The Best Month Ever For DoctorDalai.com!

January 2008 isn't quite over yet, but already we've passed the 4,000 visit mark for the month, a new record. OK, I know most popular websites have this much traffic every second or two, but to me, it's impressive. As always, many thanks for reading my kinder and gentler blog. I've been hearing through the grapevine that some of you miss the old down-and-dirty approach. Well, I wish I could oblige you, but I think you know why I had to tone it down a bit. Maybe I'll take it up a notch or two in the future, so keep your dial tuned to this station!

Star Trek XI

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Coming 12/25/08. Darn, I'm on call that day!

The Ultimate Radiology Keyboard?

As reported in PACS World, "a blog for Radiology network administrators", there is a brand new take on keyboards that would work wonderfully for PACS.

From the Art. Lebedev Studio comes the modestly named Optimus Maximus keyboard. It is rather pricey at $462.27 US, but for this you get something rather wonderful:

Each key is a stand-alone display that shows the function currently assigned to it.

Optimus’s customizable layout allows convenient use of any language—Cyrillic, Ancient Greek, Georgian, Arabic, Quenya, hiragana, etc.—as well as of any other character sets: notes, numerals, special symbols, HTML codes, math functions and so on to infinity.

If this doesn't make the idea clear, try the Optimus demo. There are some other versions coming or already here, such as the Optimus mini three:

Optimus mini three is an auxiliary keyboard-informer with OLED technology. The three keys can display static or animated images. Optimus mini three keyboard can be used as a toolbar, a remote control, an indicator or an RSS reader.

Functionality

Optimus mini three keys display information associated or independent of the running program. For example, you can be watching a film on your computer, while the keyboard displays a weather forecast, exchange rates or mail notifications.

Optimus mini three works in sync with the regular keyboard and is so configured that its current layout changes as you press the modifier keys (Ctrl, Shift, Alt, and their combinations).

This is really, really a phenomenal development. The author of PACSworld mentions the following applications to PACS:

For instance on a work list screen there may be some icons displayed on the keyboard indicating things like:

• Move patient
• Delete Patient
• Edit Patient
• etc.

But when the Radiologist is in Viewing mode there may be buttons that display icons for:

• Next slice
• previous slice
• render 3D
• annotation
• exit viewer
• etc.

The implementation of such a keyboard could mean a much shorter training period as the radiologists will have all the relevant buttons displayed to them directly on their keyboards.Now all that radiology needs is a standard set of icons that is universal to all PACS systems and the learning curve between systems will be much shorter!

This is almost like something out of Star Trek, where the LCARS (Library Computer Access and Retreival System) control panels supposedly are state-dependent and change with the current situation:

PACS is the perfect environment for such a display. But until we get to SickBay on the Enterprise, the Optimus may be a pretty good second best.

What A Difference A Year Makes

The MD Buyline reports (http://www.mdbuyline.com/) are rather pricey reviews of medical hardware and software, generally not available to those of us too cheap or too poor to buy them. Fortunately, Dynamic Imaging, rightly proud of its Number One status, has made these reports available for the past few years. Now, of course, DI's product has a different name, but we won't talk about that. Here are some exerpts from the 2008 report, and the 2007 version. I'll leave it to my astute readers to spot the differences. (Hint...look at the First Place and Last Place entries for both years.) Congrats to all my friends at DI!

2007:

Vendor Composite

2008:

Vendor Composite

Agfa's Pryor Retires, Stone Takes Over

As reported within the last few days, Bob Pryor has stepped down from the helm of Agfa HealthCare Americas, part of Agfa- Gevaert of Mortsel, Belgium. Details are pretty sparse, but apparently Mr. Pryor has chosen to retire. I can find no reference to his departure on the Agfa website itself as of tonight, 1/26/08, but I do expect one shortly. Barry Stone, currently COO, will step up to the plate. According to Healthcare Informatics, "Pryor joined Agfa with the Sterling Diagnostic Imaging acquisition in 1999. Pryor leaves behind a 34-year career in the healthcare field."


Well, OK, maybe it's time after all. (This coming from someone with a retirement count-down clock on his blog!)



I had the chance to meet Mr. Pryor at RSNA in 2003, when we were looking for a replacement to our elderly Impax 3.5, and Agfa was near the bottom of our list for various reasons. He told us that "Agfa had dropped the ball, but that they were ready to pick it up and run with it." After our other choices more or less eliminated themselves, we had the chance to find out how true this claim might prove. You've read the saga that followed in my earlier posts.



Good luck to Mr. Stone in his new position, and of course to Mr. Pryor in his new endeavours.

French X-Ray Patients Recalled...Trouble in Oui Oui Land

A scary little piece from Reuters:

LILLE, France (Reuters) - The French health service is recalling thousands of patients who might have been wrongly diagnosed or infected at five substandard radiology clinics, the Health Ministry said in a statement.

Health experts said it was the largest such recall in France, adding the case had revealed severe failings in the health system.

Authorities closed the five clinics in the north of France last December after discovering a string of serious problems. "Inspections showed major malfunctions, notably with regard to record-keeping and personnel qualification, and with respect to the rules of hygiene and equipment safety procedures," the ministry said in a statement.

Authorities will ask most of the 7,000 patients in question to be re-examined, ministry spokeswoman Geraldine Dalban-Moreynas said.
"The vast majority are patients who may have falsely received a clean bill of health after undergoing a mammogram or chest X-ray," she said.
But an undisclosed number of patients also ran the risk of infection following examinations with instruments that were not sterilised. French media said some of the patients might have contracted AIDS or hepatitis as a result of the sloppy care.

Wednesday's case followed a series of scandals last year over malfunctioning radiation machines used to treat brain cancer patients in a number of French hospitals.

France regularly tops international rankings for the effectiveness of its health care system, although some analysts say it is unsustainable given the country's ageing population, and will need more private investment to survive.

(Reporting by Pierre Savary and Brian Rohan; editing by Crispian Balmer)

Oops... This is what can happen with socialized medicine, my friends, and it isn't pretty. Is this a typical situation? Let us hope not, for the sake of the French patients. You really have to love the part about "more private investment" being required. That means the French will have to start charging for health care after all. The best things in life may be free, but they might well cut your life short.

ADDENDUM

I have received a number of comments from French readers, who are not pleased with my characterization of their system. I have to agree that my post above is a little acerbic, but if you read it carefully, I did state that I hoped this was not a typical situation. I will take the word of my readers who live in France that it is not typical at all. Still, how could a situation like this occur under the umbrella of the French system? "B" says that the radiology practices in question were closed immediately, and were "private practices". Well, with the number of reexaminations and so forth, I don't think they were closed "immediately" but rather after the problem festered for quite a while. But I guess it is a good thing that the problem was eventually dealt with at all. I would love to know if a private clinic over there has the same degree of autonomy as such a facility here.

For the record, I do not think the American system is perfect. Far from it. However, there are those here that see socialized medicine as a panacea, and that is not accurate either. Here is yet another tale of a glitch in another socialized system:

Glitch held up X-ray results

Patients' health may have been compromised

Michelle Lang, Calgary Herald,Published: Thursday, January 24, 2008

Patient care may have been compromised after a computer glitch at Calgary hospitals delayed the transmission of as many as 40,000 radiology reports such as mammograms to local doctors' offices last year, health officials said.

The Calgary Health Region revealed Wednesday that problems with software responsible for faxing radiology results began in May 2007 and continued until late July, when the region notified nearly 2,000 physicians about the delayed reports.

The health authority, which is still investigating the incident, said it's possible patients were adversely impacted, although they didn't know of any cases. Physicians said the worst-case scenario would be a delayed diagnosis of a disease such as cancer, where timely treatment might stop the illness from spreading.

"It's one of those technical glitches that occurs in a system and it's really unfortunate because it has the potential to impact patient care," CHR spokesman Mark Kastner said in an interview Wednesday.

Kastner said any patients whose reports may have been delayed would have since received the correct information from their physician, noting doctors' offices have now had the reports for several months.

Opposition parties called the situation a "mess," adding the CHR should have announced the problem last summer.

"There may have been a lot of people delayed in getting treatment for cancer and other life-threatening issues," said Laurie Blakeman, the Alberta Liberals' health critic. "People were probably failed."

The CHR's fax problems come more than two years after another computer glitch at the health body where physicians viewed incorrect lab test results for 2,000 Calgarians during a two-month period. No patients were harmed during that mix-up.

In this latest instance, the fax problem related to radiology reports from imaging tests such as X-rays or CT scans, which are performed to help doctors diagnose a wide range of conditions. CHR officials say a configuration problem with the software responsible for faxing radiology results from its hospitals and clinics to doctors offices likely began last May.

Doctors offices that receive radiology reports by mail or courier were not affected.

In June, the CHR noticed it was receiving an unusual number of calls from physicians saying they didn't receive faxed results from radiology exams.

It wasn't until July 20 that the CHR identified the problem and sent a letter explaining the issue to the 1,750 Calgary doctors who had opted for faxed radiology reports. CHR then re-faxed the reports to physicians.
The region's diagnostic imaging department, however, later became concerned that they may not have sent all the radiology reports to all physicians' offices.

Finally, in September, the CHR faxed out 40,000 radiology reports to Calgary physicians as a precaution, sending results from all radiology exams done during that period, although it isn't clear how many of those didn't make it to doctors' offices.

The health authority said it has fixed the computer problem and is still reviewing its response to the situation.

mlang@theherald.canwest.com

Hot Tips
Do you think these delays have affected you? If so, contact us.
CalgaryHerald.com

Is this the fault of Canada's socialized system? The politicians want to make it sound that way. Nice to know political spin is a universal phenomenon. I do know that if a report doesn't make it out to one of our clinicians around here, there is Hell to pay within 24 hours. Take it for what it's worth, folks.

Daxor BVA-100: Turn Up The (Blood) Volume

No doubt some of you have performed blood volume analysis in the past, or at least had to learn how it was done. Remember the good old days, when we labelled red cells with chromium (Cr-51) and the plasma with I-125 albumin, then we had to do painstaking measurements with well-counters, and lots of hand-calculations? That's probably why the test was so expensive, and why it was rarely ordered.

Enter Daxor and the BVA-100, pictured here:

This takes most of the work (and guesswork) out of the test. Basically, the old method has been streamlined and simplified, but philosphically the method is similar. The basic principle involves dilution. If I have a bucket of water of unknown volume, and I dump a gram of sugar (or a microcurie of I-131) into it, I can then take a 1 cc sample of the water, and determine how much sugar (or I-131) is in that sample, and then work my way back to the original volume. If the sample contains 1 mg of sugar, I know that the volume must be 1 cc water x (1 gram sugar/1mg sugar) = 1000 cc water! Simple algebra, right? In the old days, we used this method to determine both plasma volume with I-125 labelled albumin, and red-cell mass with Cr-51. Graphically, think of it like this:

Daxor's method is a little easier from the user's standpoint:

The BVA-100 is a semi-automated blood volume analyzer. The instrument is used in conjunction with a single-use injection kit consisting of a precisely measured standard and matching injectate (of I-131 labelled human serum albumin). The injectate is packaged in a patented flow chamber designed to ensure 99.8%+ delivery. The kit improves accuracy and eliminates the many time-consuming and difficult steps required for on-site standard preparation.

The BVA-100 utilizes five separate sampling points taken at regular intervals starting approximately 12 minutes after injection. In effect, each sample measurement is a separate, single-point blood volume determination. The BVA-100 computes the transudation time for the tracer and calculates the true zero point blood volume with an accuracy of approximately +/- 2.5%. The BVA-100 provides interim blood volume results while the samples are being measured; preliminary data is available within 30 minutes and may be used to guide decisions in emergency situations.

Daxor's stroke of genius for me is the elimination of the direct labelling of the red cells, as well as plasma. Rather, a portion of the blood sample is reserved for hematocrit determination, and that ratio of red cells to plasma is then applied to the rest of the figures, i.e., the plasma volume. Simplistically, if the hematocrit is 50%, and the plasma volume is 2,000 ml, then the red cell volume has to be 2,000 ml as well. (The volume of white cells is negligible.)

The system goes even further, normalizing the readings to the patient's height and weight (and incidentally providing a reading of how far above or below average the patient might be.)

We all remember using blood volumes to document Polycythemia, an overabundance of red cells. As it turns out, blood volume measurement can be applied to a number of other situation such as:

1. Acute blood loss during surgery or trauma
2. Hypertension
3. Syncope
4. Orthostatic hypotension
5. Congestive heart failure
6. Septic shock and hypovolemia
7. Anemia in cancer patients or HIV positive patients on chemotherapy Renal or kidney failure
8. Preoperative screening for low blood volume
9. Chronic fatigue syndrome

Have a look at this brief slide presentation from Daxor:

We purchased a BVA-100 over a year ago, and I am very pleased with the results. I am very slowly getting the word out to the clinicians as to just how much we can help them with this test, and they are actually starting to believe me! Fortunately, as the system uses I-131, it requires a nuclear license, and cannot be placed in the clinicians' offices. Sorry about that.

Is Agfa Getting SoHard?

You may recall that I reported in November, 2005, with much levity that Mercury Computer Systems purchased a German company known for 3D visualization called Sohard. Today, one of my friends from RadRounds informed me of an interesting development. It seems that right around RSNA time, Agfa signed up with Visage Imaging, a subsidiary of Mercury, to provide the Visage CS Thin Client/Server "for supplying enterprise-wide advanced visualization solutions to customers worldwide." Funny how that never got mentioned at the Agfa booth at RSNA! The press release is dated November 26, 2007, and RSNA ran from November 25th through the 30th. I can't directly connect the family tree of Visage to Sohard, but I suspect there has been some adoption of the latter's technology under the badge of the former. Perhaps "Sohard PACS" wouldn't have been a winner in this country for various reasons. Oh well.



According to the press release,

Agfa HealthCare will integrate the Visage™ CS Thin Client/Server into its IMPAX™ product line in order to provide enterprise-wide advanced visualization capabilities based on 3D thin-client technology. This integrated solution ensures that large image data volumes can reside entirely on the central server, and interactive 3D and 4D viewing and post-processing can be performed from any client computer using an innovative thin-client streaming technology. Because of the tight integration of IMPAX and Visage CS, large 3D and 4D images become instantly accessible at the click of a mouse within the PACS workflow, throughout the entire healthcare enterprise.

Sounds pretty good so far. the Visage website has this to say about the CS product:

Visage CS is blazingly fast and easy-to-use software for 3D-based image interpretation, post-processing, and image distribution. Data from virtually all modalities can be viewed and processed, including CT, MR, PET, PET-CT, SPECT, and SPECT-CT. Visage CS allows virtually “instant” access to all data anytime, anywhere inside or outside the hospital or imaging center walls, on standard PCs and even laptop machines*. Visage CS is designed to manage even the largest data volumes smoothly and efficiently. For example, the initial 3D display of a 2,000 slice series takes less than three seconds, regardless of the PC or workstation where it is viewed**.

Visage CS is a “plug and play” solution. You may use it as a standalone system, integrate it into an existing PACS workflow, or obtain a completely integrated solution consisting of Visage PACS and Visage CS.

* Although the thin client software allows users to review image data on standard PCs and laptops, the equipment used for diagnostic image interpretation must meet the legal requirements of the respective country.
** Example value based on actual performance measurements. Performance may vary depending on the actual load and concurrent traffic on the Visage CS server.

Gotta love the disclaimers. But how well (and easily) does it work? I haven't a clue. Our hospitals do need to get some sort of enterprise/thin client system for cardiac studies, and I need to piggyback PET/CT remote reading on this solution. My grandiose plan is to invite key vendors for a "shootout" to see just how well their thin (and thick) clients work in our production environment. I guess I'll be adding Visage CS to the list. More to come.

I Spy Eye Fi

Once in a while (even less frequently in the world of PACS and medical imaging), one finds a new product that actually works and does what it says it should do. Such is the Eye-Fi wireless memory card.

Basically, this is a 2 Gb SD card that will work with most digital cameras (those that use SD cards for memory, that is.) In addition to the prodigious memory, this card contains a tiny Wi-Fi tranceiver with some limited but still powerful functionality. No, it won't turn your camera into an Internet terminal, but it will let you wirelessly upload photos to your computer and to a service such as Flickr (the one I use) or Picasa, or a number of others. When you return home with your photos in camera, just turn on your camera, and the pics are automatically uploaded. There is a 2 minute set-up procedure for your computer that you have to do once, and then you are good to go.

Uploading goes very quickly on my 802.11g home Wi-Fi network. No, you can't use a public hot-spot to upload, and this is why I call the Eye-Fi's function limited. Still, it is a very powerful little device, literally allowing me to cut the cord between my computer and camera.

The card lists for $99, but can be found for less on eBay.

And it works. Quite well, as a matter of fact!

60,000 Hits!

Image credit: http://www.sourcebooks.com

Yes, it's another milestone for the kinder and gentler blog. Visitor 60K came from Amersfoort, Utrecht, Netherlands. Sadly, they didn't stay long....

General Electric Is Doing Business With Iran?

From Bill O'Reilly of Fox News ("The O'Reilly Factor," January 10, 2008) comes this disturbing report. Please don't shoot the messenger, by the way.

BILL O'REILLY, HOST: Now for the top story tonight, reaction to [charges General Electric is doing business with Iran]. Joining us from New Orleans is Christopher Holton, the vice president of the Center for Security Policy. Here in the studio is Debra Burlingame, co-founder of 9/11 Families for a Safe and Strong America. Ms. Burlingame's brother perished on 9/11. So what say you, madam?

DEBRA BURLINGAME, 9/11 FAMILY MEMBER: Well, I'd say that GE has a problem. And it's a problem that I'm glad you're airing here for the country to know.
They say that they're only fulfilling old contracts. That's lawyer talk for yes, we're still doing business in Iran. They're trying to say that they're not going to take up any new contracts, but lawyers know how to finesse that. The fact of the matter is they are defying U.S. sanctions by going around with a loophole, doing business with their foreign subsidiaries in countries like Syria and Iran.

O'REILLY: I think the American government knows this though. And you know, the State Department has not condemned them, the Bush administration has not condemned them. Other companies do it as well.

BURLINGAME: Well, there are some 35 companies that are doing it. And the SEC Office of Global Security Risk did inquire of GE in 2006, basically saying what are you doing, what's your involvement, what's the extent of your contracts? GE responded, I can summarize it for you by saying none of your business; we're complying with law; and our focus is ensuring shareholder value. That's a euphemism for we're looking after GE's profits. And on the street, that would be called blood money.

O'REILLY: What do you say, Mr. Holton?

CHRISTOPHER HOLTON, CENTER FOR SECURITY POLICY: Well, I can't say it any better than Debra Burlingame just said it. She's exactly right. The fact is companies like General Electric and others are providing corporate life support for our enemies in the war on terrorism when they do business with Iran. It would not have been acceptable in the 1940s to build a hydroelectric plant in Nazi Germany. And it's not acceptable today to be building a hydroelectric plant in Iran. Iran's killing U.S. troops in Iraq and Afghanistan.

O'REILLY: Now there were contracts, of course, canceled in World War II after Pearl Harbor, because the United States companies were doing business with the Third Reich in Germany, with Italy. I don't know whether they were doing business in Japan or not because of the relationship with them. So you can cancel contracts and anybody should know that any time you want to cancel them, just to say you're fulfilling existing contracts.

But the bin Laden business is also very disturbing, because Hockenberry, if you believe what he says is true, and he did write this for the Massachusetts Institute of Technology, which is not — he did it in an academic setting. He basically says, look, even after 9/11, even after Usama bin Laden attacked the United States, General Electric wasn't going to probe his operation vis-a-vis his family. And we know now that one of his brothers was involved in Al Qaeda and on and on. That to me is very, very disturbing.

HOLTON: Well, it's disturbing to me, it absolutely is. And it should be disturbing to all Americans as far as I'm concerned.

O'REILLY: Now Ms. Burlingame, Syria also involved, you know, also on the list of the State Department. They do help terrorists in Syria. GE does a lot of business with them as well. So I don't know, man. It's just looking pretty bad here.

BURLINGAME: Well, what really disturbs me about Syria is that we know that 90 percent of the foreign fighters who have come through the Syrian border, who have showed up in Iraq to detonate suicide bombs, IEDs, killing and maiming our troops, they're coming — they fly into Damascus and come through the western border. Our troops call it the ratline. And GE is helping the ratline by, as Chris said, by giving life support to this country.

O'REILLY: Do you see it that way, Mr. Holton? Do you think GE's actually helping the Syrian government? Or is it just a private thing?

HOLTON: They're doing business. They disclosed this themselves. They're doing business with the Syrian government and the Iranian government. GE says that they're doing business with those governments.

O'REILLY: Now when you see the skirmish that they had this week in the Persian Gulf with the boats, little Iranian boats threatening the big American warships — which I think Iran wanted the warships to fire on the little boats — you know, it just ratchets it up in an area that I think most Americans are going to be uncomfortable with. I'm going to give you the last word, Debra, you know, because this is an emotional issue for you. You lost your brother and thousands of other Americans lost people on 9/11.

BURLINGAME: I'd like the American people to understand that what GE is doing is within the letter of the law, but is most definitely violating the spirit of the law. We are trying desperately to avoid another war. These sanctions are to help give our diplomats and our country something to bargain with at the…

O'REILLY: Yes.

BURLINGAME: ...in diplomatic talks. We're trying to turn these countries into international pariahs. And when you give them goods and services, you're working against us.

O'REILLY: OK. Mr. Immelt is invited on this program if he would like to reply.
Debra, thank you. Mr. Holton, we appreciate it.

And a followup from Foxnews.com dated January 11, 2008:

Is General Electric, the parent company of NBC, doing business with Iran? And did they do business with the bin Laden family after 9/11? That is the subject of this evening's "Talking Points Memo."

Now you may remember former NBC correspondent John Hockenberry. He competed against us on MSNBC for a while and reported stories for "Dateline NBC," winning some awards. In this month's edition of Technology Review, a publication put out by MIT, Mr. Hockenberry makes a very disturbing charge.

"In early 2002, [I] was in Saudi Arabia covering regional reaction to September 11. We spent time on the streets and found considerable sympathy for Usama bin Laden among common citizens. We wanted to speak with members of Usama bin Laden's family about their errant son's mission to bring down the Saudi government and attack the infidel West. We couldn't reach the bin Ladens using ordinary means... but GE had long done business with the bin Ladens.

In a misguided attempt at corporate synergy, I called GE headquarters in Fairfield, Connecticut, from my hotel room in Riyadh. I inquired at the highest level to see whether, in the interest of bringing out all aspects of a very important story for the American people, GE corporate officers might try to persuade the bin Ladens to speak with 'Dateline' while we were in the kingdom.

Within a few hours, I received a call in my hotel room from a senior corporate communications officer who would only read a statement over the phone. It said something to the effect that GE had an important, long-standing and valuable business relationship with the Bin Laden Group and saw no connection between that relationship and what 'Dateline' was trying to do in Saudi Arabia. We spoke with no bin Laden family member on that trip."

Now CEO Jeffrey Immelt was running GE back then, and of course is the highest level of that operation. NBC News trashed Hockenberry in a statement today.

"It is unfortunate that John Hockenberry seems to be so far out of touch with reality. The comments are so utterly absurd, we will have no further comment."

Mr. Hockenberry would not come on "The Factor," but told us on the phone he stands by his story. There are also reports that General Electric continues to do business with Iran. CEO Immelt would not respond to our questions about that, so producer Jesse Watters went to him.

(BEGIN VIDEO CLIP)

JESSE WATTERS, "O'REILLY FACTORY" PRODUCER: Mr. Immelt, Jesse with FOX News. We would like to talk to you about your involvement with Iran. Are you still trading with Iran while Iranians are killing Americans in Iraq? You're not selling them airplane parts that can be used for military equipment?

(END VIDEO CLIP)

Now late today GE did issue a statement finally, saying it no longer does business with Iran, except fulfilling past contracts and humanitarian stuff. But "The Factor" has confirmed that through subsidiaries, GE is working with the Iranian government on hydroelectric, oil and gas, and medical projects.

It should be noted that Iran is currently listed as a state that sponsors terrorism, and U.S. intelligence has confirmed Iranian weapons are being used to kill Americans in Iraq and Afghanistan.

Mr. Immelt is in deep trouble within General Electric. The company's stock price is now 10 percent lower than it was when he took over from Jack Welch on September 7, 2001, four days before 9/11. Reports are there is open disenchantment with Immelt's leadership from some stockholders.

But the key issue here is how American corporations are behaving in the middle of a terror war. General Electric should fully explain both situations: the bin Laden deal and Iran.

And that's "The Memo."

I realize that there is nothing personal here, the dealings with a terrorist nation are only designed to increase the stock price. That's all. Nothing personal. Since this is all being done in their name, at least in theory, I think GE stockholders need to consider selling out. My financial advisor sold mine several months ago, but I wish he hadn't, so I could sell it now.

Unanswerable Questions

Some hypothetical scenarios:

1. My company gives me a Ford to drive. I don't like Fords for various reasons, and I publish this opinion on my blog. I get into an accident, harming someone in the process. The victim sues me. Am I in a worse position because I published the fact that I don't like Fords?

2. My company gives me a Ford to drive. I don't like Fords for various reasons, but due to Ford making it clear that they don't tolerate dissent, I refrain from publishing my opinion of Ford on my blog. I get into an accident, harming someone in the process. The victim sues me. Am I in a worse position because I knew Fords had problems but didn't publish that fact?

3. My company gives me a Ford to drive. I don't like Fords for various reasons, but due to Ford making it clear that they don't tolerate dissent, I refrain from publishing my opinion of Ford on my blog. Joe Schmoe, whom I know in passing, buys a Ford, not knowing of my dislikes. He gets into an accident, harming someone in the process. He subsequently finds out that I knew Fords had problems, but refrained from publicising this fact. Can the victim sue me? Can Joe sue me?

4. My company gives me a Chevy to drive. I like Chevys, and I publish this opinion on my blog. Based on my article, Joe Schmoe buys a Chevy, then gets into an accident, harming someone in the process. Can the victim sue me? Can Joe Schmoe sue me?

Rules Aboard the U.S.S. Dalai

I'm back from the Caribbean, having survived the rough seas off Haiti aboard the Celebrity Millennium. I would have to say that the service on board was quite good, better than we have experienced on Celebrity's sister line, Royal Caribbean. However, some of the clientele seemed, well, naive about the ways of genteel society. Or even polite society. Or even civilization. This includes Americans (whether they spoke English, Spanish, or Yankee) and non-Americans alike. I have observed every instance of the bad behaviour that the rules below would attempt to cure. Celebrity did not seem interested in educating anyone, lest they lose a potential customer for an upcoming cruise. Therefore, I have purchased the overloaded boat above, renamed it the USS Dalai, the first of the Lama Cruise Line ships. The rules for the ship are as follows. Itinaries will be published shortly.

SHIPBOARD RULES FOR THE USS DALAI

1. The overriding sentiment aboard this ship is that your rights end where those of others begin. We realize you paid an excessive amount of money to be on this lovely vessel, but that does not buy you the freedom to do whatever you please. The other two thousand passengers also paid their fee, and you do not have the right to interfere with their vacation experience.
2. This ship operates on the concept of lines and waiting one's turn. Most of us learned this by age 5, but many seem to have forgotten how it works. We have enough provisions to keep all of you well-fed and properly entertained. It does you no good to push ahead of someone else.
3. The ship represents a closed environment, and disease can spread rapidly. We give you the option to receive a full refund BEFORE the cruise begins if you become ill and do not wish to bring your pathogens aboard. As a minimal screening, we will take the temperature of all passengers at the pier before they board the ship with hospital-grade instruments, and there will be a limited physical examination. If you are found to have a febrile illnesses or other communicable disease, you will be offered a full refund if you agree not to board. If you insist on boarding, you will be issued a mask and gloves, and you will be quarantined in your stateroom until you are determined to be non-infectious. Violating quarantine will result in your expulsion from the ship at the next port and you will forfeit your entire fare.
4. Similarly, a minimal level of cleanliness is necessary for the health of our passengers and crew, and it will be enforced. You MUST wash your hands after using the restroom. We find it rather distasteful that anyone would even consider returning to the dinner table with fecal material on their hands, but sadly some of our passengers don't seem troubled by this, forcing us to take draconian measures to ensure a modicum of cleanliness. Handwashing will be periodically monitored. Obviously, we cannot and will not check to see if you wash your hands in your own stateroom, but public restrooms will be subject to spot checks by security. A warning will be issued for the first offense, a citation for the second, and you will be expelled from the ship for a third offense, forfeiting your fare.
5. Deck chairs are for everyone's use. Unfortunately, there are not enough chairs to accommodate everyone at the same time. Therefore, you will be allowed to occupy a chair for a maximum of two hours if others are waiting. You may reserve one (and only one) chair next to the one you occupy.
6. The ship's elevators cannot simultaneously serve all passengers at the same time. We ask you to be patient, and not crowd the elevators any more than necessary. When the elevator stops, please allow people to exit before getting on, or step off the elevator if necessary to allow them to pass.
7. We know you love your children, and think they can do no wrong. Please keep in mind that your children are YOUR responsibility, not that of the ship's personnel. We realize that children are not "little adults," but repeated bad behaviour, running, screaming, pushing in line, and so forth, especially in your presence, reflects badly on YOU. We have seen parents actually encourage such behaviour, and act proud of it, which goes completely against the mores of most civilizations. As per Rule 1 above, your rights, and those of your children, end where the rights of your fellow passengers begin. The most eggregious behaviour may result in your entire family being put off the ship at the next port, with forfeiture of your fare.
8. Strollers and luggage carts need to be used with care and courtesy. Repeatedly butting them into other passengers, using them to block elevator doors, trying to roll them down stairs, etc., will result in their confiscation for the remainder of the voyage.
9. We will do our utmost to provide the finest service on the seas. We are not perfect, and we may miss the mark here and there. We request that you not become hysterical when this occurs. We will provide grievance forms for these situations, and a partial refund will be issued if deemed appropriate by an unbiased third party arbitrator.
10. Respect other cultures. If a shore excursion takes you to a church, for example, and signs clearly state that one must cover one's head, arms, or legs, and not take photos, please heed these requests. They are not in place to annoy you, but to maintain the sanctity of the place of worship.
11. At our entertainment extravaganzas, the show is on the stage, not at your table. Please respect the others attending the show by keeping your voice down. Those who feel the need to shout over the music will be asked to leave the venue.
12. Enjoy your cruise!

Agfa Offers?

I'm currently onboard the Celebrity Millenium, en route back to Ft. Lauderdale. We were supposed to stop in Haiti yesterday, but the weather kept the ship out of port, so we had an extra day at sea. I really enjoy those anyway, so it wasn't a total loss, but the seas were as rough as I've seen them in the Caribbean, and we were all staggering about like, well, drunken sailors. No one became sea-sick, at least not obviously.

A friend who works for a PACS company (not Agfa) sent me this exerpt from Diagnostic Imaging:

From DI Scan Jan 3, 2008

Rumors that Agfa is for up sale gained credence this week. After vehemently denying this scuttlebutt for months, the company acknowledged that offers have been made and that it would be following up on them. CEO Jo Cornu has been instructed by Agfa's board of directors to "actively look into the expressions of interest that the company recently received," according to the company. Since the spring, Agfa has been working on a demerger that would split the company into three pieces. One will be healthcare. A source at Agfa told DI SCAN that the sale of any part of Agfa is highly unlikely until the demerger is complete. The process, which was to be completed by the end of this year, could take until spring or summer 2008.

I reported most of this in a previous blog entry. Now, I wonder which company has offered to purchase Agfa Healthcare. Hmmmm. Seems to me there aren't all that many who could pony up that kind of cash. Again, the first two on my list would be Siemens and Cerner. But you never know. There might be all kinds of venture capitalists out there wanting to take on a challenge.

Speaking of Agfa, I had the chance to read Alan Cooper's , "The Inmates Are Running The Asylum" from cover to cover as my "cruise book," and I found it very educational. Yes, Agfa Impax 6.x was the PACS designed theoretically with Cooper's methods, personnas and so forth. As near as I can tell, the process got derailed somewhere between the creation of the radiologist personna and the design of what this personna might actually want in a PACS. They should have used ME as the personna. Then the thing would have been perfect (or might not have worked at all!!)

NEWS FLASH!!!!

I was sent this link from Reuters concerning a possible suitor. This is the company that bought Chrysler from Damlier Benz. Interesting possibility, eh?

BRUSSELS, Dec 12 (Reuters ) - U.S. private equity firm Cerberus is considering a takeover of troubled Belgian imaging technology group Agfa-Gevaert (AGFB.BR: Quote, Profile, Research), a report in Belgian daily De Standaard said on Wednesday, quoting anonymous sources.
The company, which specializes in hospital imaging systems and top-end printers for publishers and newspapers, reiterated last week that it planned to split into three listed companies next year but also said that its board, which is meeting on Wednesday, was open to outside offers.
Agfa had planned to list Agfa Graphics, Agfa Health Care and Agfa Materials this year but has postponed that until mid-2008.
Previous press reports said senior company officials had been approached by potential investors.

Since its listing in 1999, Agfa has undergone a seemingly endless restructuring to cut costs and switch its products to digital from analogue technology.

I guess we'll have to wait and see. This would certainly be an interesting combination...Chrysler and Agfa. Perhaps I can predict the next PACS line. How about Viper PACS? Fast and sleek. Or perhaps the Town and Country practical line? Nah....we'll probably just get a Neon.

The Latest In USB Acoutrements

I hesitate to post this, but I got a good laugh out of it, and you will, too. These adorable little pups plug into any USB port (I think they work equally well with USB 1.0 and 2.0, although perhaps they perform faster with the latter.) Just in case you don't quite yet have the visual of exactly what it is they do, here is a movie clip of the little critters in action. I know I want one. This might be just the advertising gimick for some large companies out there to demonstrate their "loving" attitude toward their customers.

radRounds.com

I received an invitation to join a new social network from its founder, Steven Chan, MD, MS, a private practice radiologist in New York State. The idea was to create a FaceBook- or MySpace-like site to ". . . allow our natural connections with each other with the aid of the internet to foster new collaborations, idea exchange, new ventures, and job opportunities for us radiologists. We restrict membership only to invited industry leaders, radiologists, and rads recruiters (the non annoying ones)." I've personally never met a non-annoying recruiter, but I guess they do exist.



I went to Steve's site, liked what I saw, and signed up. The front page fills in more details of the site's goals:

Welcome to radRounds!

radRounds is a tool for radiologists. It was created by radiologists to help with clinical work and enriching one's career. Some examples of uses might include:

• Finding another radiologist who can help with an MR imaging sequence, job search, or tough case


• Talking privately to an inside-connection about that practice you plan to join


• Establishing a new collaboration to start a multi-center clinical trial


• Leaving radiology and looking for an investment banking job


• Searching for the dream job or hiring the dream candidate / future partner


• Keeping in touch with alumni from your residency program and old friends from the RSNA


• Discussing the latest topics and turf battles of radiology


• Finding out the next time someone gives a lecture/CME on your area of interest


• Starting your own (private or public) group or blog

And, above all, sharing one's interests, expertise, and connections with others. radRounds will most rapidly improve with the help of the people who use it. Spread the word too and invite a fellow radiologist. By the way, suggestions and comments are all strongly encouraged.

OK, I'm spreading the word. radRounds is a site worthy of our participation. I think it will be complementary to several existing radiology sites such as Filmjacket.com, and of course Auntminnie.com. Check it out!

Amicas + Siemens = ???

In response to my RSNA report about Amicas and Siemens, Anonymous asks this question:

Thanks for expressing your analysis on Amicas. I couldn't help but notice Amicas and Siemens in the same sentence. Do you think this would be a good acquisition for Siemens with the recent GE / Dynamic Imaging aquisition?

Interesting thought. The speculation on who will buy whom runs rampant, especially around RSNA time. I'll give you some rudimentary (read: uneducated) analysis about the topic, and follow that with what I hope actually does happen.

With that large company having just acquired the smaller company as mentioned by Anonymous, there aren't too many operations left that need a new PACS, let alone have the resources to afford one. Those that come to mind immediately are Siemens and Cerner. Philips bought Stentor a few years back, Fuji has their own, and Kodak has spun theirs off as CareStream (still sounds more like something the urologists should be dealing with than a PACS.)

Cerner had at one time a solution written by Cedara, now owned by Merge. I looked at it briefly in 2003 and wasn't terribly impressed. Neither were many others, as there were very few ever installed. Today, Cerner's ProVision™ PACS offering (which I didn't bother to look at whilst at RSNA) has these features according to their web site:

The Cerner ProVision™ Workstation is a comprehensive solution for diagnostic softcopy reading of digital images. In order to provide you with increased flexibility, the workstation supports multi-monitor configurations, "set up and save" viewing protocols, global user preferences, and comprehensive MPR features eliminating the need for specialty workstations.

In addition, the Cerner ProVision Workstation allows you to:

• Increase productivity and physician satisfaction with decreased report turnaround
  
• Generate continued returns from legacy investments and compliance to DICOM standards
  
• Provide increased patient safety with synchronization of patient, procedure and image information when configured with Cerner’s RadNet including voice recognition and access to the EMR

Uh, well, nothing really distinguishing there, I'm afraid. Some of our hospitals use Cerner's Millenium RadNet, and since this is a kinder, gentler blog, let me simply say that I really, really like using Empiric's Encompass.net. I'm not sure how Cerner feels about its latest PACS, nor if it is thinking it needs a replacement. But, it pays to keep one's eyes open on such things.

Siemens has had a somewhat irregular history in the PACS field. SIENET Magic PACS came and went, and I don't think anyone would consider it particularly beloved. There was much hype in recent years about SIENET® Cosmos, which was a combined RIS/PACS product using Siemens syngo® common user interface, and e.soft which Siemens in 2000 defined thusly:

"e.soft is the first medical imaging computer that will adapt itself to the way the system's users work--and then do the work for them. . ."

So, syngo is an environment of a sort, that runs under Windows. e.soft is the programming language, although some of the definitions seem to be a little fluid.

Today, Cosmos has evolved into the syngo® Suite. The environment works something like this when integrated with the Siemens Sorian RIS:

It's an interesting concept that attempts to place a common interface on everything from the order entry to the scanner to the PACS. This is a good idea in theory, but most rads don't run the scanner, and most clerks don't read the images. I use the syngo/e.soft system on my Leonardo, I mean syngo workstation on which I read my PET/CT's. It is usable, but more than a little esoteric, and quite frankly, I would find it difficult to use as a PACS. That's my opinion, and I'm sticking to it. Sales of Cosmos/syngo PACS have not been great. I suspect I'm not the only one who can't quite get used to the idea. There are those who think that the Siemens back end is bullet-proof (see this thread), and I won't dispute that per se, but I'm not sure a PACS needs to be bullet-proof in this day and age. Anyway, the bottom line to me is that Siemens really should consider a new PACS. Let the common interface idea go.

Now comes the editorial part of my answer. PACS is one tough business. Many of the small fry are either bought out or go under every year. Anonymous of course cites one of the largest PACS acquisitions, probably followed closely by Philips' buying Stentor to create iSite. As near as I can tell, iSite is doing well under Philips' stewardship. (And Sectra, the "jilted" product, is doing OK itself.) If Cerner or Siemens wanted to buy a company, who is left? I would leave out the much smaller players, such as eRad, and so forth, and make a rather short list of Amicas, Emageon, and Agfa. Yes, Agfa PACS is apparently for sale, as I noted earlier, although it has yet to be sold. I have no idea how many suitors have approached Agfa, but I suspect the number is quite small, as it is probably a very expensive purchase indeed. Emageon has had its troubles, but its stock price has stabilized this month, albeit at a rather low level. The last time I looked at the product, it seemed good, and I'm looking forward to seeing it again in Seattle at SIIM.

And Amicas? Well, that's a different story. Amicas has a lot of cash in the bank, a new product in the works, and a veteran manager, Dr. Steve Kahane, at its helm. If I were giving Siemens (or Cerner) advice, I would say buy it, buy it NOW. Siemens, in my humble opinion, needs a new interface, and Amicas has a really good one. BUT, if I were giving Amicas advice, I would say, "Stay independent!" Being your own company allows a degree of lattitude that prompts development of innovative products. I know the folks at Amicas, and they know what they're doing. Would they survive under a large company? Most likely, as long as they were given a very long leash, but a leash is still a leash, isn't it? This is one of those "if it ain't broke, don't fix it" situations.

I realize that Amicas' stock hasn't done spectacularly well, either, and it just goes to show that the market doesn't understand the PACS business too well. For what it's worth, Amicas is buying back some stock:

"AMICAS chose to repurchase under Rule 10b5-1 because a 10b5-1 plan allows us to focus on the business rather than worry about timing and trading of our stock. This plan also allows us the flexibility to repurchase shares when the company may otherwise be precluded from doing so under insider trading laws," said Stephen Kahane MD, CEO and chairman of AMICAS.

Do the Big Companies do that? I suppose so. But I'm not interested in buying the stock (sorry, Steve), but I am interested in a PACS that works. Would Amicas PACS work as well (and be as affordable) if it were Siemens Vision Series PACS? I can't answer that. But I selfishly hope the status quo continues. It's working for me.

Laziness, Or Something Else?

AuntMinnie user rogens50 asks if radiologists are "cutting our own throats" with laziness?" I've reproduced part of his post below"

This is a big pet peeve of mine. I have a group in which I think there are very good radiologists. However, I am constantly annoyed at reading reports which are basically just descriptive words and seem to make no effort to get down to the nature of the patient's problem or try to make a diagnosis. This problem is not only unique to my group, buy almost every group in which I review studies. Since we are busier and busier these days, many people in the group treat the reading list like the old "Space Invaders" game in which the only purpose it to shoot down as many enemy spaceships (in this case, patients on the PACS reading list) as quickly as possible. I guess I may be too "anal" about this since I was trained in a residency program where my favorite mentors constantly implored me that "nothing makes you smarter than the old films". In the old days, it was a pain to look at many of old studies and reports which were stuffed in the jacket, but now in the PACS era, all of this information is one or two mouse clicks away. I feel it is the radiologist role to give as accurate assessment as possible as to what is going on with the patient as opposed to generate some generic descriptive report. It seems that there is no academic curiosity or underlying desire to provide any real depth of information to the referring physician and thus help the patient. I can give numerous examples.

Rogens then does cite several situations illustrating his point, such as obvious instances when only the most recent chest radiograph (if that) was reviewed in comparison to the current study. He recommends:

In general, I feel you should try to approach the case is it were you or a family member. Certainly, you may not be quite as diligent as if they were your images, but this is at least a mindset you should have. If you read some of these reports and you and your family member had unnecessary procedures or imaging studies as a result of it, you would feel the radiologist is not doing his job.

And what might the consequences be if we continue?

By generating these kinds of reports, we are taking ourselves away from truly helping the patient. At some point clinicians and administrators may say, "If this is the kind of information I am getting, I might as well get cheaper dayhawks or maybe in the future, send them to India" Therefore, are we cutting our own throats by providing trivial readings?

But even rogens50 realizes that this may not be so easy...

I will admit when I am on call and drowning in studies, I reluctantly cut some, but certainly not all corners, but still try to provide as much information as possible. I try to address situations where the radiologists are overloaded with studies (call) at group meetings and try to correct this problem. Sometimes on call, I feel like I am the Lucille Ball character from the clip where she is trying to keep up on the candy production line. . .

I thought everyone would appreciate the video clip above in light of the analogy.

I'm going to assume rogens is fairly fresh from training. That is not meant in a derogatory manner, but just as a point of speculation. As an aside, my group has hired a number of new kids in the past year or so, and their training and work ethic has been phenomenal. I'll bet rogens is at least up to their (very high) level. Now, I'm assuming he is new because his main thesis demonstrates some naivetee. No, not the part about adding diagnostic value to the reports, and reviewing as many pertinent old studies as possible. There, rogens is spot on. This is a necessary part of our interpretations, and must not be neglected.

No, rogens goes astray with the assumption that the problem is laziness. Really, I don't think even he believes this to be the cause, but perhaps it is the first answer that comes to mind. While sloth may be the answer for some of us some of the time, and for a few of us a lot of the time, it is not the real underlying problem. Rather, the sheer volume we face each day is the biggest obstacle to providing the level of service we think optimal. Based on the "Lucy" remark, rogens understands this, too, but he only mentions "drowning in studies" on call. For most of us, that's just the beginning.

Veteran poster MISTRAD puts it best:

Our workload as rads has so dramatically increased over the last decade, I think we are getting close to our maximum capacity to read studies. Sure, you could read more hours, but frankly for me after a 9 hour shift reading 150 or so studies, I am burned out. I agree with all of your points, but I don't know if the solution, other than hiring more people, is easy.

But, hiring more radiologists means diluting the revenue, and that is the last thing most groups will consider. No, more and more of us are trying to replace shrinking reimbursement with even more volume. At some point, that too will fail, as we will indeed max out on how many studies we can read. Not only do we run the risk of issuing a "typical radiologist mumbo-jumbo, non-commital, uncompared" report, but the faster we push through that heavier volume, the more findings we will miss. At some point, the patients' welfare has got to take precedence over our scramble for one last dollar.

So, rogens50, you have a very valid point. We do need to do better in the areas you outline. But I can guarantee you that in the majority of cases, the problem is emphatically not that we are lazy, nor are we playing games to get the work done and get out. We are tired, we are overworked. I won't be so crass as to claim that we are underpaid, however, and that may be the problem. We may well be so concerned about avoiding being underpaid, that we create worse problems.

Lucy, I feel your pain.

Why Medical Care Is So Expensive

Image credit: http://www.about.com

I ran across this patient problem list the other day. This is completely real, but anonymized to protect the innocent:

1. Probable occlusive coronary artery disease but fairly asymptomatic. Patient will return for a Persantine Cardiolite.


2. Systolic murmurs consistent with mitral insufficiency and aortic sclerosis. She will return for an echocardiogram.


3. Labile hypertension. We need to rule out renal artery stenosis. Patient will have a CT angiogram of her renal arteries.


4. Historically occluded left carotid. I do not believe it with a lesion in the right. Patient will have a CT angiogram of her carotids.


5. Chronic right-sided leg pain. She could have occlusive vascular disease in her lower extremities. We will do the CT angiogram of that as well.


6. Ongoing tobacco abuse. I advised her not to smoke. She is not going to quit. She made that very clear to me.


7. History of lung cancer. Treated with radiation therapy. No evidence of metastatic disease.


8. Dizziness. Probably due to vascular disease. I do not think it is due to any significant arrhythmias. We will place a holter on her to be on the safe side, however.

At least she doesn't have kidney stones or the heartbreak of psoriasis. I'm thinking this little workup on this 80+ year-old patient is going to cost about $15,000+ or whatever Medicare will pay. Let's hope her kidneys hold up with all that iodinated contrast she's about to get.

Now you know how doctors think. Test every twinge, and if the test shows something, order more tests. I wonder why some still carry stethescopes.

JibJab's 2007 Year In Review..What More Can I Say?

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Voice Recognition and Value

Dr. Giles Boland has written an editorial about the value radiologists can provide with speech recognition (Dr. Boland prefers the more popular though less accurate term Voice Recognition). Dr. Boland is on the radiology staff of Mass General, and he is a member of RCG HealthCare Consulting, which provides "Complete IT & Management Consulting for Radiology Departments and Imaging Practices". From the RCG website, we find that Dr. Boland is:

Vice Chairman of Radiology, Massachusetts General Hospital, Dr. Boland’s areas of specialty include PACS, Teleradiology, Voice Recognition, RIS, and the enterprise digital solution to PACS and RIS integration. He has conducted aproximately 40 pesentations in over 15 countries on these topics. As a practicing radiologist, his nterests lie in Abdominal Imaging and Interventional Radiology. Dr. Boland is an Advisor to the World Health Organization, Geneva Switzerland and a reviewer for multiple scientific journals including New England Journal of Medicine, Radiographics, American Journal of Roentgenology and Journal of Intensive Care Medicine.

Those are impressive credentials. Dr. Boland's case for VRT is as follows:

Voice recognition technology cuts a swath across the process through which conventional preliminary findings metamorphose into a final report. Once a report is dictated into VRT, it is in fact a final, signed report (unless originally dictated by a radiology resident or fellow). By virtue of its electronic nature, such a report becomes available immediately across an institutional network, simultaneously to multiple caregivers. Consequently, final report turnaround times are typically drastically reduced. When VRT was introduced at the Department of Radiology at Massachusetts General Hospital in 1997, the final report turnaround time for staff dictated reports was reduced from 3 days to several hours almost immediately [11]. This efficiency was realized despite the fact that earlier VRT models were harder to use and had less efficient speech recognition software.

The implication is that the technology has improved a great deal; the closing paragraph in the editorial reads:

However, despite the real advantages to radiology customers of VRT, some radiologists would still rather promote an inferior transcription model, preferring instead to use traditional dictation methods, which delay their ability to generate final reports. Although radiologists' customers are looking for succinct, standardized, and timely final reports, some radiologists continue to use a system that their customers find less valuable. Rather than using existing state-of-the-art technology, radiologists should take an active role in convincing their peers to adopt VRT. If necessary, they should also lobby their organizations to provide the capital required to finance the transition, which generally yields a very favorable return on investment within the first year [11]. Radiologists can then rightly claim that they have been instrumental in adding significant value to their product, a major benefit to patient care and all stakeholders.

Note the derrogatory language. Those that have not embraced VRT/SR are using an inferior model. This raises some concerns. Whilst Dr. Boland has the background to know what he is talking about, the superior attitude is not particularly endearing. We have had the VR/SR debate on AuntMinnie ad nauseum, and the majority opinion amonst radiologists (NOT administrators, IT types, etc) is that it is not ready for primetime. Maybe Dr. Boland has access to more advanced software that actually works as advertised, which would make his analysis spot on. Unfortunately, the machinery that makes it out to the boonies doesn't seem to work well enough to justify the accolades. I think it is noteworthy that the JACR article contains no mention of Dr. Boland's association with RCG Consulting or the fact that RCG Consulting considers voice technology one of its areas of expertise. Perhaps it is simply understood that anyone on the Mass General Radiology staff is a part of RGC. I'm sure there is no conflict of interest here. Of course not.

I'm not so much of a Luddite that I don't appreciate what Dr. Boland is saying here. I just don't think the machinery is quite there yet. So, I'll stick with my inferior model for now, thank you.

'Twas A Month Before Christmas......A Hypothetical Bedtime Story

'Twas a month before Christmas, at RSNA,
All the vendors were tired; they'd been there all day.
The scanners were placed on the carpets with care,
In hopes that big customers soon would be there;

The techs were nestled all snug in their beds,
While big party hangovers messed with their heads;
The PACSMan with camera and me taking notes
Were on the Grand Concourse after ransoming coats,
When out on the floor there arose such a clatter,
I sprang over there to see what was the matter.
And to the exhibits I flew like a bee,
Tore right through the guards with my RFID,

The green glow of lights on white carpeted floor,
Gave a nice, eerie lustre to scanners galore,
But, what do my watering eyes then behold,
But a bright-green stretch limo with bumpers of gold
With a little old driver, who was packing some heat,
I knew in a moment this wasn't my treat.
More rapid than eagles his helpers they came,
And he whistled, and shouted, and called them by name;

"Now, Vito! now, Carlo! now, Marco and Vinnie!
On, Gino! on Louie! on, Fingers and Johnny!
To the top of the food court! the top of the wall!
Now dash away! dash away! dash away all!
Boys, grab Dr. Dalai and do it with haste,
We'll teach him to mess with us! No time to waste!"
So deep in the exhibit they took me, Dr. Dalai,
And all shook their heads at the depth of my folly.
I knew I was done for; there wasn't much question.
The pain in my chest wasn't just indigestion.

The booth then exploded with a thunderous roar,
As angry ex-customers took to the floor,
They wore plastic badges edged all in blue;
And most RFID's were torn up in two,
They came into the booth just like a great flood;
You could tell in their eyes, they were looking for blood.
Their droll little arms were all waving P.O.'s
Which they shredded all over the carpeted rows.
The stump of a pen they held tight in their fists,
One particular vendor was scratched off their lists;

The guys in the limo began looking pale,
They shook, and they quaked, and I knew they would bail.
My readers all came to my rescue that day
And I laughed when I realized I'd not soon decay,
They all winked as one, and we knew we'd prevail
Because nothing hurts like the loss of a sale;

The limo and driver and all of his minions,
Skulked out of the booth muttering "Gosh Darn opinions",
Removing his finger from inside of his nose,
And waving said finger, up the vent shaft they rose;
All over the North Hall and also the South
The news of our story came from every mouth.

Said the green-suited man as he entered the fog:
The Heck with you, Dalai, and Heck with your blog.

The Squawkie and the Cymbal...A Hypothetical Post About A Hypothetical Machine

In the vacuum of my once-productive mind, there occasionally forms some strange ideas. I wondered what might happen if one tried to combine Ultrasound and CT scanners to form an US/CT device. This idea could have some interesting consequences, and following is a fictional account of how this might play out in the marketplace... Note that the machines are not real, no one has one, and no one will ever get one.

Trying to stay at the leading edge of technology is difficult at best, and expensive to say the least. The hospitals down the road, across town, or on the other side of the country are always trying to one-up each other, buying the latest and greatest, usually to be leap-frogged by the next great development.

Here at my above-average hospital in a large town in the North, we have caught the bug to buy one of the new hybrid ultrasound/computed tomography scanners, the US/CT. This is really incredible technology, which will allow us, for example, to definitively diagnose renal lesions and declare them cystic or solid on the spot. The CT image helps orient the ultrasound and can provide depth and echogenicity adjustments.

As with most advanced products of this nature, there are several choices. Black and Decker produces a rather small and relatively compact unit called the Squawkie (UltraSOUND, noise, squawk, get it?). This is a very elegant machine, with a tiny x-ray tube mounted to the hand-held ultrasound transducer. An x-ray detector belt is placed around the patient, and both the CT and the U/S images are formed as the sonographer (wearing lead gloves) performs the exam.

Bosch, on the other hand, has their own version, called the Cymbal (Cymbals make noise like UltraSound, yes?), which, typical for European engineering, takes a battle-ship like approach, mating an automated U/S transducer on an articulated arm to a full-size CT scanner. There is a continuous flow of ultrasound gel through a port near the transducer face.

These two machines obviously represent rather diverse approaches to the problem. Which to choose? My inclination is to go with the Bosch, as I like their fuel injectors, and so I would assume their US/CT device is just as well made. But the Black and Decker folks have been very persuasive. They sent a number of articles outlining the dangers of too much CT radiation, which is kind of funny since they sell a lot of regular old CT's. But they very correctly point out that the minimalist CT approach found in the little Squawkie has less CT radiation than the full-CT of the Bosch. And there's the problem. The Squawkie's limited CT doesn't produce a great image, and no one expects it to do so given its limited radiation. Supposedly it's CT is good enough to enhance the U/S image, and some say it will work better for this purpose. BUT, to the guy looking at the study, a very important factor is the ability to match the U/S to the CT, and for that, a diagnostic quality CT is needed. Black and Decker points out that the patient has probably already had one on another machine, which may or may not be true. If they have, B&D suggests simply using the computer to match the U/S to the CT, but that doesn't always work well. Heck, even the example they have in their literature shows a pretty bad misregistration of part of the U/S relative to the CT. I don't trust that approach. But we all agree, I guess, that a diagnostic CT is needed somewhere along the line. And everyone who has a Squawkie, including the academic center in the hills north of us, says that it's CT images are, ummmmm, not diagnostic.

Bosch's approach with the Cymbal assumes that the diagnostic CT is such an important part of the study that it should be included with the U/S. So, with a little planning, the patient could have the U/S and the diagnostic CT all in one sitting, and eliminate the small but extra CT dose that he would have to have with the Squawkie. To me, that is the more logical way to do it. But that's just my opinion......

Decisions, decisions......

Dalai's Latest Phone

One of my older posts bashed Palm mercilessly, and you will still find this on my blog as Palm is probably used to this and isn't interesting in nagging me about it. I haven't had a Palm product since my old Tre0 600, and I haven't regretted the jump to Windows Mobile for a second.

I've been a little down lately, as you all know well, but nothing combats the blahs like buying a new toy. Since my old Blackjack was just over a year old, AT&T felt the need to tempt me with its new successor, the Blackjack II, and I succumbed. I'm really glad I did.

The Blackjack II, officially the Samsung SGH-i617, outdoes the older SGH-i607 in a few critical areas. First, the screen is marginally larger (about a millimeter or two in each dimension), but it is a bit brighter and sharper. The difference is quite noticeable. The Blackjack II has a great deal more on-board memory, 155MB as compared to only 55MB for the older version. That makes a huge difference in how one allocates memory space. My 2GB microSD card was easily transferred to the BJII, which is now capable of handling 4GB cards. No doubt I'll get one of those eventually. A larger standard battery means longer talk-time, and a faster processor means, well, faster processing and a bit peppier response overall.

One unfortunate change was made in the universal connector, which is how one charges the phone, connects to a computer, or plugs in headphones. It is unfortunate because I had spend a small fortune in extra chargers and headphone adapters (it works very well with Bose sound-cancelling headphones), and now I have to replace all of that. I take some consolation in the fact that the new connector (which is the same as found on Samsung's Helio phones, for some strange reason) is a little stubbier and sturdier, and has its top or front more clearly marked. I really wish Samsung had gone with a more universal mini-USB connector, which would have made my life easier. The stupid little plastic plug over the port is now chrome-plated, but still will likely break off before the rest of the phone wears out. The casing is now shiny black with chrome trim. It looks better than before, but attracts fingerprints like a magnet.

The BJII has Windows Mobile 6, with a few incremental improvements over WM5, most notably the addition of Office Mobile with limited versions of Word, Excel, and PowerPoint. There is now a GPS receiver using the SRiF Star III assisted GPS chipset. AT&T packages a trial of the TeleNav Software, which can cost $100/year to use. Fortunately, with this little tweak, you can get the GPS to work with Google Maps, which is free. Speaking of tweaks, changing the function of the right soft key in the home screen requires the use of a program such as Right-Tweaker, something that could be done with onboard software before. But, you can more easily assign shortcuts to letter keys than before. Keep in mind, this is still a Smartphone, not a Pocket PC, and it has no touch-screen. Coming from the older Blackjack, and an Audiovox PPC 6600 before that, and a Treo 600 before that, I find I really don't miss the touch screen at all.

The strangest conversion is that of the scrolling function. Previously, there was a Blackberry-like scroll-wheel on the right side of the unit. This has been removed. Instead, the D-pad controller on the front now rotates and can be used rather like the click-wheel on an iPod. I didn't believe at first that the wheel actually physically spins, but my son proved it to me by rotating it carefully with one finger whilst holding another finger steady on the wheel. It takes some getting used to, but in the end, I think it works as well as the side-mounted version. There seems to be no way to adjust the scrolling speed, however.

The bottom line: the BJ-II is a worthy successor to the BJ. There aren't any huge changes, but the improvement was adequate for me to justify the upgrade. But then, that usually isn't too difficult. Next stop, the iPhone II, due out next year...