Monday, August 27, 2007

Up For Bidding... A Fossilized Walrus' WHAT??

Image courtesy of:

I should have been able to resist, but I just couldn't let my readers miss this one. This is not a joke, by the way. From the auction site of the I.M. Chait auction house:


Odobenus species


Tamyr Peninsula, Russia

This amazing discovery occurred while Russian fossil hunters were combing the defrosting permafrost for Woolly Mammoth fossils. Mistaking this extremely rare find for a badly weathered mammoth tusk, they threw it onto their truck and hoped that it would look better once polished. Luckily, a knowledgeable fossil dealer saw this specimen prior to any cosmetic improvements and realized what it really was; an actual mummified penis from an extinct species of Walrus. Buried in the frozen tundra for tens of thousands of years, the actual skin and muscle tissue which cover the baculum has dried, allowing for this extraordinary preservation.

Among mammals, whales have the largest penis but the walrus has the largest and most robust internal bony penis. So massive is this bony element that Eskimos use it as a killing club during their hunts. The shape of a penis bone or baculum is an important diagnostic feature used to identify species within five orders of mammals: Primates, Rodentia, Insectivora, Carnivora and Kangaroos (marsupials).

This truly one of a kind fossil "member" is among the most bizarre find of ancient erotica to date. Measuring an impressive 4 1/2 feet in length, it comes with a metal display stand.

Go ahead and bid. You know you want to. Estimated sale price for this piece of natural history is $16,000 to $20,000. Size matters, so they say....

Sunday, August 26, 2007

Conversation with a Heart Surgeon on Sunday Morning

Dr. Michael DeBakey, THE Premier Heart Surgeon, courtesy of

Here is a conversation, transcribed verbatim, that I had with one of the premier cardiothoracic surgeons this morning at our heart hospital:

Dalai: Could I speak with the nurse taking care of Mr. X?
Ward Clerk: Dr. Surgeon is rounding, I'll let you talk to him.
Dr. Surgeon:
Dalai: Dr. Surgeon, this is Dalai. I wanted to let you know that Mr. X has a new, small left apical pneumothorax.
Dr. Surgeon: Do you think I give a shit?
Dalai: Well, I hope so....
Dr. Surgeon: OK, thanks....{hangs up phone before response}

Maybe he was kidding, and maybe he wasn't. That is still what I would call disruptive physician behaviour. Naturally, if I were to write him up, I would get laughed at. But you can bet your last dollar that if the conversation were reversed, I would be on the carpet in front of the MEC and Administration faster than you can say "Chest Tube". You can bet that same dollar that I would be criticised if I didn't let someone know about the positive finding. Damned if you do, damned if you don't.

Oh well, retirement in six years, 4 months, and one week, stock market willing.....


Anonymous from a large PACS company just posted this comment:

Hmmm... grouchy customer tears you a new one when you're just trying
to do your best.

Sounds strangely familiar.

Oh, dear, I have trodden on some toes, have I? Well, I do see the analogy Anonymous is trying to make. I have been on the case of the big PACS folks for a while, and some might say I have been relentless in my approach. Now, the situation above directly involved patient care. The patient had a positive finding, and I dutifully reported it. That the surgeon didn't want to know about this is his problem. I have a duty to the patient whose image I am interpreting to relay positive findings. Just ask any malpractice litigator. Had I shirked this responsibility, I would be in big trouble.

Anonymous' implication is that he and his company have done everything they should have in creating their PACS, and that I am being grouchy about their best work. I will grant you that Anonymous and his/her crew have very likely done their best within the parameters they were given by designers or whatever. My problem is that they didn't work with the users (or enough of them, anyway) to create the product that I and my partners want to use.

The purpose of complaining in this venue is to be heard, and with an international audience, I know at least someone is listening to me. I expect the vendors, to whom we pay a LOT of money, will at least listen and occasionally act on my complaints. Here is where I differentiate my situation from Anonymous' plight: The surgeon's b*tching and acerbic behaviour is foolish, because he knows, and I know that I cannot do anything different than what I did. He MUST be informed of a positive finding, whether he wants to hear about it or not. With my b*tching and acerbic behaviour, I do expect a change. That is the difference.

Things could be worse; one of my partners emails our CIO and PACS administrator with each and every glitch and hiccup of the system. Posting that sort of thing does no one any good.

Tuesday, August 21, 2007

Impressions of Compressions

There has been some talk on Aunt Minnie recently about compression, prompted by a Canadian study that showed you don't lose anything with lossy compression. Think about that one for a moment.

This prompted me to see for myself just how compression might affect an image. There is a ton of information on compression in this setting. Try the Wikipedia article on wavelet compression for starters. Frankly, the topic is so complex, I would have had to dust off my old engineering skills as well as my HP 41c, which I loaned to a physicist friend years ago. So, I thought it would be useful to (picto)graphically demonstrate what varying degrees of compression might do to a CT slice. I began with a DICOM image, the original size of which is 514 KB.

Then, using IrfanView, I applied JPEG 2000 compression (which uses wavelets) in varying degrees, with the results depicted below:

The number after "Lossy" is the degree of compression applied, which can range from 1 to 100, rather like the 1-12 selection offered for the original JPEG. IrfanView's JPEG 2000 compression plug-in uses the LuraWave JP2 module from LuraTech, if you're interested. You do have to keep in mind that I had to convert the images into regular JPEG for display here on, but you still get the idea. The image is pretty much unreadable at over 1:100 compression (I probably should have stated that as 100:1, but it's too late now!) However, I defy anyone to tell me that they can tell much difference between the higher quality compressions and the original. In particular, the lossless image is for all intent and purpose identical to the original, at least to my eye.

There are strong arguments made to store only the original full DICOM image, and this makes sense given the plummeting prices for storage. However, bandwidth, while ever less expensive, is still right up there. For example, we are having to consider the use of Metro Ethernet (MetroE) lines to boost the transmission speeds for our self-owned PACS. This will add somewhere from $50,000 to $100,000 to our yearly PACS expenses. Were we to use lossless compression, or even very high-level lossy compression, this would not be necessary. The question always comes down to this: Will I miss something on a compressed image that I would have seen on the full-fidelity original? Frankly, I don't think so.

Friday, August 17, 2007

Agfa Really Is For Sale!

My April Fool's post was just a joke, but it seems that life sometimes does imitate art. From

BRUSSELS (Thomson Financial) - Ludo Verhoeven, chairman of imaging technology and software group Agfa-Gevaert NV said the company has received interest in buying all three of the businesses which it will be spun off into next year.
Asked whether interest was coming from private equity groups, Verhoeven said 'the only thing I can say is that there has been interest for all three businesses, and that's not bad news'.
He was speaking at a news conference for the group's half-year results.
The group plans to divide into three separately listed companies; Agfa Graphics, Agfa Healthcare and Agfa Materials.
Earlier, the group said it expects the company's demerger into three separate companies to be completed by summer next year, with the group implementing the transaction based on the closing balance sheet of Dec 31 at the end of this year.
The listing of independent companies will also take place before summer 2008.

Are you listening, GE? I'm not sure there is another Big Iron company out there that would be able to afford this little purchase. Or that would be at all interested, for that matter.....

Many thanks to AuntMinnie user Daryl Thompson who spotted this little tidbit.

ADDENDUM adds this:

Agfa Split Attracts Private Equity Interest
Agfa-Gevaert NV’s split-up into three separate businesses next year may well lead to the sale of at least one of the demerged companies -- but whilst analysts agree the move is unlikely to take place in the short term, they see a number of possible buyers, including private equity groups and sectoral peers from both Europe and the US. On July 31, group chairman Ludo Verhoeven said the company has received interest from potential buyers of Agfa Graphics NV, Agfa Healthcare and Agfa Materials, but said a deal would have to be done at the right price. Analysts see the demerger as a much-needed move by a company which needs to 'get its act together', adding that it will unlock value to attract potential buyers. Arnaud Goossens at ING Securities sees the sale as a long-term goal: 'These businesses have been up for sale for almost two years,' he said, adding that many potential buyers have now invested elsewhere. Philips NV has been mooted as a possible buyer, but Siddy Jobe at Bank Degroof said the obligation to take on the declining analogue business, as well the digital hospital imaging systems, had put them off. 'If you're interested in healthcare, you have to take it all or nothing,' Jobe said. ING's Goossens, however, did not rule out the break-up of the demerged entities and said Philips could be eyeing Agfa's ORBIS hospital IT system.

Hey, wait a minute...Philips???? Didn't they just buy Stentor and make it their flagship program, ditching Sectra and inconveniencing the users of the "old" platform? I guess I'll have to learn to love iSite, eh?

Addendum 2

And there's even more bad news for Agfa, and potentially us Agfa groupies, from Forbes 7/31/07:

BRUSSELS (Thomson Financial) - Shares in Agfa-Gevaert NV plunged after the imaging technology and software group posted a disappointing set of second quarter results and put back the company's demerger by six months to focus on operational improvements...

'After a decent first quarter that gave hope for more improvement, the second quarter results are a major disappointment. Further... management admitted the major operational weakness and said it would focus more on operational improvement,' the broker said...

'The results show that Agfa is not yet worth any sign of confidence from investors. Management has a lot of difficulties in getting the ship under control.'

Uh Oh... Next thing you know, Agfa will be blaming me for their downturn, although the article suggests that the high price of aluminum is at fault. We'll see.... Actually, they did find someone to blame, acording to Forbes:

BRUSSELS (Thomson Financial) - Agfa-Gevaert NV has announced that Philippe Houssiau will be leaving his role as president of Agfa HealthCare, 'in view of the second quarter results'.

The company added that Carl Verstraelen will join the unit as Vice President Finance and Controlling.

Verstraelen will be put forward for appointment as CFO in Agfa HealthCare's executive committee after Agfa splits next year into three separate listed companies, the imaging technology and software group said in a statement.

Sunday, August 12, 2007

He's Back!

I'm back from overseas, having stayed in Italy for a few days following the meeting cruise. We spent a couple of extra days in Venice, and then took the train to Rome for the rest of our stay, with a little side trip to Pompeii at the end. That was my favorite part of the whole trip.

One of the most macabre sights I have ever seen was to be found on the main street of Rome, Via Veneto. The Capuchin Friars have a church with an indoor cemetery sitting right next to hotels and restaurants. But this is no ordinary cemetary. Here is the description of just one of the rooms:

Crypt of the leg bones and thigh bones

The side walls each have four niches occupied by a Capuchin, standing and vested in the habit. Along the rear wall, the central block is a richly imaginative composition: up above, a cross enclosed in a circle; underneath, the Franciscan coat-of-arms: Christ's bare arm crossing the clothed arm of St Francis, surmounted by a crown of vertebrae. In the ground, 18 crosses mark the graves of various friars. The central oval frame in the vault contains an arrangement of jawbones decorated with vertebrae and, on either side, two large flowers made of shoulder-blades, with hangings of vertebrae. The corridor vault has three eight-pointed stars, a massive lantern hanging from the central one.

I have borrowed a photo from the Capuchin's website since they allowed no photography within the crypts. When they say "coat-of-arms", they really mean it.

More photos can be found on the website of someone who took some "forbidden pictures"....

At the Vatican we saw the usual stuff, including the cleaner, brighter paintings of the Sistine Chapel, and the innumerable works of art within the Vatican Museum. There is a relatively new tour of the excavations beneath St. Peters, which include a necropolis from before the time of Jesus, and possibly the tomb of St. Peter himself.

I had one particularly unusual experience. Upon first meeting our guide for the Vatican, he looked at me rather strangely. I thought perhaps that he had read my blog, but he didn't seem the radiological type. As we entered the museum, he apologized for starting, and said, "you are about to see yourself inside..." It seems that I bear a striking resemblance to the portrait of the Roman Emperor Hadrian:

Yup, maybe I'm the reincarnation of Hadrian, who wasn't a particularly nice guy. That would certainly go along with a lot of opinions, wouldn't it? Oh, well. Veni, vidi, vici, right?

Tuesday, August 07, 2007

Euros, Assumptions, and Greek Islands

You may notice some degree of stagnation on the blog, as I have not posted in several weeks. I’ll try to remedy that situation.

I am presently in Rome, Italy, following a cruise of a few Greek Islands, Split, Croatia, and Venice. It was actually a meeting cruise, with a number of lectures on CT by Elliot Fishman, M.D. and other radiological celebrities. I wonder if they realize that they were on the ship with the (in)famous Dr. Dalai… The cruise itself was OK, but I do have to give one warning: Unless you are clinically deaf, avoid the Royal Caribbean ship Splendour of the Seas like the plague. It is an older ship with absolutely no insulation between decks. We could rarely sleep due to the constant banging around and dragging of chairs on the deck above us. Not good. However, there was a great deal of CT knowledge imparted to the participants, and I'm going to try to apply at least some of what I learned to my daily practice. Although the meeting wasn't about PACS, I did acquire a few tidbits here and there. Several of the other participants have Agfa Impax 6 and hate it. One fellow replaced an old (2003) Amicas system with Dynamic Imaging and loves it. Dr. Fishman himself uses Emageon at Johns Hopkins, and complained numerous times that it chokes if they try to load a CT series that contains more than 100 images. That's 100, folks, not 1000. Their solution has been to use Siemens WebSpace, a remote client version of InSpace, for multislice CT studies of more than 100 slices, which is about everything they do there at Hopkins.

There is a thread on Aunt Minnie which was prompted by my recent article, Dalai’s Laws of PACS. This discussion has gone from hashing out what clinicians should expect out of PACS (a major point that I left out of the Laws) to a longer chat about vendor-neutral archives and databases. I don't claim to have all the answers on that one, nor do I begin to understand all the underlying DICOM issues involved. However, two experiences from this trip I'm on may provide some useful analogies.

The issue was rather well-stated by David Clunie (of course!) with this post toward the end of the long thread:
We have talked about the "vendor-neutral image archive", which could be the place in which images and other (standard) composite DICOM objects live; would it also be feasible to discuss a "vendor neutral image database" as a separate entity from the archive, which multiple PACS and/or "Image Manager" actors could access ? I say this, because it is useful to have central and accessible database of the images and various additional information that may not be strictly related to or extractable from the DICOM image headers and have no business in there (e.g., read status, legal name changes like getting married, etc.) - this information is needed by multiple production systems (e.g., different PACS, different RIS, web server, EMR, etc) in addition to the image locations, yet is perhaps separate from the "PACS" functionality per se. Also, during PACS migration, such a database might not need to be changed, or could be serialized in a "vendor neutral image database interchange format" that could be "read into" the next database. In the past various folks have proposed extensions to support PACS migration that serialized a snapshot of this information (even suggesting a huge DICOMDIR for this), but I am not sure that there has ever been a serious attempt to factor out a shared, live, standardized, database. In a sense, the VNIA and the VNIDB would to in-house PACS what the IHE XDS repository and XDS registry are to cross-enterprise document sharing; not that I am suggesting that XDS is necessarily the appropriate technical solution for this. Ordinary SQL access might be an option; another might be Grid Service based queries such as are being developed for caBIG imaging, which also have the benefit of a comprehensive security model.
Early on in the discussion, I think I was mentally considering the archive and the database as one, which is not strictly accurate. For me, the bottom line is this: I want the ability to plug different tools, modalities, and especially workstation GUI's into my database. Simple concept, difficult execution, apparently. But here is where the first European example comes into play. You are all familiar with the Euro, the new currency used by the multiple countries of the European Union. Anywhere within the EU, a One Euro Coin looks like this on the back:

But on the front, the different member countries can display their own design. Here are the coins from Greece, Ireland, and Italy:

My point here is that all these coins are worth one Euro. They look slightly different, but they do exactly the same thing. Such would be my vision for a Vendor Neutral system. I want to be able to buy a database from Belgium, as it has the reputation to be the best. I want to plug in a scanner from Germany, and have it talk to my database from Belgium without any add-ons, extra interfaces, or especially extra charges. I want my interface from Greece, my 3D app from Ireland, and so on. Quite roughly, interchange DICOM for Euro, and you see where I'm going with this. DICOM needs to be the unit of currency for PACS. The only problem with this concept is the vendors' insistence on the use of Private Attributes, factors that make their systems different, but don't translate from PACS to PACS. WindowsPACSMaven proposes a possible solution:

To alleviate the above mentioned issue with Private Attributes I decided with a colleague in 1998 that we would design a PACS using "Native DICOM". Native DICOM is DICOM V3.0 with no Private Attributes! To do this we partnered with a major university to be sure that no vendor attributes got into our design...By using Native DICOM we would be guaranteeing viewability anywhere that DICOM V3.0 is present. So if we can get Radiology to start to use Native DICOM through vendor and/or open solutions the problems with storage and retrieval will be minimized going forward from here. Because the Native DICOM concept is so radical I actually lost my job for promoting this concept and am now an independent software developer for healthcare! Because of my job loss I still have to remain anonymous so that I don't affect my future income possibilities since I do consulting for healthcare vendors.
One would assume that the big boys have something to lose with this approach, eh? Therefore, it must be good! OK, OK, there is a lot more to the issue than I've presented, but the idea is clear, and I think it has a lot of merit.

So how did we get in this situation? The second lesson from my trip might explain it. On the island of Corfu, we were enticed by Royal Caribbean's shore excursion brochure to take a "4WD trip into the hills of the island, where you will see villages rarely visited by outsiders." We were intrigued and signed up for the journey. When we got to the staging area, we found 20 little 4WD vehicles. So far so good. But upon closer examination, there was one little problem: the cars all had manual transmissions! This was a problem because I've never driven a stick, and my wife hadn't done so in over 20 years! But she bravely took the wheel, and skillfully drove up and down the hills, through little passes and treacherous switchbacks like this:

It was worth it, however, to see some of the wonderful, isolated little villages. At least that's what we told my wife when we got back! She was too busy driving, and in particular trying to keep from rolling back into the car behind us in the caravan to see the sights! Here are some typical scenes:

The lesson here is that Royal Caribbean assumed that everyone was OK with their way of doing things, that no one would have a problem with manual transmissions. They were so unconcerned with the needs of their passengers in this venue that they didn't even bother to publish the fact that the cars were only of this persuasion in any of their literature. This is they way it is, kids, it would cost us money to change it, and we assume you will like it and be comfortable with it.

I'm sure you see where I'm going with this. Do I even have to say it? Oh, well, I'm not known for my subtlety. Many PACS companies have done things a certain way for quite a while, and they assume you and I will like it. The fact that we may NOT be comfortable with it, and that we may have to waste the brainpower that we should be using to view the road, I mean the image, on driving the stick instead. The DICOM currency standard would be one way to solve this problem. One could, in theory, use an "automatic" front end to a database that otherwise had a "stick shift" GUI.

Let me wrap this up before I get even further lost in weird car analogies. Ultimately, the only "vote" we have is with our dollars, (or Euros) or those that come from our hospitals. I WANT the ability to do what I have described above, and I expect the market to provide it eventually. Royal Caribbean made what could have been a very dangerous assumption (had I tried to drive myself), and the non-insulated Splendour of the Seas deprived me of valuable sleep. My vote will be to never cruise on one of their ships again. I'll be certain to exercise the same sort of thing with other big purchases as well. Hint, hint.....