, documentation of informed consent, etc. CONCLUSION : Since the transition to a paper- and filmless environment in medicine and especially in radiation oncology is unavoidable, this review discusses these issues and suggests a possible hardware and organizational architecture of an RT department information system under control of a Hospital Information System (HIS), based on combined features of genuine RT Record and Verify (R&V) Systems, PACS, and Electronic Medical Records (EMR).Hintergrund:Der Arbeitsablauf (Workflow) in der Radiotherapie (RT) ist gegenwärtig durch neue Techniken und Behandlungsparadigmen wie intensitätsmodulierte Radiotherapie (IMRT) und zunehmende bildgestützte Radiotherapie (IGRT [„image-guided radiotherapy“]) im Umbruch. Daraus resultiert eine starke Zunahme von Daten verschiedener Datenklassen. Dies erfordert für die Steuerbarkeit einer Abteilung eine zunehmende patienten- und behandlungsserienzentrierte Integration verschiedener Systeme.Methodik:Der Workflow in einer RT-Abteilung ist multidimensional und multidirektional und umfasst mindestens fünf Datenklassen (RT-/Bestrahlungsdaten, patientenbezogene Dokumente wie z.B. Befunde und Arztbriefe, ärztliche Akteneinträge, Bilddaten im DICOM-Format [Digital Imaging and Communications in Medicine] sowie Non-DICOM-Bilddaten). Diese Daten müssen sequentiell, u.U. auch im Rahmen von adaptiven Feedbackschleifen in die Patientenhistorie eingebunden werden. Dieses Vorgehen kontrastiert stark mit einer diagnostischen Radiologieabteilung, in der im Wesentlichen DICOM-Bilddaten und Befunde erzeugt werden und im Zugriff bleiben. Diese Daten müssen nach Abschluss des Prozesses kaum noch manipuliert werden. Es handelt sich also um einen überwiegend unidirektionalen Prozess. Im Gegensatz zu dieser innerhalb der diagnostischen Radiologie etablierten Standardkombination aus Radiologie-Informationssystem (RIS) und Picture Archiving and Communication System (PACS) muss ein integriertes elektronisches Radio-Onkologie-Klinik-Informationssystem (ROKIS) mit Möglichkeiten zur Speicherung/Administration von Bilddaten zusätzliche gesetzliche Rahmenbedingungen berücksichtigen (längere Speicherfristen, prozesssichere Dokumentation von wesentlichen Therapieentscheidungen sowie Abzeichnen von Bestrahlungsplänen und Dosisverschreibungen, komplexe Patienteneinverständnisse etc.).Schlussfolgerung:Der Übergang zu einer papier- und filmlosen Arbeitsumgebung in der Medizin, insbesondere in der Strahlentherapie, ist vor dem Hintergrund notwendiger Effizienzsteigerungen und steigender Archivierungskosten unausweichlich. Die vorliegende Übersichtsarbeit stellt eine mögliche apparative und organisatorische Struktur für ein ROKIS unter Führung eines Krankenhaus-Informationssystems (KIS) vor. Ein solches System vereinigt in einer Kombination und Erweiterung der originären Merkmale eines Record-and-Verify-(R&V-)Systems Merkmale einer elektronischen Patienten-/Fallakte (ePA) und integriertes Bildmanagement mit einem PACS.Background:Recent changes in the radiotherapy (RT) workflow through the introduction of complex treatment paradigms such as intensity-modulated radiotherapy (IMRT) and, recently, image-guided radiotherapy (IGRT) with their increase in data traffic for different data classes have mandated efforts to further integrate electronic data management for RT departments in a patient- and treatment-course-centered fashion.Methods:Workflow in an RT department is multidimensional and multidirectional and consists of at least five different data classes (RT/machine data, patient-related documents such as reports and letters, progress notes, DICOM [Digital Imaging and Communications in Medicine] image data, and non-DICOM image data). Data has to be handled in the framework of adaptive feedback loops with increasing frequency. This is in contrast to a radiology department where mainly DICOM image data and reports have to be widely accessible but are dealt with in a mainly unidirectional manner. When compared to a diagnostic Radiology Information System (RIS)/Picture Archiving and Communication System (PACS), additional legal requirements have to be conformed to when an integrated electronic RT data management system is installed. Among these are extended storage periods, documentation of treatment plan approval by physicians and physicist, documentation of informed consent, etc.Conclusion:Since the transition to a paper- and filmless environment in medicine and especially in radiation oncology is unavoidable, this review discusses these issues and suggests a possible hardware and organizational architecture of an RT department information system under control of a Hospital Information System (HIS), based on combined features of genuine RT Record and Verify (R&V) Systems, PACS, and Electronic Medical Records (EMR).

NEUE KONZEPTE IN DER TELERADIOLOGIE MIT DICOM-E-MAIL

English title: New concepts for teleradiology using Dicom-email The recently published Dicom supplement 54 (dicom email) defines a connection between the internet and the medical communication inside hospitals. Up to now vendor specific dicom protocol additions were needed to realize certain teleradiology solutions. The new concept relies on vendor independent standard protocols without specific additions. Main features: client-server solution using the internet designed for emergency medicine integration of various clinical informations approved security concept modularized architecture The concept was realized within the scope of a teleradiology project of the state of Rheinland-Pfalz, Germany. It will be expanded to the state of Baden-Wuerttemberg, Germany in 2002 with over 20 hospitals included. Keywordsae teleradiology, dicom, email, security

Current requirements for image management in radiotherapy

AIMS AND METHODS Treatment techniques of increasing complexity such as dynamic/rotational techniques mandate digital management and increasingly image guidance. This constantly increases requirements for image management and archiving. This article discusses the current status of these requirements and will present potential image administration strategies. RESULTS Fundamentals of image administration and storage/archiving are presented (DICOM Standard, radiotherapy-specific issues) along the typical patient pathway (demographic data, radiotherapy treatment planning, signatures/approval of plan and image data, archiving of plan and image data). Different strategies for image management are presented (archiving centered on individual application vs. integral approach with central archiving in a DICOM-RT-PACS governed by a radiation oncology information system (ROCIS)). Infrastructural requirements depending on the amount of image data generated in the department are discussed. CONCLUSION Application-centered image management provides access to image data including all relevant RT-specific elements. This approach, however, is not migration-safe, requires significant administrative work to ensure a redundancy level that protects against data loss and does not provide datasets that are linked to respective therapeutic interventions. Therefore, centralized image management and archiving that links images to patients and individual steps in the treatment pathway within a standardized DICOM(-RT) environment is preferable despite occasional problems with visualization of specific data elements.

First description of MR mammographic findings in the tumor bed after intraoperative radiotherapy (IORT) of breast cancer

The aim was to investigate changes in the tumor bed on magnetic resonance mammography (MRM) after intraoperative radiotherapy (IORT) and whether they would limit the diagnostic value of posttherapeutic MRM. We retrospectively investigated 36 patients undergoing MRM after IORT (median interval 2.8 years, range 0.4-7.1). Wound cavities with fat necrosis were common after IORT (81%). They were associated with persisting contrast enhancement, i.e., enhancement was mostly seen irrespective of the posttherapeutic interval. It normally presented as rim enhancement and did not cause any diagnostic uncertainty if viewed together with other tissue characteristics. We do not expect a limited diagnostic value of MRM after IORT.

Correlation analysis of dual-energy CT iodine maps with quantitative pulmonary perfusion MRI.

AIM To correlate dual-energy computed tomography (DECT) pulmonary angiography derived iodine maps with parameter maps of quantitative pulmonary perfusion magnetic resonance imaging (MRI). METHODS Eighteen patients with pulmonary perfusion defects detected on DECT derived iodine maps were included in this prospective study and additionally underwent time-resolved contrast-enhanced pulmonary MRI [dynamic contrast enhanced (DCE)-MRI]. DCE-MRI data were quantitatively analyzed using a pixel-by-pixel deconvolution analysis calculating regional pulmonary blood flow (PBF), pulmonary blood volume (PBV) and mean transit time (MTT) in visually normal lung parenchyma and perfusion defects. Perfusion parameters were correlated to mean attenuation values of normal lung and perfusion defects on DECT iodine maps. Two readers rated the concordance of perfusion defects in a visual analysis using a 5-point Likert-scale (1 = no correlation, 5 = excellent correlation). RESULTS In visually normal pulmonary tissue mean DECT and MRI values were: 22.6 ± 8.3 Hounsfield units (HU); PBF: 58.8 ± 36.0 mL/100 mL per minute; PBV: 16.6 ± 8.5 mL; MTT: 17.1 ± 10.3 s. In areas with restricted perfusion mean DECT and MRI values were: 4.0 ± 3.9 HU; PBF: 10.3 ± 5.5 mL/100 mL per minute, PBV: 5 ± 4 mL, MTT: 21.6 ± 14.0 s. The differences between visually normal parenchyma and areas of restricted perfusion were statistically significant for PBF, PBV and DECT (P < 0.0001). No linear correlation was found between MRI perfusion parameters and attenuation values of DECT iodine maps (PBF: r = 0.35, P = 0.15; PBV: r = 0.34, P = 0.16; MTT: r = 0.41, P = 0.08). Visual analysis revealed a moderate correlation between perfusion defects on DECT iodine maps and the parameter maps of DCE-MRI (mean score 3.6, κ 0.45). CONCLUSION There is a moderate visual but not statistically significant correlation between DECT iodine maps and perfusion parameter maps of DCE-MRI.

Aktuelle Anforderungen an das Bildmanagement in der Strahlentherapie

AIMS AND METHODS Treatment techniques of increasing complexity such as dynamic/rotational techniques mandate digital management and increasingly image guidance. This constantly increases requirements for image management and archiving. This article discusses the current status of these requirements and will present potential image administration strategies. RESULTS Fundamentals of image administration and storage/archiving are presented (DICOM Standard, radiotherapy-specific issues) along the typical patient pathway (demographic data, radiotherapy treatment planning, signatures/approval of plan and image data, archiving of plan and image data). Different strategies for image management are presented (archiving centered on individual application vs. integral approach with central archiving in a DICOM-RT-PACS governed by a radiation oncology information system (ROCIS)). Infrastructural requirements depending on the amount of image data generated in the department are discussed. CONCLUSION Application-centered image management provides access to image data including all relevant RT-specific elements. This approach, however, is not migration-safe, requires significant administrative work to ensure a redundancy level that protects against data loss and does not provide datasets that are linked to respective therapeutic interventions. Therefore, centralized image management and archiving that links images to patients and individual steps in the treatment pathway within a standardized DICOM(-RT) environment is preferable despite occasional problems with visualization of specific data elements.