Pierre Pelletan - CiteSeerX

P06 CARBON IONSEffects of carbon ion and x-ray therapies on lung cancer

P06 4D-VMAT ALGORITHMA novel simulation study to takemotion margins into account

P07 PROTON THERAPYIMPT study shows reductionin dose to healthy tissues

SCOPETemperaturemeasurementNew standards forinstrumentation

Video gametrainingA neuromuscularstimulation system

Pierre PelletanFirst medical physics textbook author

INSTITUTE OF PHYSICS AND ENGINEERING IN MEDICINE | www.ipem.ac.uk | Volume 20 Issue 3 | SEPTEMBER 2011

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PRESIDENT’S LETTER | SCOPE

hat is yourunique sellingpoint?Managementgurus tell usthat USPs can

be extremely valuable, provided thatorganisations can firstly identify theirkey role, and then pursue it withvigour. Much the same applies toindividuals, seeking to demonstratetheir value to organisations. We eachhave many attributes, skills andqualities, but in the application ofthese to healthcare, is there any onequality which stands out as the USPfor our profession? Numerate,analytical, logical, practical: all ofthese are part of daily life in physicsand engineering, but instead of any ofthese, I am going to argue forinnovation as our USP. In fact, Ibelieve that in common with otherhealthcare scientists, physicists andengineers have a duty to act as theinnovative grit which will generatepearls of benefit for patients.

A SPECTRUM OF SCIENTIFICINNOVATIONWe have a proud record of innovationin physics and engineering inmedicine in the UK, across the wholerange of our activities from CT andMR scanners to joint replacementsand communication aids. I see noreason why this flow of creative andcompassionate ideas will cease,providing we keep innovation andchange at the forefront of our minds.Innovation isn’t just about newtechnologies, or novel applicationsfor existing techniques. There is aspectrum of innovation which rangesfrom changes to booking processesand operational efficiencies, throughoptimised versions of current tests, toradically new forms of diagnostic or

WChris GibsonPresident

UNIQUE SELLING POINTSimpact of the Modernising ScientificCareers initiative. During the lastCouncil meeting of this year we willbe considering all the ways in whichMSC will affect our work, theopportunities it may provide, andany changes we need to make to ourcommittees and groups in response.Your views are important, and Iwould encourage all members tomake contact via their regional chair,the chairs of relevant IPEM groups, orthe MSC page on the IPEM website.

PLAIN SAILING?Finally, what is the President’s uniqueselling point? Sadly I am coming tothe end of my period as IPEMPresident, and in many ways I feelthe role does resemble the sailinganalogy which I tentatively identifiedat the outset, a sometimes challengingcombination of figurehead andsteersman. Although it can at timesbe hectic to run from bow to stern tofulfil these two duties, it has alsobeen great fun, and very satisfying. Iwould like to thank all thosecolleagues with whom I haveworked, as fellow Trustees, asmembers of Council, and as membersof many other IPEM committees andgroups. The Institute is utterlydependent on the voluntary effort ofthe members, and it is crucial that wemaintain our very high levels ofmember engagement andinvolvement. I would particularlylike to thank Laura Sawyer, for herdedicated work in the often unsungrole of Honorary Secretary. I wouldalso like to thank the IPEM officestaff, who have given me support andadvice on a huge range of issues.Above all I would like to thank themembers of the Institute for givingme the very great privilege of beingPresident of IPEM.

therapeutic procedures. The verywelcome shift in the NHS operatingframework from process targets tooutcome targets is itself a strongstimulus to innovation. As theMedical Director of the NHS haspointed out, one problem withefficiency targets alone is thathospitals become very good atperforming yesterday’s care in themost efficient manner possible, ratherthan recognising and implementingimproved care based on today’sknowledge and techniques. TheInstitute recognises the importance ofinnovation, and we plan to re-establish the IPEM Innovations andResearch Advisory Group to stimulateand encourage all IPEM members toput innovation at the heart of theirwork. In particular, I wouldrecommend trainee scientists,engineers and technologists tocritically assess the procedures andtechniques which you are learning.Your enthusiasm and challenge isextremely valuable, and needs to bepreserved even under the weight ofcompetency frameworks and lengthyportfolios.

RELATING THIS TO THEUNIQUENESS OF IPEMWhat is IPEM’s unique selling point?We are somewhat unusual (and all thestronger as a result) because wecombine many different roles andattributes. We are both a learnedsociety and a professional body; werepresent both physics andengineering; we have members whocome from both technological andfrom scientific backgrounds; and wealign with other institutes andorganisations working in both scienceand in medicine. This is an importanttime for the Institute to be consideringits key roles, not least because of the

It can bevaluable to beunique.

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SCOPE | SEPTEMBER 2011 | 03

04 | SEPTEMBER 2011 | SCOPE

THIS ISSUE

COVER FEATURE50

08

28

32

PIERRE PELLETANThe establishment ofmedical physics,1823–1843, and authorof the first medicalphysics textbook

08 METHODS TO DETECT A FEVERA description of new standards for instrumentation used for human bodytemperature measurement

13 E-ENCYCLOPEDIA OF MEDICAL PHYSICS EMITEL – A USER GUIDEA brief user guide for the international project, written on behalf of theEMITEL Consortium

14 CLINICAL ENGINEERING: A RECENT PATH TO CEng REGISTRATIONContinuing the theme from previous issues, another path to registrationfollowing a slightly alternative career start

16 VIDEO GAME TRAININGA novel video game-based neuromuscular stimulation system for muscletraining motivates a patient and shows significant muscle improvement

32 SOUTH WEST ANNUAL SCIENTIFIC MEETINGGregory Stephens

36 ANNUAL SCIENTIFIC MEETING OF THE IPEM SOUTH EAST GROUPMatthew Bolt, Thomas Hague, Pedrum Kamali and Emma Whitehead

39 OUTCOME MEASURES IN ASSISTIVE TECHNOLOGYKit Tzu Tang

40 RADIATION PROTECTION ADVISERS (RPA) UPDATE MEETING 2011Chris Wood

03 PRESIDENT’S LETTER Unique selling points

05 EDITORIAL Autumn flavour

06 NEWS A selection of radiotherapy-related stories

42 INTERNATIONAL NEWS Meetings occurring throughout the rest of the year

44 MEMBERS’ NEWS New members admitted to IPEM

46 BOOK REVIEWS An incredible six reviews in this issue!

REGULARS

MEETING REPORTS

28 IPEM/AAPM USA/CANADA TRAVEL AWARD, APRIL 2011Young Lee

22 RISK MANAGEMENT AND REHABILITATION ENGINEERINGMichael Dolan and Jennifer Walsh

TRAVEL AWARD

TUTORIAL

SCOPE | CONTENTS

14

COMMENT | SCOPE


MARC E. MIQUEL EDITOR-IN-CHIEF

Scope is the quarterlymagazine of the Institute ofPhysics and Engineering inMedicineIPEM Fairmount House, 230 Tadcaster Road, York, YO24 1EST 01904 610821F 01904 612279E [email protected] www.ipem.ac.ukW www.scopeonline.co.uk

EDITOR-IN-CHIEFMarc E. MiquelClinical Physics,4th Floor Dominion House,St Bartholomew’s Hospital,London EC1A 7BET +44 (0)203 4655 785F +44 (0)207 377 7100E [email protected]

ASSISTANT EDITORGemma WhitelawRadiotherapy Physics,Basement, New KGVBuilding, St Bartholomew'sHospital, West Smithfield,London, EC1A 7BEE gemma.whitelaw@barts

andthelondon.nhs.uk

MEETING REPORTSEDITORAngela CottonHead of Non-IonisingRadiation Support, MedicalPhysics & Bioengineering,Southampton GeneralHospital, Southampton,SO16 3DRE angela.cotton@suht.

swest.nhs.uk

NEWS EDITORSUsman I. LulaDepartment ofRadiotherapy, PooleHospital, Longfleet Road,Poole, BH15 2JBE [email protected] A. AmosDepartment of RadiationPhysics, The University ofTexas M.D. AndersonCancer Center, 1840 OldSpanish Trail,Houston,Texas 77054, U.S.A.T + 1 713 563 6894F + 1 713 563 1521E richamos@mdanderson.

org

BOOK REVIEW EDITORSMarium NaeemDepartment of RadiotherapyPhysics, St Thomas'Hospital, London, SE1 7EHE marium.naeem@

gstt.nhs.ukUsman I. LulaDepartment ofRadiotherapy, PooleHospital, Longfleet Road,Poole, BH15 2JBE [email protected]

ENGINEERING &ACADEMIC EDITORDr Constantinos ZervidesIntercollege Larnaca6019 Larnaca, CyprusE c.zervides@intercollege-

larnaca.comT 00357-24-747500/559F 00357-24-652213

MEMBERS’ NEWS EDITORMatt GwilliamCancer Research UKClinical MR ResearchGroup, Institute of CancerResearch and RoyalMarsden NHS FoundationTrust, Sutton, SM2 5PTE [email protected]

INTERNATIONAL EDITOR(Developing countries)Andrew GammieClinical Engineer, Bristol Urological Institute,BS10 5NBT +44(0)117 950 5050

extension 2448 or 5184E [email protected]

INTERNATIONAL EDITOR(North America)Richard A. Amos Department of RadiationPhysics, The University ofTexas M.D. Anderson CancerCenter, 1840 Old SpanishTrail,Houston,Texas 77054, U.S.A.T + 1 713 563 6894F + 1 713 563 1521E richamos@mdanderson.

org

INTERNATIONAL EDITORRyan D. LewisDepartment of MedicalPhysics and ClinicalEngineering, Abertawe BroMorgannwg University, NHS Trust, SingletonHospital, Swansea, Wales, SA2 8QAT +44(0)179 220 5666

extension 6438E ryan.lewis@swansea-

tr.wales.nhs.uk

ONLINE EDITORDr Damian JJ Farnell Division of Mathematics andStatistics, Faculty ofAdvanced Technology,University of Glamorgan,Pontypridd CF37 1DLT +44 (0)1443 484510E [email protected]

Published on behalf of the Institute of Physics and Engineering inMedicine byCENTURY ONEPUBLISHING LTD.Alban Row, 27–31 VerulamRoad, St Albans, Herts, AL3 4DGT 01727 893 894F 01727 893 895E enquiries@centuryone

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Scope is published quarterlyby the Institute of Physicsand Engineering in Medicinebut the views expressed arenot necessarily the officialviews of the Institute.Authors instructions andcopyright agreement can befound on the IPEM website.Articles should be sent to theappropriate member of theeditorial team. By submittingto Scope, you agree totransfer copyright to IPEM.We reserve the right to edityour article. Proofs are notsent to contributors. Theintegrity of advertisingmaterial cannot beguaranteed.

CopyrightReproduction in whole orpart by any means withoutwritten permission of thepublisher is strictlyforbidden. © IPEM 2011

ISSN 0964-9565

andy beaches longgone, children back atschool, IPEM annualconference just passedand a new issue of Scopeon your desks, it mustbe September.

Once again it is a full and variedissue, this time with a distinctengineering flavour.

The news, now delivered by Usmanand Richard, includes a selection ofradiotherapy-related items.

As always, we have a nice selectionof features. Slavik Tabakov andCornelius Lewis give us a quick userguide of EMITEL, the e-Encyclopaediaof Medical Physics, while Francis Ringreports on new standards forinstrumentation used for humanthermometry. The gamers in the crowdshould be particularly interested in thefeatures where Dimitry Sayenko andhis colleagues looking at the use ofvideo games in rehabilitation. Finally,David Long continues the CEng series.

In their tutorial, illustrated withvaried case studies, Michael Dolan andJennifer Walsh take a look at theapplication of risk management torehabilitation engineering.

Further along, Young Lee reports onher travels to North America, visitingradiotherapy departments in the USand Canada.

The issue obviously includes yourregular fix of meeting reportsand book reviews. In thereports we have a couple of

regional meetings, andin the books you will

find some interestingtextbooks.

To finish the issue instyle, Francis Duckdelivers the third

chapter of his historicalopus. This time the story

focuses on Pierre Pelletanwho, in 1824, wrote TraitéElémentaire de Physique

Générale et Médicale, the first textbookdevised for a medical physics course.

SAUTUMN FLAVOUR

To finish theissue in style,Francis Duckdelivers the thirdchapter of hishistorical opus

”“

In radiotherapy, certain margins

are applied around the tumour to

account for various uncertainties,

e.g. setup errors and organ

motion. The motion margin, in

particular, accounts for factors

such as respiration and variation

in bladder and rectal filling.

However, the additional motion

margin results in substantial

increase in dose to ‘healthy’

tissue. Currently, there are

techniques being used clinically

such as respiratory gating to

reduce the motion margin, but

they rely on 3D / 4D static

anatomical plans in addition to the

use of ‘respiratory tracking’

software/hardware.

Volumetric modulated arc

therapy (VMAT) delivers radiation

to the tumour volume during one

or more continuous rotational

arcs of a linac gantry. A novel

approach proposes an

implementation of a respiratory

phase-optimised 4D treatment

planning algorithm for 4D-VMAT.

Essentially, the algorithm aims to

exploit and integrate temporal

information on patient anatomy

and tumour motion directly into

the planning process to enhance

organs-at-risk (OAR) sparing. 4D-

VMAT achieves this by:

1. motion margin reduction,

2. dose redistribution of OAR

dose over the OAR volume, and

3. selective respiratory phase

optimisation.

The 4D-VMAT optimisation

algorithm was implemented in

MATLAB, with three different sets

of simulations performed using

two separate phantoms. The key

feature of the algorithm was the

progressive sampling of static

gantry beam angles over the

course of the optimisation to

approximate a continuous arc of

radiation. In the original VMAT

algorithm, all beam samples are

correlated to only one static

representation of the target. In

4D-VMAT, a continuous breathing

cycle is divided into discrete

phases of equal time intervals,

tphase to synchronise radiation

delivery with a patient’s

respiratory motion.

This novel algorithm was

tested by simulating a variety of

tumour motion amplitudes in

various directions. Its

performance was then compared

to 3D-VMAT, gated VMAT and

dynamic multileaf collimator

(DMLC) ideal-tracking VMAT.

The results showed that OAR

sparing of 4D-VMAT was greater

than 3D-VMAT in all cases due to

the smaller PTV. Compared to

DMLC ideal-tracking VMAT, 4D-

VMAT’s OAR sparing is superior

only when the relative distance

between the PTV and OAR is

changing. For gated VMAT, results

compared to 4D-VMAT are phantom

dependant.

This study, by a Canadian group,

demonstrates that generally, the

4D-VMAT system has the potential

to improve radiation therapy of

periodically moving tumours over

conventional methods.

Further work includes tumour

motion modelling during treatment

planning and an audio-visual

patient respiratory guidance,

feedback system and imaging with

tumour motion prediction during

treatment delivery.

Carbon ions:resistance?

A novel 4D-VMAT planningalgorithm: a simulation study

SCOPE | NEWS BY USMAN I. LULA AND RICHARD AMOS


(a) Example: division of respiratory motion cycle into six equal phases.(b) The 4D-VMAT algorithm links successive respiratory motion phasesto successive beam samples. (Note that more than the 21 illustratedbeam apertures are used to sample each arc.)

MORE INFORMATIONThis story was reported on MedicalPhysics Web on 27th June:http://medicalphysicsweb.org/cws/article/research/46353

MORE INFORMATIONThis story was first reported on MedicalPhysics Web on 4th July:http://medicalphysicsweb.org/cws/article/research/46442

Researchers have published a

study comparing the effects of

carbon ion and x-ray therapies on

the angiogenic response of human

lung cancer cells. Angiogenesis is

a major source of radiation

resistance as tumour cells create

additional blood vessels that

support their survival.

The researchers irradiated

human lung adenocarcinoma

(A549) cells to physical doses of 6

Gy for x-rays and 2 Gy for carbon

ions. The cells were mixed with a

basement membrane matrix such

that they could be injected into

mice to generate plugs. Ten days

post injection, histological sections

of the plugs were analysed.

Analysis showed that

angiogenesis was induced in those

A549 cells irradiated with x-ray but

not in those irradiated with carbon

ions. A significant increase in blood

vessel formation was seen in plugs

derived from cells irradiated with

x-rays, while blood vessel formation

in plugs derived from carbon ion

irradiated cells did not differ from

that seen in the control group. The

researchers also noted that x-ray

irradiation to a physical dose of just

2 Gy (as used for carbon ions) still

induced a significant increase in

blood vessel density.

After some further work, they

concluded that x-ray irradiation of

A549 cells resulted in enhanced

angiogenesis in tumours, while

carbon ion irradiation did not. They

also concluded that this effect was

mediated by x-ray dependant

induction of SCF, and suggested

that SCF signalling may represent

a therapeutic target for the

inhibition of x-ray induced tumor

angiogenesis. Furthermore, they

suggest that carbon ions may have

an advantage over x-rays for the

treatment of adenocarcinoma of

the lung; however, this needs to be

confirmed in orthotopic lung

tumour models.

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IN BRIEF

EARLY STAGEBREAST CANCERResearchers in Californiareport astounding resultsfrom a trial to study theuse of proton beams forpartial breast irradiation.The trial demonstrated lowrecurrence rates, excellentsurvival rates, and owing tothe reduction of healthybreast tissue that isirradiated, minimal sideeffects.

MYCARDIALPERFUSIONLantheus Medical ImagingInc. has initiated a clinicaltrial to assess myocardialperfusion using PETimaging with flurpiridaz F18 in patients withcoronary artery disease(CAD). The trial willcompare this techniquewith single photonemission computedtomography myocardialperfusion imaging in thedetecting CAD.

LIGHT ONDERMATOLOGYLED Medical DiagnosticsInc. is pursuing aninitiative to apply its tissuefluorescence visualisationtechnology to the detectionof skin cancer and otherdermatologic diseases. It isbelieved that thistechnology will provide aninexpensive diagnostic toolto the skin specialist.

DON’T CHANGECT DECISIONCynthia McCollough,Professor of MedicalPhysics, advised physiciansto forget about radiationrisk when ordering CTscans and to focus onwhether the scan isnecessary, during herpresentation at the ISCTannual meeting. Shesuggested that risks fromCT are negligible and arecertainly outweighed by therisk of not doing a scan.

NEWS BY USMAN I. LULA AND RICHARD AMOS | SCOPE


given in 28 fractions. All plans

achieved excellent target coverage.

The corresponding dose metrics

(e.g. critical tissue doses) were

then evaluated.

The study showed that three-

field IMPT plans were optimal for

the selected cases. They resulted in

considerable reduction (‘sparing’)

in the mean dose to critical organs

such as the lung, liver and heart

compared to the three-field SIB-

IMRT plans. It is important to note

that the dosimetric benefit of

protons needs to be tailored to each

patient according to their specific

cardiac and pulmonary risks.

Investigators are now hoping to

study IMPT in a clinical trial to

determine the maximum tolerated

dose to which the GTV can be safely

escalated.

IMPT further reduces doseto ‘healthy’ tissues: a study

(a) Axial, sagittal and coronal views of intensity-modulatedradiotherapy: simultaneous integrated boost plan with planning targetvolume treated to 50.4 Gy and gross tumour volume boosted to 65.8 Gy.(b) Axial, sagittal and coronal views of intensity-modulated protontherapy (anteroposterior/left posterior oblique/right posterior oblique[AP/LPO/RPO]) plan, with PTV treated to 50.4 Gy and GTV boosted to65.8 Gy. AP/LPO/RPO beam arrangement was optimal for achievingboth pulmonary and cardiac sparing compared with IMRT plan.

The benefits of proton over photon

therapy include better critical tissue

sparing, dose homogeneity and a

reduced ‘dose-bath’ effect – low

radiation dose to normal tissues.

Intensity-modulated proton therapy

(IMPT) allows for the modulation of

the fluence and the position of the

Bragg peak, permitting 3D dose

distributions.

The aim of a new study was ‘to

explore whether IMPT could be

used to escalate the dose to the

gross tumour volume (GTV) while

further reducing the volume of

exposed normal tissue’. Ten

patients were selected, identified

with biopsy-proven carcinoma of

the distal esophagus. It is within

such cases that there is a treatment

failure rate of ~75 per cent,

commonly within the GTV (post

chemo-radiation of unresectable

oesophageal cancer).

Plans based on simultaneous

integrated boost (SIB) IMRT

(photons) and IMPT (protons)

techniques were compared using

the same planning and clinical

target volumes (PTV and CTV

respectively).

Each patient underwent 4D-CT

scanning to account for respiratory

motion. For each patient, four plans

were developed: an IMRT plan that

included an SIB and three unique

IMPT plans, all of which were to

deliver 65.8 Gy to the GTV and 50.4

Gy to the PTV, with all radiation

MORE INFORMATIONThis story was reported on MedicalPhysics Web on 17th May:http://medicalphysicsweb.org/cws/article/research/45999

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2011.

WHO Medical Device SeriesThe WHO’s Global Initiative on

Health Technologies recently

published a new series of

documents covering all aspects

of the medical device lifecycle.

These can now be accessed

through: www.who.int/medical_

devices/en/. Follow the links on

the left of this page to find

resource guides and associated

training packages on:

n policy development,

n regulations: global overview,

n health technology

assessment,

n needs assessment,

n procurement,

n donations,

n inventory management, and

n maintenance programmes.

Also included on the site are the

results of a global survey of

country systems relating to

medical devices.

Also of interest on the above

page will be the results of a

survey of biomedical and clinical

engineering institutions and

associations worldwide.

These resources will be an

invaluable guide to all with an

interest in global issues relating

to medical devices.

he clinical thermometeris the single most usedpiece of low-costinstrumentation inmedicine worldwide. Atleast, that statement was

true until the last few decades. Themeasurement of human bodytemperature still plays a prominentpart in medicine, although thetechnology has now diversified.

The pioneer of clinicalthermometry was Dr Carl

Wunderlich (figure 1). In his 1868thesis he set out the basic principlesfor the knowledge of temperature inthe study and treatment of fever.

Many of Wunderlich’s statementson the rationale for studyingtemperature in relation to diseaseremain undisputed. A very briefsummary of some of his statementsis: ‘A knowledge of the course oftemperature in diseases is highlyimportant to the medical practitioner,and indeed, indispensable

EFJ Ring (University of Glamorgan)describes new standards forinstrumentation used for themeasuring of human bodytemperature

T

METHODSTO DETECTA FEVER


n because temperature can beneither feigned or falsified,

n because certain degrees indicatethat there is fever,

n because the height of thetemperature often decides both thedegree and danger of the attack,

n because thermometricinvestigations indicate mostrapidly and most safely, anydeviations from the regular courseof the disease, and discovers bothrelapses and ameliorations before

we should otherwise recognisethem,

n because thermometry is able to beused to regulate the results of ourtherapeutical efforts,

n lastly it furnishes a certain proofof the reality of death, when thisis otherwise uncertain.’Wunderlich’s data from a very

large cohort of patients establishedthat axillary (under the armpit)temperatures were normally 37ºC(98.4ºF), with a range of 36.2ºC to37.5ºC.1 One significant result fromhis studies of human bodytemperature was the introduction ofthe clinical thermometer thatoptimised accuracy over a limitedtemperature range, with aconstricted capillary to holdmaximum temperature recordedduring use.

In recent years other devices havereplaced the mercury-in-glassclinical thermometer, i.e. themaximum thermometer that hasbeen used worldwide since itsinception by Wunderlich.Thermocouples, thermistors andinfrared radiometers for tympanicand forehead measurement are nowincreasingly being used. Somecommercial systems have usedalgorithms for an estimate of coretemperature, although the accuracyof these devices is often challenged.2

Rectal temperature, commonly usedin small infants, is probably thenearest estimate of body coretemperature, although internal use ofthermocouples at the distaloesophagus is still regarded as thegold standard. However, coretemperature of the human body isnot constant, being affected by anatural circadian rhythm.

Rectal temperature is higher thanperipheral surface measurements,but any changes induced by physicalactivity or of circadian origin areslow, and can lag behind the moresurface-located measurements ofskin temperature. Interest intympanic membrane temperature isbased on the fact that there is ashared blood supply to the brain.However, the complexities ofmeasurement in the ear are such thatunskilled users of tympanicthermometers can relatively easilymiss febrile individuals. For exampleit has been reported that three orfour out of every 10 fevers inchildren can be missed with thistechnique, depending on the skill of

the operator.3 While different scaleshave been introduced, we in Europenow standardise on degrees Celsius.This in itself has a curious history,since Celsius himself first proposed ascale with 100 at freezing point, andzero for boiling. It was Carl Linnaeus,the Danish botanist, who a few yearslater proposed the inverse, i.e. zerofor freezing point, which has sincebecome the normal scale.

CLINICAL THERMOMETRY:NEW STANDARDRecently an important new standardhas been written pertaining to clinicalthermometry, ISO/FDIS 80601-2-56Medical electrical equipment – Part 2-56:Particular requirements for basic safetyand essential performance of clinicalthermometers for body temperaturemeasurement.

This has now been accepted by allthe participating National Standardagencies.

This standard brings togetherwithin one document the variousregional clinical thermometerstandards, including the EuropeanEN series, the Japanese JIS standardand the US ASTM standard. Itdescribes the general and technicalrequirements for electrical, includingcontact (probe) and non-contact(tympanic (ear)), clinicalthermometers (liquid-in-glassthermometers and other non-electrical thermometers are excludedfrom the standard). This standardwas developed by a committeecomprising representatives fromdifferent National MeasurementInstitutes, including the BritishStandards Institute, manufacturers ofclinical thermometers and otherinterested parties. It includesdefinitions and operationalrequirements for the minimumoutput range of the thermometer; themaximum allowed laboratoryaccuracy over this minimum outputrange; evaluation and calibrationrequirements and equipment,including tolerances for thecalibration equipment, andrequirements for assessing the clinicalaccuracy of devices. It also providesinformation about the essentialinclusions in the documentationaccompanying the thermometer, andfull operating instructions. Forexample, the descriptors required forthe rated output temperature range ofthe thermometer and the laboratoryaccuracy over the range are given. It

FIGURE 1.Dr CarlWunderlich.

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FEATURE | SCOPE

SCOPE | FEATURE


also should include the results of theclinical accuracy validation, theminimum insertion time when takinginternal measurements andinstructions for use of a probe cover,etc. It also specifies that, in relevantcases, the manufacturer provides thecorrection method used to convert themeasured temperature to the readinggiven by the thermometer. This israrely shown by manufacturers, whoseem to regard this as their own tradesecret!

In summary, the standardharmonises the various regionalstandards, and provides clearrequirements for manufacturers ofelectrical clinical thermometers withregards to performance specifications,laboratory calibration and testing ofthe thermometers, laboratory accuracyand clinical evaluation. It alsospecifies the information that shouldbe marked on the thermometer andshould also be included in theaccompanying documents andinstructions for use.

The clinical thermometers referredto in the document are described indifferent categories, as follows.

A direct mode clinical thermometeris a clinical thermometer whoseoutput temperature is intended torepresent the true temperature ofthe measuring site or object which isthermally coupled to the sensor.This means that the actualtemperature detected by the sensoris displayed as the outputtemperature; i.e., the temperaturethat is measured is indicated withno corrections.

The operation of a zero-heat flowclinical thermometer, also called anequilibrium clinical thermometer,relies on a thermal equilibriumbetween the sensor and themeasuring site, i.e. there isnegligible heat flow between themeasuring site and the sensor. Thesensor and the measuring site aretherefore in thermal equilibrium orhave nearly the same temperature.Some examples of an equilibriumclinical thermometer include asublingual ‘pencil’ clinicalthermometer and a pulmonaryartery clinical thermometer. It isimportant to recognise that anequilibrium clinical thermometer

can take a significant period of timeto reach thermal equilibrium anddisplay its output temperature. Forexample, it takes approximately 5minutes for a ‘pencil’ sublingualclinical thermometer, and about 10minutes for an axilla clinicalthermometer, to achieve thermalequilibrium.

ADJUSTED MODETHERMOMETERSThe output temperature indicated bya clinical thermometer is notnecessarily the same as thetemperature of the sensor that isthermally coupled to the measuringsite. In the direct mode the outputtemperature indicated by a clinicalthermometer is the same as thetemperature of the sensor that isthermally coupled to the measuringsite, but direct mode thermometersmay be inconvenient. For example,the time response for an accuratemeasurement might be too slow, or itmight be impossible to place thesensor close to the desired body site.

Some clinical thermometers willgive the output temperature as the

Thereadingsmade byparentsdiffered bya clinicallysignificantamountfrom thereferencestandardusinghospitalequipment

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announcement of H1N1 swineinfluenza reaching pandemicproportions in June 2009. In recentyears there has been an increase insales of thermal imagers for theapplication of fever screening.5

The International StandardsOrganization has produced aguidance document on the use ofthermography in fever screening. Aninternational committee has beenworking for some 3 years, under ISOTC121/SC3-IEC SC62D, resulting inthe standard Particular requirementsfor the basic safety and essentialperformance of screening thermographsfor human febrile temperature screening.

This was followed by a technicalreport on the deployment of thesedevices, ISO/TR 13154:2009 ISO/TR80600, Medical electrical equipment –Deployment, implementation andoperational guidelines for identifyingfebrile humans using a screeningthermograph.

These documents provide a bestpractice guide to the important targettemperature assessment, using theinner canthus of the eye, whichrequires a close-up sharply focussedand well-calibrated thermal camera.It also shows that the incorrect use ofa thermal imaging camera mountedat an angle, or attempting to image amoving crowd, is bad and inaccuratepractice. Even so, there have beenmany reported uses of thermalimagers incorrectly used in a numberof international airports.

In summary, a thermal imagingcamera with defined sensitivity andaccuracy should be mounted on aparallax-free system to obtain athermal image of the face, optimisedfor viewing the areas around theeyes, so that the temperature of theinner canthi can be measured with atleast 9–16 pixels per eye region. Thisrequires the subject to look directly at

result of a signal adjustment orconversion and so the mode ofoperation is called the ‘adjustedmode’. An example of this will bewhere an infrared probe can beplaced in an ear canal but the digitaldisplay (output temperature)indicates an estimated sublingualtemperature of the patient. In thiscase, the temperature is corrected toallow for the difference betweensublingual and tympanictemperatures, based on clinical dataand physiological and anatomicalproperties of the two sites. Suchadjusted mode clinical thermometerscompensate for limitations of directmode clinical thermometers by usingsignal processing algorithms toestimate temperature from measuredvalues, though there is often acorresponding reduction in clinicalaccuracy.

TEMPERATUREMEASUREMENT SITESDifferent patient sites can be used fortemperature measurement both fordiagnosis and regular or continuousmonitoring. These will range fromthe detection of fever and life-threatening situations (e.g.malignant hyperthermia or sepsis) tothe determination of ovulation,monitoring a physiological responseto medications and procedures, theeffects of exercise and physical work,etc. Temperature can be measuredfrom internal organs or from the skinsurface. Either location can providevaluable information about bloodperfusion and transcutaneoustemperatures, such as those of theunderlying arteries and veins.

In the detection of fever, bodytemperatures have been historicallymeasured by contact clinicalthermometers in the sublingual,rectal or axilla measuring sites.However, most externally accessiblemeasuring sites have not representedthe body core temperature with aspecific quantitative relationship.Thus, during surgical proceduresand intensive care, temperatures areoften measured by invasive probesplaced at recognised coretemperature measuring sites, e.g.pulmonary artery, distal oesophagusand urinary bladder. The concept ofcore temperature is oftenoversimplified, there is no singleunique core temperature, andvariations can be found acrossinternal organs of the body.

TRAININGAs well as the requirement for aninternationally agreed standard forclinical thermometers, there is alsothe requirement for adequate trainingfor nursing staff and professionals toensure instruments are used correctly.This is particularly true for some ofthe newer thermometers currently inuse, such as tympanic (ear)thermometers. The National PhysicalLaboratory in the UK has developed atraining course to address this need(within the project ‘NPL TrainingFramework For Measurement InMedical Health & Optical RadiationTechnologies’, in conjunction with theSouth East England DevelopmentAgency).

Robinson et al.4 reported a studyin which parents and then nursesmeasured the temperature of 60children with a tympanicthermometer designed for home use.The readings made by parentsdiffered by a clinically significantamount from the reference standardusing hospital equipment, with afailure to detect fever in some 25 percent of cases.

THERMAL IMAGINGIn recent years, since the SARSoutbreak in south-east Asia, moreattention has been given to thepotential of temperaturemeasurement as a method ofscreening for fever in travellingpassengers. The first organised guideof good practice in this field waspublished by SPRING, the standardsagency of Singapore. The mostefficient way to screen for fever isconsidered to be the use of aninfrared thermography camera toimage the face. Interest in the methodincreased with the appearance ofH5N1 avian influenza, and after theWorld Health Organization’s

FIGURE 2.

Correctlyacquiredthermogram ofthe face. Thesubject on theleft is normal,while that onthe right has afever – the innercanthi of theeyes are ›38°C,while theforehead iscooler. Thissubject wouldbe missed in ascreeningsystem basedon foreheadtemperature,which is morethan 1°C coolerthan thescreeningthreshold.

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the lens of the camera for severalseconds (figure 2). Spectacles,sunglasses, face masks and largehead coverings must be removed toobtain a reliable temperaturemeasurement. Positive, high-temperature recordings will alert thescreening operator with a visible andaudible alarm. If a febrile individualis detected this will then lead to amore exhaustive evaluation of thatindividual by a clinical practitionerto ascertain their febrile condition.

There are a number of practicalissues arising from the standard thatmust be worked out in field trials,and the design of an optimal mountand alignment system is stillrequired. Most infrared cameramanufacturers sell thermal imagingsystems for industry where portabletripod mounts are adequate. Theseare unsuitable in an airportinstallation for use on humansubjects of different heights and ages.

More clinical data is required toestablish limits of normality for innercanthi maximal temperatures inhealth and in fever, and theirrelationship to the conventionalclinical thermometry methods thatwill be used to verify any personswho register the high temperaturealarm during screening. One suchstudy is in progress at the PaediatricClinic in the Military Institute ofMedicine in Warsaw, since childrenremain at higher risk of suchinfection.6 Although infrared

thermography has been in use in anumber of medical researchinstitutes worldwide, few studieshave focussed on fever detection,and the relationship betweenthermal data from the face withother methods of clinicalthermometry. The Warsaw data(in progress) indicates that infebrile children, there is ahigh correlation betweeninner canthitemperatures andaxillarythermometry.

Finally, for themeasurementswith a thermal imaging system to bewidely accepted, and to achieveinter-centre agreement ontemperatures, it is essential that theimagers be regularly calibratedtraceably to national standards ofradiance temperature.7,8

There is one remaining issueconcerning the use and selection ofthermal imagers and a moreuniform methodology to determineand present their specification. Inthe current situation this can lead toconfusing and conflictinginformation on differentmanufacturer’s data sheets. Thisimportant issue is now beingaddressed by the sub-committee ofIEC TC/SC/WG5 (June 2009) thatshould during 2011 bringrecommendations on how thermalimager specifications can be unified.

SUMMARYAll three of the abovenew documents shouldhave a significant positiveimpact on the use of thermometersand thermal imaging in medicine.While the fever screening standard isprimarily intended for that specificpurpose, it provides some clearguidelines for how a thermalimaging system should be correctlyused in clinical medicine. The newSpecification Standard for ThermalImaging will provide an essentialplatform for the properimplementation of the two feverscreening standards.

These documents not only dictatestandards in manufacture andspecification for performance but arespecific in the description ofcalibration procedures that lead totraceability to both national andinternational standards fortemperature. n

REFERENCES

1 Wunderlich CA. On the Temperature in Diseases, a Manualof Medical Thermometry. Translation from German by W.Bathurst Woodman. London: The New Sydenham Society,1871.

2 Crawford DVC, Hicks B, Thompson MJ. Whichthermometer? Factors influencing the best choice forintermittent clinical temperature assessment. J Med EngTechnol 2006; 30: 199–211.

3 Dodd SR, Lancaster GA, Craig JV, Smyth RL, WilliamsonPR. In a systematic review, infrared ear thermometry forfever diagnosis in children finds poor sensitivity. J ClinEpidemiol 2006; 59: 354–57.

4 Robinson JL, Jou H, Spady D. Accuracy of parents inmeasuring body temperature with a tympanicthermometer. BMC Fam Pract 2005; 6:http://biomedcentral.com/1471-2296/6/3

5 Ring EFJ, Jung A, Zuber J. New opportunities for infraredthermography in medicine. Acta Bio-Opt Inform Med 2009;15: 28–30.

6 Ring EFJ, Jung A, Zuber J, Rutkowski P, Kalicki B, BajwaU. Detecting fever in Polish children by infraredthermography. Proceedings of the 9th InternationalConference on Quantitative Infrared Thermography.Krakow, 2nd–5th July 2008: 125–8.

7 Machin G, Simpson RC, Broussely M. Calibration andvalidation of thermal imagers. Proceedings of the 9thInternational Conference on Quantitative InfraredThermography. Krakow, 2nd–5th July 2008: 133–47.

8 Simpson R et al. In field-of-view thermal image calibrationsystem for medical thermography applications. Int JThermophys 2008; 29: 1123–30.

If afebrileindividualis detectedthis willthen leadto a moreexhaustiveevaluationof thatindividual

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articles (figure 1). The latter allowssignificant increase of the potentialof the e-Encyclopaedia, includingsearching for related terms,acronyms and synonyms (theauthors made all efforts to includethese in the text). To use thispowerful facility the user has toselect Encyclopaedia plus Search in fulltext, specify the category/area of thesearch (e.g. radiotherapy) andproceed as above. In the case of UKor American/English differences(e.g. colour > color; optimise >optimize) try both spellings orsearch only part of the term (e.g.colo, optim). At the end, mostentries include references andrelated articles. To see the latter,copy and paste the related articletitle into the search window.

To use both the encyclopaediaand dictionary, select Combined andproceed as above (this search is

limited only to the title of the article,not inside its text). The text andimages of the articles allowcopy/paste in another file (n.b.formula-related text is presented asan image).

CONTENT MANAGEMENTRecently a content managementsystem was added to the EMITELwebsite (by our partner AM Studio).This allows not only online editing ofthe materials, but also adding newterms/entries, diagrams/images,including new languages, etc. TheEMITEL Network has editorialcontrol over the online material andwill be happy to receive suggestionsfor expanding the entries, newmaterials/images or new terms withexplanatory articles. Our aim is tojointly develop EMITEL as anexpandable free online reference formedical physics. n

FIGURE 1.An example ofthe ‘searchinside’ feature ofthe EMITEL e-Encyclopaedia (inall areas):here the searchfor the term‘phase’ hasresulted in a listof articles, where‘phase’ ismentioned in thetext, includingone with asynonym of‘phase wrap’ –‘aliasing’.

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bout a year ago theinternational projectEMITEL launchedthe e-Encyclopaediaof Medical PhysicsEMITEL

(www.emitel2.eu). The projectattracted more than 300 specialistsfrom 36 countries as contributorsand developed an expandabledatabase of specific medical physicsterms which were translated into 29languages. To build theencyclopaedia each term from thisdictionary was covered by anexplanatory article (entry) inEnglish. Many articles are supportedwith images and diagrams. The e-Encyclopaedia includes c. 3,400entries. Currently EMITEL has6,000+ users per month. To answerquestions about the most effectiveuse of EMITEL we present a briefuser guide.

To use the dictionary, selectDictionary, choose the input andoutput languages, write the termyou want to see at the window andthen click Search. A list with terms isdisplayed, where the terms arefound either as a single word or incombination with other words (thee-dictionary assumes that the user’sInternet browser already supportsthe languages). Terms without anexisting translation are in English.

To use the encyclopaedia articletitles only (quick search in English),select Encyclopaedia plus Title. Writethe term you want to see in thewindow and then click Search. A listwith terms is displayed – againsteach one is a blue hyperlink relatedto the area of the term. Click thehyperlink to read the article. Thissearch covers only the titles of thearticles. Some articles have twoentries (related to two categories,e.g. magnetic resonance andultrasound). To minimise problemswith spelling the search may usepart of the word only.

The website was built with twosearch engines – one searching intothe lists of terms (in all languages)and another one (in English only)searching inside the text of the

ASlavik Tabakov and Cornelius Lewis (on behalf of the EMITEL Consortium)

e-Encyclopaedia of Medical PhysicsEMITEL – a brief user guide

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ngineering is, I believe,in my genes. At ayoung age I wasbuilding machines outof Lego and throughmany moments of

elation and frustration learnt a lotabout the laws of physics. Soon Iwas building radio-controlled cars.Having obtained my driving licenceI turned my hand to larger projectsand before long I was busyrestoring a 1973 MG Midget whilstat the same time keeping it as mydaily driver – very challenging! Myfather has always been verypractical and I think some of hisskills and enthusiasm have rubbedoff on me.

AFTER SCHOOLFollowing GCSEs I studied for aBTEC Ordinary National Diplomain engineering. I proceeded touniversity to undertake a BEng(Hons) in Manufacturing SystemsEngineering with a year out inindustry. During my sandwich yearI spent 9 months on a placement inEngland and 3 months in Germany,both companies specialising in theautomated assembly of electronicdevices. Whilst at college anduniversity I worked part-time at aspecialist car garage. The proprietorwas a professional engineer and

encouraged me to develop mythinking and to apply a logicalapproach to solving problems. Hewas keen for me to work alongsidethe mechanics and this encouragedme to apply and develop myengineering knowledge and skills.

FIRST STEPS TO HEALTHCAREHaving finished university I wasentirely unclear which way to turnbut quite liked the idea of doingsomething completely different fora while. I came across an advert forcare work at a local day centre foradults with learning difficultiesand challenging behaviour.The people whointerviewed mewere curious asto why I shouldwant such a jobgiven my recentgraduation, andmy parentswere, to put itmildly,concerned. ButI got the job and spent 18months in a predictably rewardingenvironment doing a range of workfrom assisting people with personalcare through to taking groups outon social trips. There were fourpeople at the day centre who usedwheelchairs. Three of these had

very curious looking seats thatseemed to be shaped to theindividual (two ‘Derby’ mouldsand one ‘matrix’, as I was later tolearn). I really enjoyed workingwith the people at the day centreand now saw an opportunity to linkthis with my training inengineering, but this was not tohappen quite yet.

HONING MY SPECIALISMMy next opportunity was a fixed-term contract with CoRE (Centre ofRehabilitation Engineering), abranch of Medical Engineering andPhysics at King’s College Hospitalin London. I became a researchassistant on the EMPAT project(Effective Methods for theProvision of Assistive Technology)

CLINICALENGINEERING David Long (Nuffield Orthopaedic Centre NHS Trust,Oxford) continues the CEng theme from previous issues ofScope with his path to registration

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A RECENT PATH TO CEng REGISTRATION

I wasbuildingmachinesout ofLego andlearnt a lotabout thelaws ofphysics

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also believed it would be a positiveattribute for future careerdevelopment. I had my viva in 2008and as with any interview therewere some aspects I knew I couldhave presented better, but overall itwas a good experience, theexaminers being very facilitatoryand encouraging.

I am pleased to have beenawarded CEng and wouldrecommend other engineers toapply. It adds to our professionalstanding as engineers in our ownright and in the healthcare settinggenerally. As an engineer, I believe Ihave an important role to play inthis context, bringing both clinicaland engineering experience not onlyto clinical service provision, but alsoto the training of new clinicalscientists and to the otherdisciplines that attend the coursesrun in my department on which Iteach, including physiotherapists,occupational therapists and nurses.

I have chosen the images you seein the photographs as they illustratethe variety of my work. I relish achallenge and gain a great sense ofsatisfaction from solving problemsfor which commercially producedequipment is not available. To mymind, this is a fundamental reasonfor professional engineers to engagewith healthcare. n

working under Dr Alan Turner-Smith. My job was to visit as manywheelchair services as possible andinterview their staff about their jobsfrom a variety of angles. I visitedover 70 services in the space of 15months and this exposed me towhat was to come. In the office nextdoor worked a gentleman by thename of Paul Richardson who wasthe head of the RehabilitationEngineering Division for King’s.Paul was instrumental in gettingmy career truly started in offeringme the position of rehabilitationengineer at the special seatingservice in Stanmore, Middlesex,where I started in the summer of1998. Initially, my role was to repairseating systems on issue from theservice. This quickly turned into aclinical role and by the followingyear I was part of the clinicalassessment team which was headedby Dr Linda Marks, a consultantphysician in rehabilitationmedicine. Linda welcomed inputfrom anyone during clinics, but onehad to provide a clear rationale forone’s argument. It was a superblearning environment.

HIGHER EDUCATIONIn 2000, my line manager left and Itook over managing therehabilitation engineering section

of the service. This prompted areview of my position and thewheels were put in motion to assistme in moving towards becoming aclinical scientist and towardsbecoming chartered. In 2001 Istarted the MSc in ClinicalEngineering at Cardiff Universitywhich I completed in 2004.Alongside my academic studies Ideveloped professionalcompetencies that would later fulfilthe requirements of both corporatemembership of IPEM and CEngregistration.

STATE REGISTRATION ANDCHARTERSHIPIn 2004, I moved to work at theOxford Centre for Enablement,based at the Nuffield OrthopaedicCentre NHS Trust in Oxford, underthe leadership of Dr David Porter,Consultant Clinical Scientist. Myrole was still to be based largelyaround specialist wheelchairseating. In 2005 I finally becameregistered as a clinical scientistwhich provided me with a greatsense of achievement. Followingthis I started to prepare myapplication for corporatemembership of IPEM and CEngregistration. I wanted to becomechartered as to me it signified someform of maturation as an engineer. I

TOP LEFT.Mobility systemfor a child with abrain injury.

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TOP RIGHT.Assessing rangeof hip joint motionin a child withcerebral palsy.

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BOTTOMRIGHT. Vacuumconsolidationcasting forbespokecontouredwheelchairseating.

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LEFT. A logicalapproach tosolving problemswas the start of acareer.

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pinal cord injury (SCI) isa complex andfrequently devastatingcondition for bothpatients and theirfamilies. It also has an

enormous cost on the healthcaresystem.1 SCI can affect the physical,psychological and emotional aspectsof occupational performance, andactivities of daily living.2 Reduction orloss of skeletal muscle function hasbeen described as one of the mostsignificant problems impacting thehealth and quality of life of personswith SCI. It has been demonstratedthat secondary health conditions, suchas pressure sores, low impactfractures and deep venousthrombosis, are at least partiallyrelated to musculoskeletal atrophyand disuse in these individuals.3 Thus,one of the major components ofphysical therapy in this population ismuscle strengthening.

Neuromuscular electricalstimulation (NMES) uses trains of

short electric pulses to generate musclecontraction.3,4 By stimulating a specificset of muscles and employing specificstimulation sequences, NMES cangenerate functional movements inindividuals with paralysis, such asindividuals with SCI. It is wellestablished that NMES training cancounteract musculoskeletal atrophy. Ithas been shown that, as withneurologically intact muscle, repetitivemuscular overload elicits the greatestimprovements in paralysed musclestrength and endurance.5 Acomparatively novel therapeuticapproach implements coupled NMESand goal-oriented exercises to elicitand facilitate spinal cord repair viaadaptive plasticity of spinal cordcircuits.6 It has been hypothesised thatthis approach can elicit regenerativecellular events that could contribute toimproved outcomes. Moreover, it hasbeen shown that some elements ofspinal circuitry associated with motorcontrol clearly remain after SCI andcan be improved by task-specific and

goal-oriented training,7 which suggeststhe existence of spinal networks andraises the possibility of greaterfunctional outcomes as well asclinical/physiological improvementsafter training. As such, NMES could beused to promote neuroplasticity andassist neurological patients improvetheir voluntary function. However, aswith any training protocol, a criticalissue with this rehabilitative approachlies in maintaining the participants’interest in performing repetitivetraining tasks and in ensuring theircontinued motivation to complete thetraining.5 Novel approaches forphysical rehabilitation are needed topromote interactive and entertainingexercise. These approaches shouldoffer the chance for the intensiverepetition of meaningful task-relatedactivities necessary for effectiverehabilitation in a manner that can bemore interesting and conducive to self-direction than either conventional orleading-edge therapies. In other words,there is a need to develop a method

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VIDEO GAME TRAININGA NEUROMUSCULAR STIMULATION SYSTEM

FIGURE 1.Schematicdiagram of themaincomponents andsequence ofaction of thetraining system:(a) joystick, (b)neuromuscularelectricalstimulator(Compex Motion,Compex SA,Switzerland) and(c) foot platform.

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DG Sayenko, K Masani, MF Robinson, M Milosevic and MR Popovic (TorontoRehabilitation Institute, Canada)


which would allow clients to have funwhilst stretching their physical andfunctional capabilities.

Recent advances in technologyhave resulted in the availability ofvideo games that have the capabilityto be used in rehabilitation.2,8 It hasbeen suggested that since interactivecomputer gaming plays an importantrole in the lives of many people, videogame applications may be also used toenhance motivation duringrehabilitation. The use of rewardingactivities and entertainingenvironments during game-basedrehabilitation can substantiallyimprove people’s motivation toadhere to their treatment regimensand result in better functional andpsychological outcomes. Moreover, avideo game-based approach can beimplemented when the course ofconventional therapy is completed,thus encouraging patients to furtherimprove their functions afterdischarge from rehabilitation. To date,the implementation of the videogame-based approach has beenlimited because of the lack or absenceof motor control in individuals withneuromuscular impairments. Bycoupling NMES with a video game weintend to combine and augment theadvantages of both rehabilitationtechniques.

Consequently, by combining twokey technologies, namely NMES andvideo gaming, we believe that we canprovide a training method that willpromote muscle strengthening andmotivate individuals withneuromuscular disorders to adhere totheir treatment regimens. The aim ofthe present study was to determinethe feasibility and efficacy of a videogame-based NMES training systemwith respect to physiological andpsychological outcomes in individualswith complete SCI.

METHODSParticipantThe male participant was 57 years oldand sustained chronic SCI (T3–T4) 4years prior to taking part in this study.The participant’s lesion completenesswas classified as AIS A (AmericanSpinal Injury Association ImpairmentScale classification A). At the time ofinitial assessment, the participantdemonstrated complete motor andsensory loss below the T4 level. Hispersonal treatment goals were toprevent secondary health conditionsassociated with impaired blood

circulation and bone demineralisation,and to improve his muscle mass inorder to be able to participate inrehabilitation programmes that useNMES. The participant gave writteninformed consent to the experimentalprocedure, which was approved bythe local institutional ethics committeein accordance with the declaration ofHelsinki on the use of human subjectsin experiments.

Experimental setupThe participant was actively involvedin the training procedure by operatingthe video game via NMES-inducedankle joint motions (figure 1). Theparticipant adjusted the level ofelectrical stimulation delivered to hisplantarflexors or dorsiflexors usingthe joystick, which was connected tothe programmable four-channelneuromuscular electrical stimulator.The applied electrical stimulationevoked corresponding musclecontractions that controlled the videogame through the resulting changes inankle joint angular displacement(figure 1). The training systemconsisted of a dynamic ankle joint

training device, a tilt sensor, anelectrical stimulator, a joystick and avideo game-based visual feedbacktraining software program (figure 2).

Dynamic ankle joint training deviceDuring the training, the participantwas seated on a padded bench with abackrest support. The position of thehip and knee joints were set to 90º offlexion, and the feet were firmlystrapped to the foot platform (figure2(a)). The platform was attached to themain shaft of the training device,which was inserted in the sidebearings allowing for smooth rotation.The axis of rotation of the main shaftwas aligned with that of the anklejoints. The main shaft was composedof two sections, one of whichsupported the foot plate and the otherheld the inverted pendulum (figure2(b)). The inverted pendulum was 1 min length and was held in the uprightposition by the notch in the mainshaft. The system allowed theparticipant to perform plantarflexionsand dorsiflexions using NMES. Thecontractions were performed againstexterior resistance (inverted

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FIGURE 2.An overall viewof the footplatform with theinvertedpendulum lockedin place at theend of the mainshaft, and aparticipant on apadded benchusing thesystem: (a) footplatform, (b)invertedpendulum, (c)NMES electrodesand (d) joystick.

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pendulum with a weight on it), andthe angle of the ankle joints was usedas the control input to the video game.To prevent excessive joint movementsduring the training exercise, the rangeof angular displacements of the footplatform was mechanically restrictedfor safety consideration within therange of 30º plantarflexion and 20ºdorsiflexion. The stoppers werecovered by softer materials to absorbpotential mechanical shocks when theplatform stopped moving. Thereaction torque sensor (TS11-200,Durham Instruments, Germany) wasmounted to the main shaft to measurethe torque produced during thetraining exercise.

Tilt of the foot platform in thefrontal plane was registered by anaccelerometer-inclinometer (KXM52-1050, Kionix Inc., USA), which wassecurely attached to the rotatingplatform between the left and the rightfoot. The tilt was used as the real-timecontrol input to the video game. Real-time data acquisition, processing,visualisation and storage wereperformed using the LabVIEW 8.5software package (NationalInstruments, USA).

Neuromuscular electrical stimulationA programmable four-channelneuromuscular electrical stimulator(Compex Motion, Compex SA,Switzerland) was used to delivertranscutaneous electrical stimulationto the ankle joint muscles. Two pairs ofself-adhesive gel electrodes(ValuTrode, Denmark) were placedover the motor points on proximal(active electrode) and distal (referenceelectrode) ends of the triceps suraeand tibialis anterior muscles of eachleg, i.e. the surface of plantarflexorsand dorsiflexors, respectively. The 9 ×5 cm electrodes were placed on theplantarflexors and 5 × 5 cm electrodeswere placed on the dorsiflexors (figure2(c)). NMES applied to plantarflexorsgenerated an ankle torque that causeda forward rotation of the ankle joints,whereas NMES applied to dorsiflexorsresulted in a backward rotation of theankle joints.

The stimulation current had arectangular, biphasic, monopolar pulsewaveform with a pulse duration of 300µs, and the stimulation was deliveredwith a frequency of 40 Hz. Themaximal amplitude (intensity) of thestimulation was set to 80 per cent ofthe intensity required to producemaximal torque. The range of the

NMES intensity was determined priorto the training exercise and was basedon the muscles’ motor threshold(lower limit) and 80 per cent of theintensity required for maximumtorque elicitation (upper limit). Forthe individual in this study, thestimulation ranged from 30 to 80 mAand from 20 to 60 mA forplantarflexors and dorsiflexors,respectively.

JoystickThe stimulation intensity wascontrolled by the participant inresponse to the video game scenariousing an analogue joystick controller(figure 2(d)). A forward inclination ofthe joystick, which was connected tothe electrical stimulator through ananalogue input port, resulted instimulation of plantarflexors, whereasa backward inclination resulted instimulation of dorsiflexors. Theintensity of the stimulation increasedlinearly with joystick motion.

Game-based exerciseThe goal of the game was to navigatea moving ‘snake’ (figure 3(a)) aroundthe screen in an attempt to hitrandomly appearing targets (figure3(b)). The turning radius of the‘snake’ was controlled by the positionof the ankle joints detected by the tiltsensor. Although only one type ofankle joint motion was used (i.e.plantarflexion and dorsiflexion in thefrontal plane), the video game utilisedthree types of motion: with the jointsin neutral position, the ‘snake’ movedin a straight line; in order to produceclockwise or counterclockwise turnsof the ‘snake’, the participant had toelicit plantarflexions (forwardinclination of the joystick) ordorsiflexions (backward inclination ofthe joystick), respectively.

Visual feedback was provided by alarge monitor placed at eye levelabout 1.5 m in front of the participant.To motivate the participant toimprove his performance, a scorerepresenting the number of collectedtargets was displayed (figure 3(c)).With an increased number of collectedtargets, the ‘snake’ increased itslength. The trial was restarted everytime the snake crossed the borders ofthe screen (‘out of bounds’). The gameparameters were adjustable (figure3(d)); namely, the speed of the snakeand the number of targets, as well asthe neutral position in the ankle jointsand the sensitivity of the tilt sensor to

the angular displacement of the footplatform. In addition, the amount ofadditional weights added to thependulum varied the resistive force(torque) during movements of theankle joint. For the purpose of thisstudy, the parameters were set by theresearcher.

The training was performed threedays per week for a total of 48sessions. Each session lasted up to 60minutes with a total time of the NMESof at least 45 minutes. The study wasperformed at the TorontoRehabilitation Institute. A researcherassisted with the initial setup (i.e.electrode placement and gameparameters) prior to each trainingsession. During the training, theparticipant was focussed on the gamemost of the time, and did not interferewith the researcher.

Outcome measurementsThe following parameters wererecorded throughout the trainingperiod: (a) the NMES intensity, (b) theoverall torque representing resultanttorque exerted by the stimulatedmuscles and passive torque producedby the training device, and (c) theangular displacement of the footplatform (corresponding to ankle jointposition). In addition to theaforementioned recordings, an open-question interview was carried out toassess motivational aspects of thetraining and to capture theparticipant’s opinion on how thetraining system could be improved.

RESULTSFigure 4 shows an example of onecycle of the exercise fromplantarflexion to dorsiflexion and backto plantarflexion. Two kinds of muscleactivities were utilised. First, isotonicconcentric contractions occurredduring rotation of the foot platformfrom plantarflexion to dorsiflexion andvice versa. The peak torque valueswere exerted when the pendulum wasmoved away from its outermostposition towards the upright position.As the angle in the ankle jointsapproached the neutral position, themagnitude of the torque decreased dueto the fact that the inverted pendulumapproached the upright position. Afterthe pendulum reached the verticalpoint, it continued to move under itsown weight until the foot platformreached the opposite outermostposition (i.e. dorsiflexion orplantarflexion). Second, while the foot

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FIGURE 3.Interface ofgame-basedexercise: (a)‘snake’, (b)targets, (c) scoreand (d)adjustableparameterswhich include:speed of snake,number oftargets,adjustment ofneutral positionof ankle jointsand range ofmotion (i.e. peakplantarflexionand dorsiflexion).

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platform was kept in its outermostposition, the participant continued toapply stimulation, which resulted inisometric contractions until arotation in the opposite direction wasrequired by the game.

The training resulted in asignificant improvement of thestrength and endurance of theparalysed lower leg muscles.

During the first training session,the peak torque values reached 11.0 ±1.7 Nm and −5.1 ± 0.8 Nm duringplantarflexion and dorsiflexion,respectively, whereas during the 48thsession, the torque values increasedto 27.0 ± 4.0 Nm and −16.0 ± 2.0 Nmduring plantarflexion anddorsiflexion, respectively (figure5(a)).

The range of motion of the anklejoints also increased from 17.7 ± 2.1ºand −2.9 ± 0.8º (first session) to 28.7 ±3.4º and −17.9 ± 1.5º (48th session)

during plantarflexion anddorsiflexion, respectively (figure 5(b)).

The game score representing theoverall number of collected targetsduring the first session reached 12points. However, the score increasedthroughout the training period,reaching 421 points by the 48thsession.

During the interview, theparticipant reported that he enjoyedcontrolling the video game-basedtraining. He stated that the videogame was challenging to play, butcould be easily adjusted to meet theneeds of the participant. Theparticipant also reported that theinstruction to maximise his scoreduring each trial motivated him toplay and to keep his attention on thegame throughout the whole session.The participant was encouraged toparticipate in this training programmeon a regular basis.

DISCUSSIONWe developed a new training systemthat integrates NMES and visualfeedback. We demonstrated that theprotocol used in this study yieldedsignificant training effects on thestrength and endurance of theparalysed lower leg muscles, as seenthrough increased torque values andtraining session duration, andimproved the range of motion of theankle joints. As opposed to existingtraining programmes, our approachincorporated non-isometric concentriccontractions against different levels ofresistance, included an entertainingcomponent and required minimalsupervision by staff.

Often, the existing protocols oflower leg muscles’ NMES-training inpopulations with SCI includestimulation during isometriccontractions, i.e. with a constantmuscle length and fixed ankle joints.

▼

Theparticipantreportedthat heenjoyedcontrollingthe videogame-basedtraining

“

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FEATURE | SCOPE


Such conditions introduce a higher riskof bone fracture, decreased bloodcirculation and decreased ankle jointmobility.9,10 We therefore suggested asystem that includes dynamicplantarflexion and dorsiflexionmovements against exterior resistance,and thus decreasing the probability ofthe aforementioned risks. Themotivation to obtain a higher scoreguided the participant through theprotocol, thus providing an overloadfor the muscles during the training. Webelieve that the muscle overloadinduced by the current protocolresulted in an increment of the musclestrength, and, thus, almost tripledtorque by the end of the training periodin comparison with the initial values.

Another key observation resultingfrom this study was that the interactivegaming NMES intervention canmotivate a person with chronic SCI toperform muscle-training exercises. Ourparticipant indicated that he enjoyedthe video game-based tool, and that hewould like to continue the treatment.We believe that the proposed videogame-based NMES trainingprogrammes will be effective inmotivating participants to train morefrequently and adhere to otherwisetedious training protocols. Moreover, avideo game-based approach can beimplemented when the course ofconventional therapy is completed,thus encouraging patients to furtherimprove their functions after dischargefrom inpatient care.

Additionally, the feasibility of oursystem was demonstrated in anindividual with motor and sensorycomplete paraplegia. It has been notedearlier that a regular trainingprogramme might not be available ormight be too difficult to participate in,either physically and/orpsychologically.11 Our systemparameters could have been changedpermitting the participant tosuccessfully train even withprogressively increasing fatigue. Webelieve that characteristics of thesystem would allow individuals witheven less preserved motor function (i.e.with weaker muscles, a higher degreeof muscle atrophy, and/or withnarrower ROM in the ankle joints) toparticipate in this training programme.

Finally, the system setup andapplied protocol required minimalsupervision from medical or researchstaff: once the game parameters, rangeof motion and the level of resistancewere set, the participant was able to

perform the training without anyfurther assistance.

As an extension of the present study,we designed a portable foot platformwhich does not require the participantto transfer from their wheelchair, andcan be easily used in both clinicalsettings and during home-basedtraining programmes. Further researchalong with a randomised control studywill be performed in the future toinvestigate and compare themotivation level and to what extentmuscle function might be enhancedusing our system and otherrehabilitation approaches.

CONCLUSIONThe proposed system that integratesNMES and video gaming successfullymotivated the participant and resultedin significant training effects on thestrength and endurance of theparalysed lower leg muscles as well asimproved the range of motion of theankle joints. This research programmerepresents an extension of our previouswork in the field of improvement andrestoration of neuromuscular functionsusing NMES-based technologies. Thisapproach can be implemented in thefuture in a clinical setting starting at avery early post-injury stage byproviding a regular physical exerciseprogramme in the hospital that canthen easily be transitioned to a home-based training programme. Finally, theproposed approach has the potential tobe implemented in other neurological,orthopaedic and geriatric populations.It can help the targeted patientpopulation achieve higher levels ofindependence in activities of dailyliving by improving their function andconfidence, and decreasing the severityand likelihood of secondary healthconditions. In the future, we propose tocollaborate with game developers todesign different types of rehab-oriented video game-based exerciseswith the goal of making them asenjoyable and appealing as possible.We believe that in this day and age, it istime to create the whole niche forrehabilitation games which can be usedby millions of needed users. n

1 Spinal cord injury facts and

figures at a glance. J Spinal Cord

Med 2010; 33(4): 439–40.

2 Kizony R, Raz L, Katz N,

Weingarden H, Weiss PL. Video-

capture virtual reality system for

patients with paraplegic spinal

cord injury. J Rehabil Res Dev

2005; 42(5): 595–608.

3 Ragnarsson KT. Functional

electrical stimulation after spinal

cord injury: current use,

therapeutic effects and future

directions. Spinal Cord 2008; 46(4):

255–74.

4 Popovic MR, Keller T. Modular

transcutaneous functional

electrical stimulation system.

Med Eng Phys 2005; 27(1): 81–92.

5 Shields RK, Dudley-Javoroski S.

Musculoskeletal adaptations in

chronic spinal cord injury: effects

of long-term soleus electrical

stimulation training. Neurorehabil

Neural Repair 2007; 21(2): 169–79.

6 Nandoe Tewarie RD, Hurtado A,

Bartels RH, Grotenhuis JA,

Oudega M. A clinical perspective

of spinal cord injury.

NeuroRehabilitation 2010; 27(2):

129–39.

7 Edgerton VR, Roy RR. Robotic

training and spinal cord plasticity.

Brain Res Bull 2009; 78(1): 4–12.

8 Sayenko DG et al. Positive effect of

balance training with visual

feedback on standing balance

abilities in people with incomplete

spinal cord injury. Spinal Cord

2010; 48(12): 886–93.

9 Crameri RM, Cooper P, Sinclair

PJ, Bryant G, Weston A. Effect of

load during electrical stimulation

training in spinal cord injury.

Muscle Nerve 2004; 29(1): 104–11.

10 Petrofsky JS, Stacy R, Laymon M.

The relationship between exercise

work intervals and duration of

exercise on lower extremity

training induced by electrical

stimulation in humans with spinal

cord injuries. Eur J Appl Physiol

2000; 82(5–6): 504–9.

11 O'Connor TJ et al. Evaluation of a

manual wheelchair interface to

computer games. Neurorehabil

Neural Repair 2000; 14(1): 21–31.

REFERENCES

ACKNOWLEDGEMENT The primary author (DS) is supported bythe fellowship programmes of theCanadian Paraplegic Association ofOntario. We thank Mr Egor Sanin for histechnical contributions. This project wassupported by the Toronto RehabilitationInstitute, which receives funding under theProvincial Rehabilitation ResearchProgram from the Ministry of Health andLong-Term Care in Ontario.

FIGURE 4[LEFT] Exampleof one cycle ofthe exerciserecorded duringthe secondminute of thefirst trainingsession:transition fromplantarflexion todorsiflexion andback toplantarflexion.(a) NMESintensity; (b)torque (boldblue line) andangulardisplacement(bold greenline). Periods ofisotonicconcentriccontractions areshown by greycolour. Scale forthe torque isshown on theleft; scale for theangulardisplacement isshown on theright.

▼

FIGURE 5[RIGHT] Peak(a) torque and(b) angulardisplacement ofthe footplatform duringthe first and48th trainingsessions.Positive valuesrepresentparametersduringplantarflexion;negative valuesrepresentparametersduringdorsiflexion.Asterisksindicatestatisticallysignificantdifferences incomparison withthe first trainingsession (* P‹0.05).

▼

RISK MANAGEMENT AND REHABILITATION ENGINEERING:COMMON ISSUES IN AN UNCOMMON AREA OF WORKMichael Dolan and Jennifer Walsh (NHS Lothian) describe the application of riskmanagement in rehabilitation engineering illustrated with case studies

ONE OF THE MANY DAILY ISSUES faced

by members of IPEM is that of risk

management. Risk management can

range from an, apparently, quick

decision to a lengthy process involving

assessment of all possible risks and

their probability of occurrence. In the

end, the benefit of the procedure or

equipment needs to outweigh the risks

involved. It is the application of risk

management in the area of

rehabilitation engineering (RE) that is

dealt with in this tutorial.

RE has been defined as the ‘clinical

application of engineering principles and

technology in the provision of services,

research, and development to meet the

needs of individuals with disabilities. It

involves the reduction of environmental

barriers, and/or the restoration or

improvement of the physical, mental and

social function of a person with a

disability’;1 for example, wheelchairs and

specialised seating systems or

environmental controls. A key function of

any RE service is the ‘analysis of risks

associated with the use, provision, or

development of technology’.1

In the field of RE, patients are issued

with equipment on a long-term loan that

they will use on a daily basis. Such

equipment can permit an increased

quality of life by allowing the person to

mobilise or perform a function that they

were previously unable to do

independently without this equipment.

This daily, unsupervised interaction with

the provided device makes the

management of the associated risk of

paramount importance. This is not new

in the RE field, but as medical devices,

such as infusion pumps and ventilators,

have become more portable and

sophisticated, making it possible to treat

and monitor chronic conditions outside

of the hospital, it is now an increasingly

widespread consideration for other

areas of healthcare science.

Wheelchairs and seating account for

the largest quantity of RE equipment

supplied on long-term loan to patients

by the NHS. The importance of

managing risk for users of NHS

wheelchairs has recently been

highlighted in the Clinical Standards for

NHS Scotland Wheelchair and Seating

Services.2 Indeed, the Standard for

equipment provision and management

states that ‘wheelchairs, seating and

associated equipment are medical

devices and should be safe and fit for

purpose and provided in a timely manner

in accordance with risk management

principles’. Clinical scientists and other

healthcare science professionals are

often responsible for risk management in

this area.

Risk management attempts to reduce

identified risks proactively to an

acceptable level by creating a culture

founded upon assessment and

prevention, rather than reaction and

remedy. Risk management is not solely

applied to the use of technology but has

wider application to the patient safety and

quality assurance in the provision of

healthcare generally and can be

considered to be part of clinical

governance.3 Risk management can be

seen as the balance between benefits and

harms, which may be judged both at the

level of the individual and at the level of

society; for example, the balance between

costs of an intervention and the potential

for cost savings to society as a whole.

RISK MANAGEMENT AND MEDICAL DEVICESThe application of risk management to

medical devices is set out in ISO

14971:2009.4 The concept of risk has two

components:

n the probability of the occurrence of

harm, and

n the consequences of harm; that is,

how severe it might be.

Medical devices are defined as ‘any

instrument, apparatus, implement,

machine, appliance, implant, in vitro

reagent or calibrator, software, material

or other similar or related article,

intended by the manufacturer to be used,

alone or in combination, for human

beings for one or more of the specific

purpose(s) of:

n diagnosis, prevention, monitoring,

treatment or alleviation of disease,

n diagnosis, monitoring, treatment,

alleviation of or compensation for an

injury,

n investigation, replacement,

modification, or support of the

anatomy or of a physiological

process,

n supporting or sustaining life,

n control of conception,

n disinfection of medical devices,

n providing information for medical

purposes by means of in vitro

examination of specimens derived

from the human body, and which

does not achieve its primary intended

action in or on the human body by

pharmacological, immunological or

metabolic means, but which may be

assisted in its function by such

means.’

In the field of RE, examples of medical

devices include:

n aids for daily living (e.g. commodes,

bath aids),

n environmental controls (e.g. personal

alarm systems, remote control of

doors),

n mobility aids (e.g. wheelchairs,

walking frames, prostheses),

n moving and handling systems (e.g.

hoists, stair lifts),

n posture management (e.g.

wheelchair seating systems),

n pressure management (pressure

redistribution/relief), and

n speech and hearing aids.

Manufacturers of these low-risk ‘class I’

devices must fulfil the Medical Device

Directive’s 93/42/EEC (MDD) Essential

Requirements set out in Annex I. These

include conforming to the safety

principles:

n eliminate or reduce risks as far as

possible (inherently safe design and

construction),

n where appropriate take adequate

protection measures including

alarms if necessary, in relation to

risks that cannot be eliminated, and

n inform users of the residual risks

due to any shortcomings of the

protection measures adopted. ▼

In thefield of RE,patientsare issuedwithequipmenton a long-term loanthat theywill use ona dailybasis

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24 | SEPTEMBER 20 11 | SCOPE

The terms ‘risk analysis’, ‘risk

evaluation’, ‘risk assessment’ and ‘risk

management’ are often used

interchangeably, but they are distinctly

different and must be understood. They

are defined in ISO 14971:2009 as follows:4

Risk analysis: systematic use of

available information to identify hazards

and to estimate the risk.

Risk evaluation: process of comparing

the estimated risk against given risk

criteria to determine the acceptability of

the risk.

Risk assessment: overall process

comprising a risk analysis and a risk

evaluation.

Risk management: systematic

application of management policies,

procedures and practices to the tasks of

analysing, evaluating, controlling and

monitoring risk.

The relationship between these

elements is illustrated in the schematic of

the risk management process (figure 1).

The ISO 14791:2009 standard

specifies a procedure by which a

manufacturer can identify the hazards

associated with medical devices,

estimate and evaluate the risks, control

these risks and monitor the effectiveness

of the control. Importantly, though, the

standard does not apply to clinical

judgements relating to the use of a

medical device. It might be thought that

any risk associated with a medical device

would be acceptable if the patient’s

prognosis were improved. Nevertheless,

this cannot be used as a rationale for the

acceptance of unnecessary risk. Any risk

should be reduced to the lowest level

practicable, bearing in mind the benefits

of accepting the risk and the practicability

of further reduction.

In the real world, and particularly in

the RE field where equipment is used

unsupervised in the community for long

periods, it is not possible to eliminate all

risks. The emphasis, therefore, needs to

be on minimising and managing risks.

MODIFYING MEDICAL DEVICESIt is often overlooked that the

modification of CE-marked medical

devices and the in-house manufacturing

and off-label use of devices to meet

particular needs are subject to the

requirements of the MDD. Technically

modification counts under the terms of

the MDD as re-manufacture, meaning

liability, should ‘modified’ devices fail,

rest with the modifier. Modifying existing

devices or using them for purposes not

intended by their manufacturer (which

also counts as modification of a device)

may have serious safety implications.

▼

TABLE 1

Section Heading/content

Title of deviceName and profession of assessorDate completedFile nameUnique identifierName of patient/recipient body

A General description of disability / problem

B Summary of proposed solution

CSources of hazard[contains 37 questions based on Annex C of ISO 14791:2009 requiring yes/no responses]

D Action taken to address any hazards identifiedabove

E Other hazards with action taken

F What standards apply in the design of thisdevice?

G

Risk assessment summary:In your opinion are residual risks balanced by the therapeutic/ rehabilitativebenefits?Does the user have an opinion or understand the benefits vs. residual risk?

TABLE 1. Summary of the primary risk assessment form.

FIGURE 1. Schematic representation of the riskmanagement process (adapted from ISO 14971:2009).

Most prescriptions of RE equipment

can be met by commercially available

equipment, though devices from

different manufacturers are often

combined. However, in cases where

there is no commercially available

equipment to meet the needs of the

patient it might be possible to design and

provide bespoke equipment. This design

might involve the combination and/or

modification of existing devices or the

manufacture of a completely new device.

The modification or manufacturing may

be done internally by an RE service or

externally by a commercial contractor.

Modifying a CE-marked medical

device can be deemed to be subject to

the same regulations as manufacturing

a new device and may therefore be

subject to the requirements of the

Medical Devices Regulations (MDR). In

these circumstances it is necessary to:

n keep a full record of the design,

n carry out and document a risk

assessment,

n consider the ethical and legal

implications,

n implement suitable precautions to

minimise the risk, and

n review the risk assessment at

suitable periods.6

This tutorial does not attempt to

cover the use of third party spares,

which can also be deemed to be a

modification.

RISK ASSESSMENT IN A CLINICAL SETTINGThe application of the concepts

described above to a clinical setting will

depend on a number of factors including

the organisation and scope of the

services offered. The practical

interpretation described here is based

on the system used at the Southeast

Mobility and Rehabilitation Technology

(SMART) Centre, Edinburgh. It was first

introduced in 1998 and has been revised

as required to keep current with updated

standards and best practice.

The system requires the responsible

clinical scientist to determine the level of

risk during the design phase of a new

device (which includes the modification

of devices). Three levels of risk are used:

n significant risk,

n low risk, and

n no risk.

The level that applies is, in each case,

at the professional judgement of the

clinical scientist who is responsible for

the design. ‘No risk’ would apply in

cases whereby a CE-marked medical

device is being used as the

manufacturer intended.


TUTORIAL | SCOPE

TABLE 2. Risk factor matrix.

FIGURE 2. Drawing of ventilator housing (restraining straps not shown).

Experience has shown that the vast

majority of designs in this area can be

treated as ‘low risk’. In low risk cases a

primary risk assessment is conducted.

This covers devices that are regularly

prescribed by the service. If a particular

model of assistive technology is

provided to different patients but has

the same intended use then a single

assessment can be conducted.

Table 1 summarises the content of

the primary risk assessment form that

is used. The responsible clinical

scientist completes the form and

details the problems, the proposed

solution and identifies any possible

sources of hazards using the prompts

based on Annex C of ISO 14791. They

must then address the identified

hazards, reduce them as much as

reasonably practicable and evaluate if

the overall residual risk is acceptable.

The completed form and associated

documents, such as engineering

drawings, are linked to the patient’s

records (which together constitute the

risk management report). Any issues

arising after production or once in use

are recorded and linked for future

reference and any subsequent use of

the device. The six steps illustrated in

figure 1 are thereby covered. The

detailed nature of this process ensures

that all relevant standards are being

met and a safe and effective device is

provided.

For devices with levels of ‘significant

risk’, a more extensive full risk

assessment is conducted that

incorporates a semi-quantitative

estimation of risk. This involves the

calculation of the risk factor (or

criticality) for each identified risk,

before and after each risk reduction

method is carried out using the

qualitative measures of ‘likelihood’ (or

probability) and ‘severity’ (table 2). This

encompasses the two components of

risk described at the start of the section

on risk management and medical

devices above. Other methods of risk

estimation are detailed in Annex D of

ISO 14971:2009.

CASE STUDIES BASED ON REALCLINICAL EXAMPLESThese case studies are based on real

clinical examples that were risk

assessed by clinical scientists working

at the SMART Centre, Edinburgh. The

SMART Centre provides a wide range of

RE services for the south-east of

Scotland, covering Lothian, Fife and the

Borders NHS Boards. These include

mobility and postural services

TABLE 2

Likelihood Risk factor = likelihood x severity

5 Certain 5 10 15 20 25

4 Very likely 4 8 12 16 20

3 Likely 3 6 9 12 15

2 Unlikely 2 4 6 8 10

1 Very unlikely 1 2 3 4 5

Severity

1 Insignificantinjury / illness(no treatment)

2 Minorinjury /illness

(first aid athome)

3 Significant

injury / illness(hospital /doctor)

4 Major injury /

disability

5 Death

(wheelchairs and special seating),

prosthetics, bioengineering services

(electronic assistive technology and

special needs design equipment), a

Disabled Living Centre and Gait

Analysis Service.

Case 1: mounting a ventilator on a

powered wheelchair

This case study considers the

mechanical mounting of a ventilator

on a powered wheelchair. For some

patients who have a tracheotomy and a

powered wheelchair, mounting a

ventilator to the back of a wheelchair

will provide them with a considerable

amount of freedom. The development

of small-sized, self-contained

ventilators has reduced the level of

restrictions on these patients. This

independence can be optimised when

the patient has a powered wheelchair.

In the past, larger ventilators that

could only be used for short periods of

time on battery power could be

supplied by the powered wheelchair’s

batteries, but, as in this case, this is

now rarely necessary due to

improvements in ventilator and

battery technology. Wheelchairs and

ventilators are, of course, medical

devices and will be risk managed by

their respective manufacturers.

However, rarely will the

manufacturers have considered the

interaction of these two devices, let

alone provide a mounting kit.

The housing used to hold the

ventilator in place must be robust and

provide protection to the ventilator in

case of a collision with another object

(figure 2). The ventilator must be ▼

Thedetailednature ofthisprocessensuresthat allrelevantstandardsare beingmet

“

”

SCOPE | TUTORIAL


removed from the wheelchair

when the patient transfers out of

the wheelchair – this will also have

associated risks. The design of the

mounting device must ensure that

the air inlet pipe is not blocked

even if the ventilator is positioned

back-to-front. A primary risk

assessment was conducted,

identifying a number of sources of

hazard. The four main sources are

listed in table 3, along with

descriptions of the actions taken

to reduce the identified hazards.

This design has been used

successfully for a variety of

patients.

Case 2: hair dryer holder for

unilateral upper limb amputees

An example of a device specially

designed due to there being no

commercially available product is

a hair dryer holder for unilateral

upper limb amputees. These

patients are unable to hold a hair

dryer and also style their hair. The

design of the device must be able

to hold the hair dryer securely and

allow for it to be tilted, thus

enabling the patient to style their

hair as needed. A primary risk

assessment was conducted. In

addition to the hazards associated

with a hair dryer’s normal use,

such as it being a heat source, four

other main possible sources of

hazard were identified. These are

listed in table 4, along with

descriptions of the actions taken

to reduce the identified hazards.

This device was designed for a

single patient and has since been

issued to other patients

presenting with the same needs.

Case 3: upper limb prosthesis

attachment for bench press

exercise

Many patients wish to participate

in recreational activities despite

their impairment. An example of a

bespoke device to enable someone

with an upper limb amputation to

lift weights is described here. Due

to the inherent risks associated

with weightlifting, the potential for

harm was deemed to be

significant and therefore a full risk

assessment was undertaken. The

design comprises a stainless steel

yoke, central shaft and two

gussets to increase welded

connection and buckling strength

(figure 3).

TABLE 3

Source of hazard Specific hazards and action taken to address

Interacts with otherequipment

Mounted on powered wheelchair. The danger is that it becomes loose.This is addressed through the design of mounting – the carrier fits ontolateral trunk support receiver runners. The air taken in by the ventilator isdrawn in from underneath. The hole in the carrier shell allows for thisintake. The carrier has clear space underneath.

Requires adjustment by theuser / client

May involve more than onecarer / operator

The user’s carers are required to fit the ventilator into the carrier correctlyand secure it using adjustable straps which hook onto D rings designed forone of the ventilator’s carry strap to be attached to. Carers will be shownhow to fit and secure. If the ventilator was put in back-to-front there isanother hole that has been cut out to allow for the connection of mainsand auxiliary power cables that will allow for air intake.

Is mobile or portable

Due to the ventilator being on the back of the wheelchair there is a chancethat, if the wheelchair is reversed into an object, the ventilator could becrushed. The carrier has a PVC shell around it to protect it and this isadditionally supported by steel tubing underneath.

TABLE 3. Hazards associated with a ventilator mounted on a powered wheelchair.

TABLE 4. Hazards associated with a hair dryer holder for unilateral upper limb amputees.

TABLE 5. Hazards and risk factors associated with upper limb prosthesis attachmentfor bench press exercise. L = likelihood, S = severity, R = risk factor (L x S).

TABLE 4

Source of hazard Specific hazards and action taken to address

Interacts with otherequipment

The device supports the hair dryer by means of a cradle. The hair dryer islowered into place. Does not obstruct airflow, does not interfere withleads.

Requires adjustment by theuser / client

The user is trained in one-hand adjustment of tilt and height. By design thecradle cannot fall down the support poles. The device is semi-portable assupport poles can be disassembled from the chassis by unscrewing across-knob – instruction is given on issue.

Freely standing The device freely stands and is wheeled to allow repositioning. Is forindoor use only – instruction to the user will be given.Is mobile or portable

TABLE 5

Hazard Source of hazardBefore After

L S R L S R

Injury to skin and softtissue of residual limb

Patient’s method ofsocket suspension

3 2 6 2 2 4

Loading of soft tissuesvia socket duringweightlifting manoeuvres

3 2 6 2 2 4

Serious injury resultingfrom the failure to controla weight during a lift

Mechanical failure of thedevice

3 4 12 1 4 4

▼

SCOPE | JUNE 07 | XX

0 1 3 2

1 2 0 3

2 3 1 0

3 0 2 1

2

3

0

1

2

3

2 3 1 0

3 0 2 1

0 1 4 2 3

1 2 0 4 3

0 2 1 3 4

4 0 2 3 1

4 2 1 0 3

0 1 4 2 3

1 2 0 4 3

0 2 1 3 4

4 0 2 3 1

4 2 1 0 3

1 Fortis et alter Homerus JCurare, ut critici este levitercurare videtur este videtur,quo promissa alter inter vilisperfectos, October 1824.

2 Fortis et alter Homerus JCurare, ut videtur, quopromissa alter inter vilisperfectos, October 1824.

3 Fortis et alter Homerus JCurare, ut critici este levitercurare videtur este videtur,quo promissa alter inter vilisperfectos, October 1824.

4 Fortis et alter Homerus JCurare, ut perfectos, October1824.




8 Fortis et alter Homerus JCurare, ut critici este levitercurare videtur esteperfectos, October 1824.

9 Fortis et alter Homerus JCurare, ut perfectos, October1824.

Receniurgia finisest curaesapines etpromisafortis esteperfectoscentumqui deciditest vetusnovis etscrireestes

“

”

The risk assessment included a

detailed examination of the

compressive, bucking and off-axis

loads that would be applied to the

device when in use. The main

potential hazards and sources are

summarised in table 5. The highest

risk factor was 12 due to the

likelihood of a significant injury in

the case of the mechanical failure

of the device. Risk reduction was

clearly necessary. It was

determined that in terms of the

design, the risk could not be

reduced without compromising its

purpose. Therefore, in order to

minimise the residual risk, detailed

written instructions and guidance

were issued to the patient covering

the requirements to:

n check the skin and soft tissues

of their residual limb,

n visually check the condition of

the socket and the device prior

to each use,

n check that the socket

continues to fit the residual

limb properly,

n not exceed the press load limit

of 60 kg, and

n use with the U-shaped bar

holder oriented vertically

upwards.

After the application of these

risk control activities, the highest

risk factors were reduced to 4. This

FIGURE 3. Upper limb prosthesisattachment.

was considered to be an

acceptable level of risk in this

case.

SUMMARYThis tutorial has illustrated the

application of risk management

in the rehabilitation engineering

field. This is an area where

medical devices are frequently

modified, issued to patients and

subsequently used

unsupervised in the community.

It is often not appreciated by

non-healthcare scientists that

the off-label use or the

combination of devices from

different manufacturers is

tantamount to the manufacture

of a new device and is therefore

subject to the requirements of

the MDR.

A number of case studies

based on the system used by the

SMART Centre in Edinburgh

were presented and described in

detail. Nevertheless, it should be

appreciated that no one

approach is applicable to each

and every situation. Existing

models and techniques used in

rehabilitation engineering need

to be adopted and adapted to

suit the prevailing

circumstances and intended

application. n


REFERENCES

1 IPEM. Policy Statement: Rehabilitation EngineeringServices. York: IPEM, 1999.

2 Scottish Government. NHS Scotland Wheelchair andSeating Services – Clinical Standards. Edinburgh, 2011.

3 NHS Quality Improvement Scotland. ClinicalGovernance and Risk Management – NationalStandards. Glasgow, 2005.

4 ISO. BS EN ISO 14971:2009 Medical Devices –Application of Risk Management to Medical Devices.London: BSI, 2009.

5 ISO. BS EN ISO 13485:2003 Medical Devices – QualityManagement Systems – Requirements for RegulatoryPurposes. London: BSI, 2003.

6 MHRA. Medical Device Alert Action Update,MDA/2010/001. London: MHRA, 2010.

FURTHER READING

Blache L, Robbins P, Brown S, Jones P, Liu T, LeFever J.Risk Management and its Application to Medical DeviceManagement. York: IPEM, 2008.

IPEM. Report 74: Application of Medical Device DirectiveGuidance Notes. York: IPEM, 1997.

MHRA. Managing Medical Devices Guidance forHealthcare and Social Services Organisations, MHRADB2006(05). London: MHRA, 2006.

Medicines and Healthcare products Regulatory Agency(MHRA), http://www.mhra.gov.uk/index.htm

Southeast Mobility and Rehabilitation Technology (SMART)Centre, NHS Lothian, http://www.smart.scot.nhs.uk

Medical Devices Regulations 2002. Statutory Instrument2002, No. 618,http://www.opsi.gov.uk/SI/si2002/20020618.htm

ACKNOWLEDGEMENT The authors would like to thank theircolleagues, in particular Rob Farley,Susan Hillman and James Hollington,who have contributed to the developmentof the system described and who haveprovided background material on thecase studies.

Theoff-labeluse or thecombinationof devicesfromdifferentmanufacturers istantamountto themanufacture of a newdevice

“

”

eing a Canadianradiotherapyphysicist trained andworking in the UK,there is so muchabout NorthAmerican radiation

physics that I wanted to see andexperience for myself. My aims forthis trip were to expand myknowledge of clinical physics andpractices, and use the opportunity todiscuss my work focussing onpaediatric radiotherapy. I was keen tobring back useful information thatcan improve our centre’s practicesand had chosen three centres thatspecialise in complication modelling,stereotactic body radiotherapy(SBRT), proton therapy and imaging.

MEMORIAL SLOAN KETTERING(MSK), NEW YORKWith slight apprehension at leavingmy 2-year-old son with my husband,who has never looked after him onhis own for longer than 3 days, Iboarded the plane in the hope ofrelaxing for the trip and getting to myhotel early enough to be prepared formy visit to MSK. Unbeknown to me,a 2-hour flight delay, non-workingreading lights and a diversion to

Boston due to the thunderstorms atJFK airport awaited!

My visit to MSK, located in theUpper East Side of Manhattan,started with a guided tour by DrGrace Tang, a graduate of UCL whois currently doing her clinical physicsresidency. The main radiation physicsdepartment is located mainly on the11th floor of the 23-storey buildingbut some of the offices are locatedelsewhere near the machine andplanning areas. The physics team ismade up of physicists, dosimetrists,residents, post-doctoral fellows,associate physicists, engineers andcomputer scientists. The departmentuses an in-house planning system,which is in constant development.Though not as visually sophisticatedas some of the commercial systems, itseemed flexible as access to theprograms behind the algorithms,planning methods and analyses waspossible.

A large number of patients withspine, lung, liver cancers and bonymetastases are treated with SBRT. DrMichael Lovelock is involved in aninnovative liver tumour SBRT studywhere the respiratory motion ishalted through general anaesthesiausing apneic oxygenation during

treatment. The liver tumour is treatedwith 24Gy in a single fraction after it is‘parked’ in position such that there isvirtually no movement. This is donewith the aid of fiducial markers andcone-beam CT (CBCT) imaging (figure1). Though the cost of treatment maybe high with the requirement of ageneral anaesthetic team, the fact thatit is only for a single fraction and thepatient can go back to work the nextday are exciting aspects of thetreatment.

Dr Susanne Wolden, a paediatricconsultant, discussed the issues oftreating paediatric patients and theproblems they pose to radiotherapydepartments. As many of thesepatients survive well into theiradulthood, changes to their growth,hearing and sight can play adetrimental effect on theirdevelopment. At MSK, they havealmost eliminated hearing loss inpatients by using intensity-modulatedradiotherapy to treat posterior fossatumours. She was especially interestedin the effect of radiotherapy on bonegrowth because for many paediatriccancers, high doses are needed toachieve tumour control. Depending onthe tumour locations, bony anatomymay be partially irradiated, which canlead to deformities.

The chair of Medical Physics, DrJoseph Deasy, who recently relocatedfrom Washington University, isleading the research group to focus onpredictive modelling of tumour andnormal tissue response based onmulti-institutional datasets. There’salso interesting work being doneusing bio-markers to predict normaltissue complications such as radiationpneumonitis. I was able to continuethe conversation on modelling and theimportance of data collection with DrsAndrew Jackson and Ellen Yorke, whowere heavily involved in theproduction of QUANTEC (Int J RadiatOncol 2010; 76(3 Suppl)). Our mainfocus of discussion was on howdifficult it is to extrapolate theQUANTEC data for paediatricpatients as different parameters and

B

IPEM/AAPM USA/CANADATRAVEL AWARD, APRIL 2011YOUNG LEE Principal Radiotherapy Physicist, Royal Marsden NHS Foundation Trust

FIGURE 1.A single axialCBCT slice of aliver tumourpatient treatedwith a singlefraction. Thelack of organmotion allowsincrease inimage quality(courtesy of DrMichaelLovelock).

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SCOPE | TRAVEL AWARD



variables are introduced and work isneeded to strengthen this area ofstudy.

For three days, I was ‘wined anddined’ (well, no wine but hey! Seefigure 2) for lunch by the various post-docs and residents in the department.We chatted about their individualresearch interests as well as the stateof US radiation physics, managementof home/work life and medicalphysics accreditation. It wasfascinating to hear how different it isto get ‘accredited’ in medical physicsin the US, a more exam-orientedprocess compared to the UK.

UNIVERSITY OF FLORIDAPROTON THERAPY INSTITUTE,JACKSONVILLEAfter being in New York City wherethe maximum temperature never wentabove 12°C, sunny 30°C Jacksonvillewas a bit of a shock! The hottemperature was soon forgotten as Ihopped from one air-conditionedbuilding to another.

There is a huge amount of interestin proton therapy, especially by thepaediatric community as the steepdose gradient created by the treatmentshould result in a large reduction inorgans-at-risk and normal tissue dose.Special paediatric cases from the UKget referred for proton therapy andthe Proton Therapy Institute hashosted some of these patients. Thecentre, which opened in 2006 (figure3), is well-equipped to deal withpatients from far away with roomywaiting and children’s play areas, andall the staff including clinicaloncologists, information technologystaff as well as secretarial andfundraisers share a floor.

The physics team led by DrZuofeng Li is made up of ninephysicists and around 20 associatephysicists, dosimetrists and engineers.The iba proton therapy machine withthree gantries has a 24-hourengineering service (figure 4). One ofthe gantries is dedicated to treatingprostate cancer patients and another isdedicated to paediatrics, wheregeneral anaesthetic staff are availablefor the whole day. The centre also hastwo Varian linacs and PET/CTscanner, CT simulator and a 0.23T MRscanner. Most proton treatments inFlorida use the double-scatteringtechnique and the shapes of beams areformed using individual brassapertures and the dose is conformedat the distal target end using a Lucite

SCOPE | TRAVEL AWARD

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TRAVEL AWARD | SCOPE


compensator. The end of thecompensator is positioned as close tothe patient as possible and the setup ischecked using images acquired usinga pair of kV x-ray sources anddetectors. It was good to observe theoperation of the machine andplanning of the treatments so that Ican evaluate the pros and cons of thesystem compared to linacs.

The current rationale behindpaediatric proton treatment, asdiscussed with Dr Danni Indeligato, apaediatric consultant, is to achieve thesame survival rate as achieved withthe equivalent photon treatments andto study the long-term benefits tohaving proton therapy. Thereforeequivalent dose prescriptions are usedfor protons as in the photonradiotherapy. The main selectioncriterion for paediatric proton therapycases here is that the patients areexpected to have a good long-termsurvival (>40 per cent). There is a lotof effort to conduct long-term follow-up for these patients, but as manypatients are not from the area, chasingand co-ordinating data collection arecomplicated.

One of my projects is to improvethe current craniospinal axisradiotherapy. The proton therapy forthis site is very different to photontherapy. Though the doseprescriptions are similar, the spinetarget for proton therapy is anterior tothat of the vertebrae, whereas inphotons it is usually anterior to thespinal canal. This is in order to avoiddefective bone growth that can resultif the steep dose gradient in protontherapy lies in the middle of thevertebrae. The dose to the anteriorpart of the patient is much lower thanwhat is seen in photon treatments.

PRINCESS MARGARETHOSPITAL (PMH), TORONTOFlying back up north meant that onceagain I had to brace myself for thecold. I flew from Jacksonville toBuffalo (a US city about 2 hours’ drivefrom Toronto) and spent a lovelyweekend with my parents who live inNiagara Falls, Canada. Then I headedup to Toronto on Sunday for my visitto the well-renowned PMH.

My visit started with the head andneck rounds at 8am on Monday. Therounds are a forum for differentclinical oncologists to discuss theirdifficult or unusual cases with theteam (organised into cancer sitegroups), which consist of oncologists,

radiotherapists and physicists. PMHradiotherapy department is one ofthe largest departments in the worldand treats more than 9,000 patientsper year. It has 16 Varian and Elektalinacs and over 60 Pinnacle treatmentplanning system terminals as well asits own multiple CT, MR and PET-CTscanners. In such a large department,the weekly rounds serve multiplepurposes of keeping team membersinformed, promoting discussions onissues that arise and keeping theteam together.

The division of cancer sites intoteams seems to promotespecialisation. During the week, Iwas fortunate enough to spend timewith all four of the physics teamleaders, Drs Stephen Breen, TomPurdie, Tim Craig and DanielLétourneau, and I also had a chanceto speak to some of the oncologists.The oncologists and physicistsoccupy offices that are located in thesame area, which appear to promotespontaneous discussions that mayhelp in development and researchespecially in setup imaging. Some ofthe other imaging studies that arecurrently underway are: using PET-CT during and post lung treatmentsto observe tumour progression forthe purposes of adaptive planningand imaging tumour perfusion usinga 320-slice volumetric CT to see thechanges during and post treatment.

Many of the planning andchecking procedures are heavilyscripted (programmed to runautomatically), which can helpdecrease human error that may occurthroughout the process. Thedepartment is ‘paperless’ with theuse of MOSAIQ (record and verifysystem, RMP Publishing). Thisallows easy access to all the recordsthroughout the department and it ispossible for oncologists to approveplans and physicists to check parts ofthe plan off-site. Thereare shared scriptsthroughout theteams butthey aremanagedseparatelyby theteamleaders.One of themostfascinatingautomationprocesses I

observed was the ‘fully-scripted’breast plan, which results in minimalinteraction between the planner andthe planning system (Purdie TG etal., Int J Radiat Oncol 2011; 13 Jan[Epub]).

Most of the physicists areinvolved in managing machines andchecking plans, but the qualitycontrol and pre-treatmentverification measurements are doneby associate physicists. This frees upthe physicists’ time to concentrate ondevelopment and research as well aspresenting their work at nationaland international conferences. Manyof the physicists are also involved inco-ordinating meetings and courseson IMRT, image-guidedradiotherapy and quality control.

Considering the size of thisdepartment (located in a multi-storey building just like MSK), it hadthe feeling of a small departmentand there was good communicationbetween the teams. Patients’treatments were run smoothly andthe control areas were clutter-freedue to the ‘paperless’ system.Frequent quality meetings attendedby all members of oncology staff todiscuss and analyse errors and nearmisses also seem to keep everyonewell-informed and promotedreporting of problems.

I felt a little sad when my tripcame to an end as I had been madeso welcome at the three centres, butat the same time I felt glad to bereunited with my family. This triphas given me the opportunity toexperience and get a feel for thedifferent approaches to both clinicalpractices and research in the US andCanada. I had a wonderful time andfeel a sense of renewed excitementfor the work I do. I have come backwith some interesting project ideasas well as how I want to continuemy current work. I recommendanyone who has the time andinterest to apply for this award as itis a fantastic opportunity to learnand grow.

FIGURE 2.Lunch with DrJoseph Deasy’sgroup in an Italianrestaurant in NewYork.

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FIGURE 3.Enjoying a nicecup of coffee withDr StellaFlampouri in frontof the entrance tothe University ofFlorida ProtonTherapy Institute.

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FIGURE 4.Gettingacquainted with aproton therapygantry.

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ACKNOWLEDGEMENTSFirstly, I would like to thank the IPEM andAAPM for the giving me this opportunity tovisit some of the most excitingradiotherapy departments in NorthAmerica. I would also like to thank my hostcentres, with special thanks to Drs HowardAmols, Stella Flampouri and StephenBreen who organised my visits. Finally, Iwould like to thank the Royal Marsden NHSFoundation Trust, especially myDepartment of Radiotherapy Physics, forallowing me the time to visit these centres.

SCOPE | MEETING REPORTS


SOUTH WEST ANNUAL MEDICAL PHYSICS ANDCLINICAL ENGINEERING SCIENTIFIC MEETING

PENINSULA RADIOLOGY ACADEMY, PLYMOUTH 13th–14th May 2011

GREGORY STEPHENS Plymouth Hospitals NHS Trust

OUR SOUTH WEST REGIONAL SCIENTIFIC MEETING isheld annually; the host is chosen on a rotational basis fromacross the region. This year’s meeting was held atPlymouth Hospitals NHS Trust on the 13th and 14th May2011 in the Radiology Academy. This 2-day event providedan opportunity for regional medical physics and clinicalengineering departments, manufacturers and suppliers andother delegates to meet, present novel work and discussissues relevant or unique to the region, and consisted of ablend of entertainment, management service meetings anda scientific meeting (figure 1).

The purpose of the meeting is ‘to celebrate success andshare ideas and best practice in pursuit of excellent medicalphysics and clinical engineering services for the purpose ofimproving the understanding, detection and treatment ofdisease and the management of patients’.

The meeting kicked off with a Head of Departments’meeting. Thereafter, two different visits were on offer: a tripto Plymouth dockyard or to the Sharpham winery. The visitto the winery was thoroughly enjoyed by all, and led to aconsiderable quantity of wine and cheese being consumed.The trip to Plymouth dockyard showed a fascinating sideto Plymouth, not usually seen by members of the public(the historical dockyard is still a naval base and, therefore,usually inaccessible to the public). The day was rounded off

by a dinner hosted in the Royal Citadel; home to the 29Commando Regiment Royal Artillery (figure 2).

Following registration coffee was served, surrounded byposters displaying work by regional physicists andengineers. A good range of industrial sponsors andexhibitors displayed their products and services wheredelegates were having tea, coffee and lunch (figure 3). Thisfacilitated a convivial atmosphere unlike the normalinteractions between company and customer, and allowedthe companies to discuss issues that affect departmentsacross the region.

The meeting was opened by the Trust’s Chairman,Commodore Steven Jermy RN, who emphasised the needfor innovative solutions to problems facing the NHS at thistime. He spelled out the serious constraints that the NHS isfinding itself under and provided a cautious but upbeatassessment of the future. The theme of innovation wascontinued throughout the meeting by three invitedspeakers from diverse areas of expertise: academia, RayJones (Plymouth University); government, Nick BucklandOBE (Technology Strategy Board, Swindon) (figure 4), andindustry, Darrel Mann (Systematic Innovation Ltd,Clevedon). Collectively the invited speakers challengeddelegates to consider their role within the innovationlandscape, and described how developing partnership

FIGURE 1.Attendees atconference.

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FIGURE 2. Conferencedinner.

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FIGURE 3. [LEFT]A manufacturer’sstand.

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FIGURE 4. [RIGHT]Nick Bucklandtalking.

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working across public, private, academic and third sectorsis able to foster product and service innovation.

Talks were on offer from the entire region with a goodmixture from both the engineering and physics fraternities.Amanda Brason (Cheltenham General Hospital) presentedher work of the fusion of nuclear medicine images and CTto locate anatomical areas of radiopharmaceutical uptake.In particular she presented some of the issues they facedand the solutions they found. Emma Podnieks (BristolGeneral Hospital) presented a detailed analysis ondosimetry from cone beam CT. In particular the issuewhere there is only a partial rotation was discussed; theclinical significance of this, and a method to accuratelyprovide effective dose calculations under this regime, werepresented. Matt Cann (Royal Devon and Exeter NHSFoundation Trust, Exeter) continued the theme ofdosimetry in cone beam CT with a talk on commissioningwork he undertook as part of his physics training on theVarian on-board imager.

Laurie Barron (Plymouth Hospitals NHS Trust),demonstrated his electro-mechanical design of a dynamicheart phantom. This uses an ECG signal to accuratelyinflate a liquid-filled, heart-shaped latex balloon (figure 5).This innovative device accurately mimics the expansionand contraction of the human heart. This allows contrast-filled tubes attached to the latex heart to be used as adynamic image quality tool, which can directly comparedifferent reconstruction algorithms in CT and othermodalities where dynamic imaging is used. Ratherentertainingly, the audience was then given ademonstration of the heart at work.

Michelle Scott-Cleasby (Royal Devon and Exeter NHSFoundation Trust, Exeter) spent some time providing aninnovative solution to a problem a number of hospitalshave; namely how to comply with legislation on non-

coherent light sources without the use of a spectrometer.Her solution was risk based and provided an excellentmethod to quickly assess numerous sources.

Pam Bowen (Torbay Hospital, Torquay) was the secondradiotherapy speaker who discussed their experiencesstarting a new head and neck IMRT service, while RobertRoss (Royal Cornwall Trust, Truro) provided an interestingvisual discussion on water damage in gamma cameracrystals, and defects not usually seen by physicists andengineers. Ruth Ruddlesden (Royal United Hospital Bath)discussed issues around paediatric imaging and herattempts to optimise dose. Of particular interest was theissue over varying dose for similar procedures, and theneed to obtain clinical assistance in the optimisationprocess. Savvas Rizkalla (Plymouth Hospitals NHS Trust)talked about his experiences treating wet AMD withepimacular brachytherapy, a service he has recently beengiven the responsibility of starting, while Steve Perring(Poole Hospital NHS Trust) spoke about his work onoesophageal reflux. Of particular interest was that thestudy showed that proximal reflux is a good indication ofeffectiveness of anti-reflux surgery in suppressing chroniccough and that their work improved the assessment ofdistal and proximal pH by the use of two channelpH/impedance monitoring; thus providing goodinformation to improve patient care in their service.

As is usual, the regional IPEM business meeting wasthen held, after which the Director of Healthcare Scienceand Technology, Plymouth, Andy Nevill, formally handedthe ‘baton’ to the head of the next organising department,Diane Crawford, Director of Medical Physics, Bristol.Finally, after appreciation for the presenters and sponsorswas expressed, the meeting was closed and delegates wereable to take part in departmental tours to round off thisyear’s event. n

FIGURE 5.Laurie Barrontalking.

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Department of Medical PhysicsCombined Radiology/Nuclear Medicine PhysicistClinical Scientist – Radiology Physicist – Nuclear Medicine PhysicistBand 7£30,460 - £40,157 per annum, Ref: 344-6883CSK37.5 hours per weekApplications are invited for an innovative combined post set up between the Radiology Physics and Nuclear Medicine support sections of the Department of Medical Physics at EKHUFT, based in Canterbury (Kent). In Radiology, duties will include work with equipment and applications in General Radiography, Advanced Radiology (e.g. Interventional, Cardiology), CT, Mammography and Dental, and may extend into other areas such as Ultrasound and Medical Lasers. In Nuclear Medicine, work will cover support of a wide range of diagnostic and therapeutic procedures.

Work common to both specialities such as Quality Assurance, Radiation Safety and staff training will also be undertaken. This post is an excellent opportunity for a physicist to expand and refi ne his/her skills and knowledge in a supportive professional environment.

Senior Nuclear Medicine Physicist Clinical scientist – Nuclear Medicine PhysicistBand 8a£38,851 - £46,621 per annum Ref: 344-6882CSK37.5 hours per weekApplications are invited for the position of Senior Medical Physicist in Nuclear Medicine, based in Canterbury (Kent). Key duties will include leading our scientifi c support to therapeutic and diagnostic services in this important specialisation, supporting our Nuclear Medicine consultants with clinical work, acting as a Medical Physics Expert, and helping to ensure the safe and proper use of radioactive materials in relation to regulatory requirements. Encouragement and support will also be given to undertake research and development activities in Nuclear Medicine and Medical Physics. Applicants who are accredited to act as a Radiation Protection Adviser (RPA) will be welcomed, though this is not essential. This post provides scope for a physicist with good specialist skills to help shape and develop a very important Trust service. Recruitment at a higher banding may be considered if appropriate.

Situated in Kent, EKHUFT is now one of the largest NHS Trusts in the UK, with three major sites at Canterbury, Ashford and Margate.

Canterbury is an excellent location to live, providing all the benefi ts and facilities expected from an historic Cathedral City, along with rapid access to both the Kent countryside and continental Europe.

Please do not hesitate to contact for further details about this post or to arrange an informal visit. Enquiries in the fi rst instance should be made to Mark Hanson, Director of Medical Physics, using Tel: (01227 864148) or e-mail to [email protected]

Applications for the post must be made on-line at www.ekht.nhs.uk

Closing date: 18th September 2011.

East Kent Hospitals University NHS Foundation Trust is exempt from the Rehabilitation of Offenders Act 1974. All positions within the Trust working regularly or unsupervised with children or vulnerable adults will require an enhanced CRB disclosure. All other posts will require standard checks. The Trust is committed to safeguarding children and vulnerable adults.

We positively promote fl exible working practices. To ensure that our workforce refl ects the population we serve, we welcome applications from all sections of the community.

www.ekhuft.nhs.uk



ANNUAL SCIENTIFIC MEETING OF THEIPEM SOUTH EAST GROUPMATTHEW BOLT

1

, THOMAS HAGUE2

, PEDRUM KAMALI1

AND EMMA WHITEHEAD1

1

Royal Surrey County Hospital NHS Foundation Trust 2

St George’s Healthcare NHS Trust

THE ANNUAL SCIENTIFIC MEETING of the IPEMSouth East Group was hosted by the Medical PhysicsDepartment at the Royal Surrey County Hospital on9th June 2011. This was excellently organised bycurrent IPEM Part II trainees with the day runningextremely smoothly from start to finish. Several of thecompanies who ensured the event could be held free ofcharge were present in the exhibition area, showcasingtheir latest developments and ensuring no-one wenthome without a few freebies.

CAN WE AFFORD NOT TO HAVE PROTONTHERAPY IN THE UK?A warm welcome was given to all by Head of MedicalPhysics Andrew Nisbet (Royal Surrey CountyHospital, Guildford). The day’s programme was full,and got off to a good start with an upbeat and highlyentertaining talk given by Russell Thomas (NationalPhysical Laboratory, Teddington) on the future benefitsproton therapy may have, especially in paediatrictreatments. The topic of proton dosimetry was

discussed, including a description of the dosimetrychain of intercomparison that was establishedfollowing the inauguration of the first proton therapycentre in the UK. A thought-provoking conclusion wasdelivered where the financial implications of protontherapy were discussed, closing with the line: ‘Can weafford not to have proton therapy in the UK?’.

ISSUES SURROUNDING PREVENTION ANDPROTECTIONFollowing the lunch break, Tom Jordan (Royal SurreyCounty Hospital, Guildford) gave a sobering talk onthe lessons learned from radiotherapy accidents,noting that reliance on software safety devices simplyis not adequate. It was clear that many lessons hadbeen learned through mistakes of the past, and it wasonly through vigilance of staff that some of these hadcome to light. Thankfully, solutions were found andradiotherapy is continuously becoming safer and moreeffective for the patient.

An intriguing presentation was delivered by NedaShiravand (Queen Alexandra Hospital, Portsmouth),who discussed her recent project work investigatingthe effectiveness of eye shields for radiotherapy. It wascommented that these shields are often used whentreating superficial skin lesions close to theradiosensitive eyes and the project focussed onassessing the shield’s effectiveness against themanufacturer’s specification. A photograph takenduring the phantom study is presented in figure 1.

RESEARCH INTO BREAST CANCER IMAGINGWITH X-RAYSKen Young (Royal Surrey County Hospital, Guildford)is Consultant Physicist and Head of the National Co-ordinating Centre for the Physics of Mammography(NCCPM), and has played a leading role indeveloping the technical standards for mammographyin the UK and the rest of Europe. Professor Youngpresented ‘Research into breast cancer imaging with x-rays at NCCPM’. The background to this research isthe introduction of digital imaging technology in theNHS breast screening programme where 39 per cent ofx-ray systems are now digital.

Digital breast tomosynthesis (DBT) is one of thelatest developments and the TOMMY research trial atsix clinical sites is comparing DBT to 2D imaging.Professor Young discussed the potential of DBT toimprove lesion detection and reduce recall rates. Thesepotential benefits arise from the system’s ability toreduce uncertainty due to overlapping tissuesmimicking or obscuring a lesion by using a limited

ROYAL SURREY COUNTY HOSPITAL NHS FOUNDATION TRUST 9th June 2011

FIGURE 1.Ananthropomorphicphantom proveda useful toolwhen assessingeye shieldtransmission.

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FIGURE 2. Schematic ofdigital breasttomosynthesis(DBT).

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FIGURE 3. Simulatedclusters areinserted onto aclinical image.

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number of projections of the breast (11–25) to constructtransverse slices at 1 mm spacing (figure 2).

Recent work including an observer study measuringthe impact of detector performance and imageprocessing on cancer detection was also presented.Simulated calcification clusters were added into clinicalDR and CR images while adding the appropriate levelof blurring and image noise expected for these imagingsystems (figure 3). Eighty-one normal cases and 81abnormal cases (using 113 subtle added clusters) wereexamined by seven clinicians at six image qualitylevels. The results showed that calcification detectionwas sensitive to the quality of the images. It is expectedthat this data will be used to review the minimum andachievable performance standards in the UK and EUprotocols.

NUCLEAR MEDICINEThe last session of the day was focussed towardsnuclear medicine. Leah Hunt (Medway MaritimeHospital, Gillingham) informed us about theimplementation of SPECT V/Q in her department,which is currently a common theme in nuclearmedicine departments across the region. BrianMcParland (GE Healthcare Medical Diagnostics,Amersham) gave us an insight into the difficultiesarising when determining the activity foradministration in paediatric PET studies due to therange of methods that can be used.

An automated method of radiochromatography waspresented to us by Matthew Bolt (Royal Surrey CountyHospital, Guildford), describing the process he went

through to commission and implement theradiochromatogram scanner in the radiopharmacy atthe Royal Surrey County Hospital. The scanner will beused with thin layer chromatography (TLC) strips todetermine the radiochemical purity ofradiopharmaceuticals as an alternative to the ‘cut andcount’ method. The TLC strips are passed under aNaI(Tl) detector to obtain the activity profile across thestrip. We heard about the commissioning processwhere NEMA documents were used as a guide due tothe absence of current published material. The detectorlinearity (as shown in figure 4), sensitivity and spatialresolution were assessed to determine the capabilitiesof the detector. The scanner was deemed to be avaluable alternative for TLC and a QA programme wasestablished with simple and reproducible QC testsdesigned, enabling the resolution and sensitivity to bemonitored on a weekly basis.

IN SUMMARYAfter the final talk, a prize was awarded to MichaelHughes (Oxford Radcliffe Hospitals) for the ‘Besttrainee presentation’. This was a tough decision thisyear due to the high standard of presentationsdelivered by each speaker. The winning talk wasenergetic and very interesting, discussing theimportance of dose rate for IMRT planning.

Everyone left the meeting feeling better informedabout the continuous progression that is being madethroughout the region, with the prospect of holding themeeting on the beach in Brighton next year being metwith warm approval. n

FIGURE 4.The first resultsfrom linearityand sensitivitytests duringcommissioningof theradiochromato-gram scanner.

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MEETING REPORTS | SCOPE


OUTCOME MEASURES IN ASSISTIVETECHNOLOGY: IPEM MEETING

CARDIFF UNIVERSITY 21st June 2011

KIT TZU TANG Leeds Teaching Hospital NHS Trust

THE MAIN PURPOSE OF THE MEETING was to discusscurrent practices and research that have been usingoutcome measures (OMs) and their related issues for usewithin the field of assistive technology (AT).

AT includes a wide range of assistive, adaptive andrehabilitative devices for people with disabilities. This alsoconsists of the process used in selecting, locating and usingthese devices. Within clinical/rehabilitation engineering,AT includes seating and postural management; electronicassistive technology; functional electrical stimulation (FES);orthotics and prosthetics; mobility aids such aswheelchairs; gait analysis, and other aids for daily living.

In the field of rehabilitation engineering, there is atendency to assume the benefits of AT usage are self-evident. However, with an increasing importance towardsevidence-based practice, there is a need for OMs that canprovide a reliable method of measuring the efficacy of anychosen clinical intervention. This would then enable a morerobust practice with significant evidence base. The maintypes of OMs are either objective measurements orqualitative/psycho-social measures (e.g. questionnaires),which could be used to inform choices of intervention,clinical governance, assess service quality and delivery.

The meeting began with an opening by Paul O’Connell(Rookwood Hospital, Cardiff), who also chaired the firstsession. Firstly, Max Feltham (Oxford Brookes University)gave an overview on an alternative method (DataGait) toobjectively measure spatial temporal gait parameterswithout the need for the more expensive and time-consuming 3D gait analysis system. He was followed byGareth Adkins (ABM University Health Board, Swansea)who presented on the framework for OMs in AT that theRehabilitation Engineering Unit in Swansea was using toprioritise its work and development of using OMs. Currentand future research on OMs at Swansea was also discussed.

After coffee, Gary Derwent (Royal Hospital for Neuro-disability, London) detailed his work on the developmentof web-based software to support goal-attainment scalingin AT. Goal-attainment scaling (GAS) has been developedas a form of qualitative outcome measurement tool, whichcould be integrated into clinical practice by goal setting.Gary described his ongoing research into developing aweb-based tool to support clinicians to write, manage andanalyse goals in AT by using pre-set elements to ‘build’goals for each individual. Megan Dale (Cardiff and ValeUniversity Health Board, Cardiff) then described anothertype of qualitative outcome measurement tool, the patientreported outcome measures, which has been used in theNHS since 2009. This method could potentially be used inthe field of AT given that it is validated for the populationof interest.

The last presentation in this session was given by Yat-Ting Kwan (Salisbury District Hospital), who talkedthrough the three alternative OM techniques that theNational Clinical FES Centre at Salisbury has recently

adopted. The visual analogue scale, the BORG rate ofperceived effort scale replacing the physiological costindex (PCI) test, and the goal attainment scale have beenadded to the treatment pathway to measure patientspecific goals.

Following lunch, there were a further threepresentations which looked at different OM in AT. HollyJenkins (Cardiff and Vale University Health Board,Cardiff) detailed a comparison study between PCI and thetotal heart beat index (THBI) for estimating gait efficiency,where THBI uses ECG data to determine the number ofheart beats per metre. Robert Lievesley (NuffieldOrthopaedic Centre, Oxford) followed this with a talk on apossible OM for computer access bit rate calculation,which is a measure of the amount of information a usercan successfully send to a computer in a certain period oftime using a brain computer interface. The lastpresentation was given by Mary McDonagh (CentralRemedial Clinic, Dublin), who shared her experience ofusing different OMs for their seating and mobility service.She outlined the advantages and disadvantages of eachmeasure used and barriers of using OMs in clinical seatingservices. One of the lessons learned from Mary’s work wasto start small and then build up; for example, focus on aspecific patient group or target a single intervention first.

The day ended with Paul O’Connell leading an opendiscussion. This was a good opportunity to exchange ideasand facilitate a discussion for the way forward, such assuggestions for IPEM to promote alliances between similarservices to reduce duplication of effort; creation of aREBSIG working party and/or sub-group in this area andto provide guidance in best practice for OMs in AT. Thegroup also thought that OMs could be an integral part of aquality management system; however, currently OMstended to be measures of service delivery in therehabilitation engineering sector and not the outcome of anintervention. There were also some concerns over the waysin which FES services are funded differently. Some centresare having their funding withdrawn even though NICEhas recommended the use of FES based on evidence. Thismay suggest that there is an increasing need for OMswithin FES services in order to provide up-to-dateevidence of the efficacy of the intervention when applyingfor funding.

Everyone acknowledged the fact that there is a realneed to carry out OMs in AT, but the difficulty is to knowwhere to start. It was thought that knowing your targetaudience and focus on a specific group first would beessential. Both objective and/or subjective measures couldbe used depending on its validity and the required aim.

Although no ground-breaking new solutions becameapparent, the meeting was useful and raised importantconsiderations. It provided a platform where ideas of OMsin AT were exchanged and facilitated a discussion on thescope for future developments within this area. n



RADIATION PROTECTION ADVISERS(RPA) UPDATE MEETING 2011

MANCHESTER CONFERENCE CENTRE 14th June 2011

CHRIS WOOD Northampton General Hospital

THE ANNUAL RADIATION PROTECTION ADVISERS(RPA) UPDATE organised by IPEM’s Radiation ProtectionSpecial Interest Group and held in Manchester drew anaudience of 140 delegates keen to hear what was currentin radiation protection.

The morning session saw talks from the regulatorybodies, kicking off with Rob Wellens (Health and SafetyExecutive, London) providing an update on changes tothe Basic Safety Standards (BSS) Directive. The first pointto note is that this has changed from a ‘recast’ to a‘revision’, and as such all articles in the BSS are now opento negotiation. IPEM, through representatives onstakeholder working groups, are working to ensure thatthe implications on the healthcare sector are considered.The Health and Safety Executive will be offering a chanceto contribute to discussions by creating an electronic‘community of interest’ on their website.

Bob Russ (Environment Agency, Bristol) then deftlytrod the minefield that is the review of the ExemptionOrders to give an update on progress. Given that this hasbeen described as ‘the biggest change in the regulation ofradioactive substances in 50 years’, this is certainly nomean feat and explains why the review has beenunderway since 2006. It is hoped that the regulations willcome into force by 1st October 2011, and a transitionalarrangement will be made to allow users to continue tooperate under the ‘old’ provisions until 1st April 2012.Should the radioactive material you use no longer becovered by an exemption order, an application for either anew permit or a variation to your existing permit willhave to be made during the transitional period.

The prize for the funniest moment of the day wasawarded to a heavily pregnant Gillian Rodaks (Healthand Safety Executive, Aberdeen) for her impression of aNorth Sea oil rig worker who just realised that he hasinadvertently handled a 50 GBq Cs-137 source. Given thatthis was well before the watershed, and to spare theaudience’s blushes, Gillian gracefully omitted theprobable word(s) used.

Whilst an oil rig in the North Sea is about as far as youcan imagine from the hospital environment, the failingscausing the incident (inadequate risk assessment,insufficient training, lack of procedures, lack of awarenessof local rules) are applicable to all work situations. In thisinstance the introduction of a simple procedure to checkthe source location could have spared the employerprosecution and a £300,000 fine.

Back on dry land, the HSE have been kept busy withreports of staff doses exceeding the statutory limits. All ofthese notifications have come from staff membersmonitored using TLDs supplied by approved dosimetryservices. Lessons learned include liaising with thedosimetry service for their input and informing the HSEpromptly, unless it can be shown beyond reasonabledoubt that the dose limit was not actually exceeded.

Pat Horton (Royal Surrey County Hospital, Guildford)gave the first of the day’s two talks concerningradiotherapy as he described progress on the rewrite ofthe IPEM report on radiotherapy room design (IPEMReport 75). In a field of rapidly advancing technology(tomotherapy, Cyberknife), new techniques (IMRT,particle therapy) and new building materials (Ledite,Verishield), a review of shielding requirements waswarmly welcomed by the audience.

The working group hopes to make further use ofworkload data extracted from radiotherapy managementsystems in the future. These will provide factors for use indesign calculations and back up the assumptions made inthe previous report. Such management systems open upthe possibility of easily collecting data on workload, dutycycles, orientation factors and IMRT factors. In addition, itis hoped that in the future the calculations presented inReport 75 will be compared with Monte Carlo simulations.

Stuart Green (University Hospitals Birmingham) gavea glimpse into the future as he gave an excellentpresentation on the radiation protection issues associatedwith proton therapy. Whilst proton therapy may offerimproved clinical outcomes by taking advantage of theproton’s favourable characteristics in tissues (figure 1),hardware issues and size may be the treatment’s limitingfactor at present (figure 2). Such treatments will have aconcomitant neutron dose, the biological effects of whichremain a research area, but Stuart argued that protontherapy units spare the patient from the leakage radiationand scatter dose associated with photon treatments.

Issues that will trouble the RPA include the activationof machine components and neutron shielding. Given theclinical advantages of proton treatments, Stuart hopedthat the RPAs of the future will be kept busy as thetechnique becomes increasingly prevalent in the UK.

Karen Fuller (Sheffield Teaching Hospital) gave acautionary tale involving an intra-oral x-ray unit thatspontaneously exposed. Two staff members were close tothe tube head when this occurred, but doses weresubsequently estimated to be fairly negligible (effectivedose <10 μSv).

On investigation moisture was found in the handswitch which had lead to corrosion of components, aresult of the switch being cleaned with wet wipes afterevery exposure in line with local infection controlprocedures. Such a failure could feasibly occur on anytype of x-ray unit with a similar hand switch.

This incident highlighted the fact that radiationprotection advice has to fight amongst all sorts of otheradvice – in this case from the infection control department– within the healthcare sector, and a common senseapproach must prevail. The department in question arenow considering using disposable sheaths in order topractice safe radiography whilst preventing infection andavoiding accidents. n

MEETING REPORTS | SCOPE


FIGURE 1. Example of aproton therapytreatment.

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FIGURE 2. Proton therapygantry.

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SCOPE | INTERNATIONAL NEWS


MEETINGS 2011

IPEM MEETINGS

Meeting Venue and dates More information

Specifying, Evaluating and Selecting MedicalEquipment

7th Annual IPEM Medical EngineeringTechnologists Study Day

Laser Output Measurement Workshop

Oncology Management Systems and their Usein Cancer Care

IPEM Report 32 Volume 7: Experiences withTesting CR and DR

Pass or Fail: Determining Acceptable MedicalDevice Governance

MR Safety Update

Electrons: Dosimetry, Planning and Treatment

Appropriate Healthcare Technology forDeveloping Countries

17th Annual Scientific Meeting of the BritishChapter ISMRM

Bioengineering11

Safety Acceptance Criteria: Is ALARP Enough?

Improved Outcomes in Radiotherapy: ThePromise of New Technologies

Engineers and Surgeons: Joined at the Hip III

Incontinence: The Engineering Challenge VIII

13th International Radiation ProtectionAssociation (IRPA) Congress

National Railway Museum, York 13th September

York Racecourse22nd September

Wessex Specialist Laser Centre,Salisbury29th September

MIC Centre, London11th October

British Institute of Radiology, London21st October

Fairmont House, York1st November

Society of Chemical Industry, London9th November

Austin Court, Birmingham10th November

IME, London7th September

University of Manchester7th–9th September

Queen Mary, University of London12th–13th September

Safety & Reliability Society, Manchester15th September

IET, London19th September

Royal College of Surgeons, London1st–3rd November

IME, London7th–8th December

Scottish Exhibition and ConferenceCentre, Glasgow13th–18th May 2012

This meeting on medical equipment procurement will explorehow to specify, how suppliers should respond to specificationsand how to evaluate the responses and make objectivedecisions, bearing in mind financial and other regulations

The 7th Annual IPEM Medical Engineering Technologist StudyDay, in conjunction with Draeger

This workshop will include hands-on sessions measuring andmonitoring the output from a number of medical lasers/IPL, aswell as lectures and discussion sessions

This meeting is an opportunity for people working with oncologymanagement systems to share their experiences across a rangeof topics such as configuration, management, integration,upgrading, data extraction and other potentially innovative uses

One year on from the publication of IPEM Report 32 Volume 7,this meeting will be a chance to discuss experiences with thebasic and quantitative tests, as well as optimising AEC set-ups

This meeting will provide an opportunity to hear directly fromrepresentatives of organisations with a medical devicegovernance remit, as well as a forum for debate

This meeting is intended to provide the MR workforce with apractical update on current issues in MR safety

This scientific meeting will be a chance to focus on currentdevelopments and issues in electron beam therapy, includingdosimetry, treatment planning and delivery

http://events.imeche.org/EventView.aspx?EventID=1036

http://www.bii.manchester.ac.uk/bc-ismrm2011

http://www.bioeng.org.uk

http://www.sars.org.uk/conf.htm

https://www.rcr.ac.uk/membersarea/multievents/displayEvent.asp?Type=Full&Code=COASM2011

http://events.imeche.org/EventView.aspx?EventID=919

http://events.imeche.org/EventView.aspx?code=s1545

http://www.irpa13glasgow.com

OTHER UK MEETINGS


INTERNATIONAL NEWS | SCOPE

MEETINGS 2011

EUROPEAN MEETINGS


Sensors and their Applications XVI

5th European Conference of theInternational Federation for Medical andBiological Engineering

Joint ECCO 16, 30th ESTRO and 36th ESMOMultidisciplinary Congress

IAEA: International Conference on ClinicalPET and Molecular Nuclear Medicine –Trends in Clinical PET andRadiopharmaceutical Development

IAEA: International Conference on the Safeand Secure Transport of RadioactiveMaterial: The Next Fifty Years of Transport -Creating a Safe, Secure and SustainableFramework

IAEA Workshop: Monte Carlo RadiationTransport and Associated Data Needs for

Medical Applications World Molecular Imaging Congress

7th Annual Harvard Medical SchoolBrachytherapy Review

MICCAI 2011: 14th International Conferenceon Medical Image Computing and ComputerAssisted Intervention

Computational Bioimaging: Special Track ofthe 7th International Symposium on VisualComputing (ISVC11)

ASTRO’s 53rd Annual Meeting

AAPM CT Dose Summit

Nuclear Medicine and PET Hands-OnWorkshop: Physics, Testing, andAccreditation

8th Annual Memphis BioImaging Symposium

Radiological Society of North AmericaAnnual Meeting

Cork, Ireland12th–14th September

Budapest, Hungary 14th–18th September

Stockholm, Sweden23rd–27th September

Vienna, Austria8th–11th October

Vienna, Austria17th–21st October

Trieste, Italy17th–19th October

San Diego, CA7th–10th September

Boston, MA16th–17th September

Toronto, Canada18th–22nd September

Las Vegas, NV26th–28th September

Miami Beach, FL2nd–6th October

Denver, CO7th–8th October

Houston, TX14th–16th October

Memphis, TN3rd–4th November

Chicago, IL27th November–2nd December

www.eventsforce.net/iop/frontend/reg/thome.csp?pageID=36439&eventID=104&eventID=104

www.embec2011.com/?mod=content&cla=content&fun=access&id=84&mid=1&temp=base

http://www.ecco-org.eu

http://www-pub.iaea.org/MTCD/Meetings/Announcements. asp?ConfID=38296

http://www-pub.iaea.org/MTCD/Meetings/Announcements.asp?ConfID=38298

http://www-nds.iaea.org/MC2011/MC2011.htmlx

http://www.wmicmeeting.org/homeEmail: [email protected]

http://cme.med.harvard.edu/index.asp?SECTION=CLASSES&ID=00311359

http://www.miccai2011.org

www.isvc.net

http://www.astro.org/Meetings/AnnualMeetings/index.aspx

http://www.aapm.org/meetings/2011CTS/default.asp Email: [email protected]

Email: [email protected]

http://www.membis.org

http://www.rsna.org

NORTH AMERICAN MEETINGS

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SCOPE | INTERNATIONAL/MEMBERS’ NEWS

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The Process of Quality Assurance in ProstateBrachytherapy MD Anderson Cancer Center

Symposium: Practical Aspects of Stereotactic BodyRadiation Therapy (SBRT)

12th Mexican Symposium on Medical Physics

Houston, TX3rd–4th December

Stanford, CA9th–10th December

Oaxaca, Mexico20th–22nd March 2012

http://www.mdanderson.org/education-and-research/education-and-training/schools-and-programs/cme-conference-management/conferences/cme/conference-management-the-process-of-quality-assurance-in-prostate-brachytherapy.html

http://xinglab.stanford.eduEmail: [email protected]

http://www.hraeoaxaca.salud.gob.mx/SIMPOSIUM/Invitation.htmlEmail: [email protected]

NORTH AMERICAN MEETINGS CONTINUED

MEETINGS 2011

Full name Job title Organisation Town

Coral Stockley Senior Clinical Technologist Dorset County Hospital NHS FT Dorchester

Andrew Day-Smith Rehabilitation Engineer Plymouth Hospitals NHS Trust Plymouth

Stephen Vincent Senior Electronics Technician Stoke Mandeville Hospital Aylesbury

Wayne Jarvis Senior Electronics Technician Stoke Mandeville Hospital Aylesbury

John Hirons Technical Manager, CCISS University Hospitals Birmingham NHS FT Birmingham

Mark FieldsSenior NCO MDSS Workshop &Training

RAF Henlow Cam

Mark Powell Medical Physicist Royal Sussex County Hospital Brighton

Mohammad Saleem Medical Technical Officer Pinderfields General Hospital Wakefield

David Turner Senior Healthcare Scientist The Leeds Teaching Hospitals NHS Trust Leeds

Bhupinder Rai Trainee Clinical Scientist University Hospital Coventry & Warwickshire Coventry

James Dicks Medical Physicist University Hospitals Birmingham NHS FT Birmingham

Ka Ho Chiu Electrical Technician Prince of Wales Hospital Hong Kong

PrasanasarathyNariyangadu

Lead Radiotherapy Physicist Mount Vernon Hospital Northwood

Richard Twycross-Lewis Research Supervisor Mile End Hospital London

James Neill Egan Radiotherapy Scientist Betsi Cadwaladr University Health Board Rhyll

NEW MEMBERS 2011


INTERNATIONAL/MEMBERS’ NEWS | SCOPE


Basic Clinical Radiobiology: ESTRO EndorsedTeaching Course

IAEA: International Conference on Research Reactors– Safe Management and Effective Utilization

32nd Annual Conference of the Association of MedicalPhysicists of India

International Conference on Biomedical Engineering

12th International Conference on Electronic PatientImaging (EPI2k12)

Rotorua, New Zealand30th October–3rd November

Rabat, Morocco14th–18th November

Vellore, India16th–19th November

Manipal, India10th–12th December

Sydney, Australia12th–14th March 2012

http://www.nzradbio2011.orgEmail: [email protected]

http://www-pub.iaea.org/MTCD/Meetings/Announcements.asp?ConfID=38299

http://www.ampicon2011.org.inEmail: [email protected]

http://uic.manipal.edu/icbme

http://epi2k12.org

REST OFTHE WORLD

MEETINGS 2011

Qualifications New memberor transfer Category Date elected

HNC Medical Physics & Physiological Measurement, London Transfer Incorporated 7 Apr 11

New member Incorporated 7 Apr 11

BSc (Hons) Telecommunication & Electronics, Milton Keynes New member Incorporated 7 Apr 11


BA (Hons) Electronics & Computer Science, Milton Keynes New member Incorporated 7 Apr 11


BSc (Hons) Physics with Management Studies, Brighton New member Incorporated 7 Apr 11


BSc (Hons) Natural Sciences, Milton Keynes / MSc Medical Science, Milton Keynes New member Incorporated 7 Apr 11

BSc (Hons) Physics, London / MSc Medical & Radiation Physics, Birmingham New member Associate 11 May 11

BSc (Hons) Chemistry, Birmingham / PhD Bioinorganic Chemistry, Nottingham New member Associate 11 May 11

MEng Biomedical Engineering, Hong Kong New member Associate 11 May 11

BSc Physics, Chennai / MSc Medical Physics, Chennai New member Corporate 21 Apr 11

BSc (Hons) Sport & Exercise Science, London / MRes Advanced InstrumentationSystems, London / PhD Medical Engineering, London

Transfer Corporate 21 Apr 11

BSc (Hons) Physics, Liverpool / MSc Medical Physics, Aberdeen Transfer Corporate 25 May 11


SCOPE | BOOK REVIEWS

elcome toanother newissue of theScope bookreview section.In this issue, wepresent our

readers with six interesting reviews: fivefrom the medical physics genre and onefrom the popular science genre.

The first review is of the 2010published ICRU Report 83 (IMRT), by acolleague from my own centre here atPoole, Stephen Moloney. This is followedby Professor Angela Newing’s review ofRadiation Physics for Nuclear Medicine.Sarah Cade examines Tomographic ImageReconstruction and Quantification forPET/SPECT, and Julian Minns presents areview of Biomaterials for TissueEngineering Applications. Imaging fromthe Radiotherapy in Practice series ispresented by Tony Greener. Finally, MarcMiquel, our own Editor of Scope, haswritten a review (one of many!) of TheBeautiful Invisible.

The ‘Just Published!’ section contains agood mix of recent or soon to bepublished medical physics andengineering texts. The ‘New Reports’section contains some very interestingreports, including the new ICRU Report85 – Fundamental Quantities and Unitsfor Ionizing Radiation.

As always, if you are interested inreviewing any of the new texts (or evenreports) listed in this issue, please dropus an email so we can send you details ofjoining our online workspace – Ubidesk.The workspace details a selection ofbooks we have available for review,reviewer guidelines, submission (ofreview) area, noticeboard and muchmore.

Reviewing has its own perks (apartfrom taking some of your ‘free’ time!) – itallows one to learn, analyse, reflect andcommunicate findings to more than 3,500IPEM members, with an added bonus: itcounts towards your CPD! Please join us!

Usman I. Lula([email protected])Marium Naeem([email protected])

Wfigures. This would make an excellentintroduction to these concepts for someoneencountering them for the first time.

Chapter 5 gives a useful, if brief, guideon dealing with some tricky situations ininverse planning, e.g. conflicting goals foroverlapping volumes. The report endswith two appendices, one on the physicalaspects of IMRT and another givingclinical examples. The former brieflycovers topics such as beam modelling,dose algorithms and commissioning/QA.

The section on clinical cases is clearlyand comprehensively written. There areno obvious errors here and the examplecases are good. The definitions are verydetailed and readable. The text was foundto be generally well written andreferenced.

Although its title does not reflect itscontents well, the report achieves the aimsset out in its early sections. There areelements of this report that are essentialreading for physicists, dosimetrists andclinicians in any department performingor planning to perform IMRT.

There are some poorly written sections,particularly earlier on, and the figures arenot of a uniformly high standard.Fortunately, for most of the document thisis not the case and the report would makeuseful reading for those mentioned above.

Due to the cost, I would notrecommend that an individual purchasesthis report, but a radiotherapy departmentshould have it in its library.

Stephen Moloney and Joe Davies, PooleHospital NHS Foundation Trust

Prescribing,Recording andReporting Photon-Beam Intensity-Modulated RadiationTherapyAs the title suggests, this report builds onthe advice given in ICRU Reports 50 and 62,regarding treatment specification for photonbeam radiotherapy. However, this title onlyapplies directly to one chapter.

The report as a whole serves a differentpurpose. As the authors state, as well asproviding the information necessary tostandardise techniques, it broadly discussesall aspects of IMRT, describing in somedetail the physical, technical, treatmentplanning and clinical considerations.

The introductory chapter gives a shorthistory of radiotherapy planning anddiscusses ICRU Reports 50 and 62, IMRTdelivery, imaging and margins. A chapter onoptimised treatment planning follows. Thereis an interesting explanation of the inverseplanning process, although some of theexamples are perhaps too specific to aparticular treatment planning system. Thechapter contains much repeated material – afeature of the first third or so of this report.The chapter also contains some errors in theexplanation of equations and diagrams. I feltthat the document improved in the thirdchapter and for its remainder. This is wherewe get to material relating to the document’stitle, presenting the quantities suggested foruse in reporting and prescribing IMRT, andgiving clear explanations as to why. Of these,the most notable are the PTV ‘near-minimum’ and ‘near-maximum’ doses(D98% and D2%, respectively), which thereport recommends should replace theminimum and maximum doses. The ICRUreference point dose is also replaced with themedian dose (D50%).

Chapter 4 gives an explanation of thevolumes that need to be defined intreatments. There is little new here, but thechapter does give a very good recap of thevolumes defined in ICRU 50 and 62 (GTV,CTV, PTV, etc.) with good examples and

Radiation Physics forNuclear MedicineI found this book somewhat difficult tonavigate. It was produced following atraining course on ‘Radiation physics in

PRESCRIBING, RECORDING AND REPORTINGPHOTON-BEAM INTENSITY-MODULATEDRADIATION THERAPYJOURNAL OF THE ICRU, VOLUME 10, NO 1 (2010),REPORT 83Publisher: Oxford University PressISSN: 1473-6691 (print) 1742-3422 (online)Pages: 106

It allows one to learn,analyse, reflect andcommunicate findings tomore than 3,500 IPEMmembers“”

BOOK REVIEWS | SCOPE


nuclear medicine’ held in Milan in 2008,and is a collection of the lectures broughttogether as chapters in the book. It is thejob of book editors preparing material fromcourses and conferences for publication toiron out the differences of style of thevarious authors and to put the chapters inthe order that makes them hang together asa textbook. I do not think that these editorshave succeeded in either goal.

The order of chapters is not what Iwould have chosen. The details of everyparticular technique in nuclear medicineare all available somewhere in the text, buta student wanting to read up on PET, forinstance, will find information about PETscanners and the isotopes used in Chapter5, but will have to wait until Chapter 8 tofind out what PET is and how it works.The same applies to SPECT. What works ina taught course, where students can askquestions and clarify details as they goalong, does not always hold true for abook.

There is a wealth of useful informationhere with good diagrams and plenty of up-to-date references. Any student wanting agrounding in nuclear medicine will findthe book useful once they have found theirway around it.

Angela Newing, Gloucestershire NHSFoundation Trust (retired)

nuclear medicine image reconstruction. Thefirst chapters cover background and areview of the literature relating to the topic.Both of these chapters cover the essentialpoints but do not explain the basics and sowould be of limited use to readers withoutprior knowledge of the subject matter. Thereadability of the book is generally limitedby frequent grammatical errors and anumber of typographical errors. There arealso a number of places where the variablesused in equations have not been definedand the labelling of figures (such as graphaxes) is illegible or non-existent.

In the text, the author proposes amedian-based prior for use in penalisedlikelihood image reconstruction andcompares the use of this prior to otherpriors such as quadratic priors. The bulk ofthe text analyses the performance of theproposed prior in terms of resolutionrecovery, partial volume correction andnoise characteristics. The use of the priorsin list mode reconstructions is alsodiscussed.

This book is most likely to be of interestto researchers working in a similar area tothe author. However, it is noted that theauthor of the book has published a numberof journal articles on topics similar to thosecovered in this book, and so with arecommended retail price of £61 for thebook, it is unlikely to represent good valuefor money.

Sarah Cade, Royal United Hospital, Bath

topic’. The three main sections deal with: 1. the variety of types of materials … forengineering a range of tissues;2. the biomaterial component in theengineering of specific tissues (and manyexamples are given), and3. translation of these new tissues to theclinic, such as trial design.

The first two sections mentioned couldreally be combined but the material withinthese sections is excellently produced withgood clear diagrams and an exhaustivereference list at the end of each chapter. Thelast section, a single chapter, is a majordisappointment which says the obviousabout material implant development andthe regulatory framework that exists. Itcould have had other chapters citing someexamples of materials in tissue engineeringthat have succeeded in being used in theclinical market and why they are successful,a big-let down and an opportunity missed.

The biggest fault I found with this bookwas the total dominance of workperformed in the US by these so-called‘emerging experts’. With the exception oftwo groups in Canada, all of the work citesresearch performed in America withpractically no reference to any researchperformed outside the States. There ispioneering work being performed on stemcells with biomaterials in Europe, notablyLondon and Sweden, and biomaterials intissue engineering applications in Germanand Italian laboratories which are notdescribed or cited at all. Anyoneconsidering purchasing this book orconsidering it as a useful reference sourcein tissue engineering should bear this inmind.

It is, however, a rich reference source ofStateside research in this area and issuperbly produced with high-qualityreproduction of the diagrams throughout.

Julian Minns, University of Wales Institute,Cardiff, and Newcastle General Hospital(retired)

Biomaterials forTissue EngineeringApplicationsThis book is in three sections, and to quotethe editor’s opening remarks, ‘we askedseveral emerging experts who we thoughtmay contribute a fresh perspective on this

Tomographic ImageReconstruction andQuantification forPET/SPECT This book is the publication of the author’sPhD thesis and as such does not flow in theway one would expect of traditionaltextbooks covering a similar topic. The bulkof the text is devoted to an in-depthcoverage of a very small area of the topic of

RADIATION PHYSICS FOR NUCLEAR MEDICINEMARIE CLAIRE CANTONE AND CHRISTOPHHOESCHENPublisher: SpringerISBN: 978-3-642-11326-0HardbackPages: 285

BIOMATERIALS FOR TISSUE ENGINEERINGAPPLICATIONS: A REVIEW OF THE PAST ANDFUTURE TRENDSJASON A. BURDICK AND ROBERT L. MAUCKPublisher: SpringerISBN: 978-3-709-10384-5Pages: 564

TOMOGRAPHIC IMAGE RECONSTRUCTION ANDQUANTIFICATION FOR PET/SPECT – NON-UNIFORM RESOLUTION AND PARTIAL VOLUMERECOVERY METHODSMUNIR AHMAD AND ANDREW TODD-POKROPEKPublisher: VDM Verlag Dr MullerISBN: 978-3-639-21421-5Pages: 196

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We asked severalemerging experts who wethought may contribute afresh perspective on thistopic“”

SCOPE | BOOK REVIEWS


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Just Published!Physics MCQs for the Part 1 FRCR byShahzad Ilyas et al. (Cambridge UniversityPress) is a must-have revision resource forthe new format Part 1 FRCR exam,covering the complete curriculumincluding ultrasound and MRI. It is writtenby a team of specialist registrars who haverecently successfully passed the Part 1FRCR exam and a renowned medicalphysicist.

Imaging(Radiotherapy InPractice) If Tony Blair had chosen clinical oncologyas a career path rather than politics, onecould imagine his education mantra beingreplaced with imaging, imaging and moreimaging. The latest book in the popularRadiotherapy in Practice series covers thiscrucial area, attempting to bridge the gapbetween detailed imaging books andgeneral oncology texts.

The book leads with basic descriptions ofthe most common imaging modalities, i.e.plain x-rays, ultrasound, CT, MR, nuclearmedicine and PET, providing the readerwith sufficient information to interpret thefollowing 19 chapters. Each of thesesubsequent site-specific chapters has beenjointly written by an oncologist and aradiologist, providing an authoritativeoverview covering clinical background,diagnosis and staging, imaging forradiotherapy planning and finallytherapeutic assessment and follow up. Thisstructure ensures that on the whole inter-chapter consistency is maintained.

Small variation in content is arguably tothe reader’s advantage with, for example,several chapters providing more detaileddiscussion of the tumour, node, metastases(TNM) clinical staging system. Theperformance of staging imaging tests areoften referenced in terms of their sensitivity(ability to pick up disease) and specificity(ability to exclude disease) providing auseful reminder that there is no perfectimaging modality. Additionally there arecautionary warnings of the dangers of overstaging which could negate potentiallycurable treatment options for some patients.

The role of imaging in treatmentverification is only touched on in somechapters and the more recent advances suchas cone beam and megavoltage CT remainlargely unmentioned.

Last but not least, there is a chapter onradiation protection issues when imagingpatients for radiotherapy. This provides avery useful synopsis of the basic doseindicators used in imaging along with aresumé of relevant legislation. Justification

and assessing the patient imaging dose isdiscussed in the context of a radiotherapyepisode along with tables of dose perexamination for a range of sites.

The appendices provide further usefuldetail, covering research and imaging inradiotherapy along with useful radiationprotection data.

As you would hope from a book onimaging, there are plenty of well-annotatedillustrations, with a central section ofcoloured images. The main remit of thebook, to provide guidance to oncologistsand radiologists on the use of imaging inthe management of patients withmalignancy, is achieved.

I would recommend this book toradiotherapy physicists, dosimetrists andradiographers involved in treatmentplanning. It will also be of interest to otherimaging physicists requiring a conciseoverview of imaging for staging andtreatment planning in radiotherapy.

Tony Greener, Guy’s and St Thomas’ NHSFoundation Trust, London

Endeavouring to narrate some of theideas of theoretical physics as a gallery of‘invisible paintings’ is a noble andpoetical concept that Vignale tackles inhis second book, The Beautiful Invisible.However, readers might find it a bit off-putting and very limiting to choose todescribe, right from the onset of the book,theoretical physics, the ‘science of theinvisible’, as a ‘modern form oftheology’. Last time I checked, you couldnot test theology with well-designedexperiments, nor could you easily predictfuture discoveries thanks to it.

Vignale successfully sticks to hispromise not to teach but to introduceimportant ideas and concepts withminimal use of mathematics. However, Ifelt that the author’s constant referral toart and extensive use of quotes (RobertMusil definitely is his favourite) distractsfrom and weakens his objective andcentral aim, to demonstrate the creativityand imagination of his field of science.

Nevertheless, the book really comes tolife in the latter quantum chapters, thepace quickens and one can feel theauthor is back in his favouriteenvironment.

The Beautiful Invisible is an easy andenjoyable book to read, it is inspirationalat times but more often than not, it lacksthe invisible spark that would make ittruly beautiful.

Marc E. Miquel

IMAGING (RADIOTHERAPY IN PRACTICE) PETER HOSKIN AND VICKY GOHPublisher: OUP, OxfordISSN-13: 978-0199231324Pages: 336

THE BEAUTIFUL INVISIBLE: CREATIVITY,IMAGINATION, AND THEORETICAL PHYSICSGIOVANNI VIGNALEPublisher: OUP OxfordISSN-10: 9-780-19957-484-1Pages: 320

The BeautifulInvisible: Creativity,Imagination, andTheoretical PhysicsThe link between creativity, the arts andscience is an easy one to make; you caninstantly think of Leonardo Da Vinci,architecture, symmetry (if you haven’t,please read Marcus Du Sautoy’s FindingMoonshine) or the work by anatomists fromthe écorchés of Jacques Fabien Gautierd’Agoty to Paul Pfurtscheller ‘s amazinganimal charts. However, the general publicmight have more difficulty to link artisticcreativity to the apparently dry world ofphysics; only because we were badly taughtthe boring side of physics before reachingtheoretical physics, would argue GiovanniVignale.

The general publicmight have more difficultyto link artistic creativity tothe apparently dry world of physics“”

BOOK REVIEWS | SCOPE


Examinations. AAPM Report 204;2011.

n Quality Assurance of US-guidedExternal Beam Radiotherapy forProstate Cancer. AAPM Report 154;2011.

n Quality Assurance for RoboticRadiosurgery. AAPM Report 135;2011.

n Health Risks from Radioactive Objectson Beaches in the Vicinity of theSellafield Site. HPA-CRCE-018; 2011.

n Assessment of Personal Exposures toNon-laser Optical Radiation inEntertainment. HPA-CRCE-016; 2011.

n Monitor: Newsletter of the PersonalDosimetry Service (formerly PersonalMonitoring Services). HPA; 2011.

n Modernising Scientific Careers (MSC)Checklist (and associated material),www.NHSEmployers.org; 2011.

n Implementation of the InternationalCode of Practice on Dosimetry inDiagnostic Radiology (TRS 457):Review of Test Results. IAEA HumanHealth Reports No. 4, STI/PUB/1498;2011.

n Clinical Training of Medical PhysicistsSpecializing in Nuclear MedicineTraining Course Series No. 50. IAEA-TCS-50; 2011.

Computed Radiation Imaging – Physicsand Mathematics of Forward and InverseProblems by Esam M. A. Hussein (ElsevierScience Publishing) addresses both thephysical and mathematical aspects of theimaging problem. It discusses the inherentphysical and numerical capabilities andlimitations of the methods presented forboth the forward and inverse problems.

Nuclear Medicine Physics (The Basics), 7thRevision by Ramesh Chandra (LippincottWilliams & Wilkins) is resource for radiologyresidents and practitioners, nuclearcardiologists, medical physicists andradiologic technologists. It includes morethan 100 illustrations that underscoredifficult concepts, review questions at theend of each chapter to help you master thematerial, and more.

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Practical Biomedical Signal AnalysisUsing MATLAB by Katarzyna Cieslak-Blinowska and Jaroslaw Zygierewicz (Taylor &Francis) bridges the gap between themethods and practice of biomedical signalanalysis for solving concrete problems.

Lasers in Dermatology and Medicine byKeyvan Nouri (Springer) is an up-to-date

review of medical applications involvinglasers – a welcome and highly practicaladdition to the literature. Itscomprehensive content covers everythingfrom dermatology to gynaecology toneurosurgery.

Biomechanics of the Brain by Karol Miller(Springer), a first in brain biomechanics,presents an introduction to brain anatomyfor engineers and scientists. Experimentaltechniques such as brain imaging andbrain tissue mechanical propertymeasurement will be discussed, as well ascomputational methods for neuroimageanalysis and modelling of braindeformations due to impacts andneurosurgical interventions.

Handbook of Particle Detection andImaging by Claus Grupen and Irene Buvat(Springer) centres on detection techniquesin the field of particle physics, medicalimaging and related subjects.

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n Medical Cyclotrons (including PETRadiopharmaceutical Production).IPEM Report 105; 2011.

n Size-Specific Dose Estimates (SSDE) inPediatric and Adult Body CT

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A HISTORY OF MEDICAL PHYSICSFRANCIS DUCK has the third instalment in his series on the history of medical physics

PIERRE PELLETAN AND THE ESTABLISHMENT OF MEDICAL PHYSICS, 1823–43

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book was published inParis in 1824 entitledTraité élémentaire dephysique générale etmédicale. It was the firstever textbook for a

course in medical physics. This is thestory of the author, Pierre Pelletan, andof his battles to unite the academicdisciplines of physics and medicine.

PIERRE PELLETAN (1782–1845)Pierre Pelletan was born in Paris on 6thJanuary 1782. His father, Phillippe-JeanPelletan, was a leading doctor whowould later become a leading surgeonduring the Napoleonic era. His mother,Elisabeth, died when he was only 5years old, and he was only 12 whenRobespierre’s execution marked theend of the Terror. As normalityreturned, his father remarried: figure 1was painted at about this time.

In spite of the instabilities during hischildhood, Pierre had sufficient talentto gain entry to the École Polytechniquein 1797. The next few years set thestage for the tensions that woulddominate his life. On the one handthere was his father, guiding his sontowards a successful career inmedicine; on the other, Pelletan’snatural inclination and talent as aninventor and entrepreneur. Theseconflicting forces would ultimatelybecome mutually destructive.

Pelletan’s father supported theRevolution. In 1796 he was appointed,with Jean-Noël Hallé,1 to the medicaland surgical section of the Institutnational, where his circle of colleaguesincluded leading scientists of the age.He joined the commission toinvestigate galvanism, working withJacques Charles (1746–1823), pioneer ofthe hydrogen balloon and creditedwith establishing the law ofproportionality of gas volume withtemperature. This contact may have ledto Pierre’s first brief academicappointment as Charles’ assistant. Butvery soon, in 1799, Pelletan’s fathersent his son off to be a military surgeonin the Napoleonic army. Pelletan was17, and his only medically relatedqualification was that he had taught acourse in chemistry. Nevertheless hecarried out his duties effectively, andwas later awarded the Croix d’honneurfor services to soldiers with typhus.

FROM MEDICINE TO INDUSTRYOn his return to Paris, he commencedhis medical training, obtaining, in 1803,an internship at the Hotel-Dieu where ▼

his father was by then head of surgery.But then, in his first major break withhis father’s wishes, and halfwaythrough the 4-year surgical internship,he abandoned medicine and went offto open a soda factory in Rouen.

From his teaching of chemistry,Pelletan would have been aware of theLeblanc process for making sodiumcarbonate (soda) from sodiumchloride. In 1791, Nicholas Leblanc(1742–1806) had been granted a patentfor producing soda, highly importantto the French cotton-dying industry.The Leblanc process emittedhydrochloric acid fumes, and therewere increasing complaints to theHealth Police (the Napoleonicequivalent of the HSE) of their effectson health and the environment.Pelletan devised a method to fix thegas, using a heated, winding, lead-lined pipe filled with limestone, and soprevent its escape. Leblanc latercommitted suicide, having lost controlof the industry he had founded.

FROM INDUSTRY TO MEDICINEBy 1813 Pelletan had left his sodafactory behind and was back in Paris.Why? Perhaps his political antennaeand monarchist tendencies sensed thatNapoleon’s days were numbered?Perhaps he still wanted to please hisfather? Perhaps it was for the love of agood woman? On 10th July 1813 hemarried Sophie Barthés, the widow ofBaron Kinkelin, in Paris. The couplewould have no children of their own,but Sophie brought one son, Jules,whom Pierre later adopted. Fourmonths earlier, on 13th March,Pelletan had presented his doctoralthesis to the Faculty of Medicine: ‘Onthe influence of the laws of physicsand chemistry on the phenomena oflife’ (figure 2). The thesis is dedicatedto ‘Mon père et mon meilleur ami leChevalier Pelletan … En témoignage derespect, de reconnaissance et d’amourfilial’. (‘To my father and my bestfriend, Chevalier Pelletan… As a tokenof respect, in gratitude and with ason’s love’.) Pierre had come home.The president of the examining boardwas Pierre’s father.

PIERRE PELLETAN’S THESISPelletan’s thesis is a remarkabledocument, and deserves a muchlengthier discussion than space allows.Characteristic of its time, it reducesphysics to Newtonian forces at adistance, and chemistry to questions ofaffinity. But Pelletan opposed the

vitalist view of the physiologist XavierBichet (1771–1802), that sensitivity andcontractility are basic ‘vital’ propertiesof living matter, and instead assertedthe non-vitalist view, that all life canultimately be reduced to physical andchemical fundamentals, even thoughthe knowledge of how this may beachieved has not yet been discovered.This was quite unconventionalthinking for the time, and the vitalistswould not lose their grip onphysiology for many decades to come.But he challenges false models at amore fundamental level. ‘When thehuman mind meets an apparentlyinsurmountable obstacle’, he says, ‘itinvents an ingenious explanation. If itis widely accepted, this preventsfurther exploration, the contentedmind abandoning, for a dream, theslow, laborious work that leads toknowledge.’

He goes on to discuss thecirculation. His analysis of arterialpulse propagation was much closer tothe true explanation than most at thattime, very similar to Thomas Young’sanalysis from a few years earlier.2

Pelletan also considers the effects oftube branching and tapering onarterial blood flow, distinguishingbetween speed and volume flow, andtheir development as the cross-sectionof the arterial tree alters with distancefrom the heart. He correctly attributesvenous flow to the action ofsurrounding muscles, criticising thethen widely-held view that it wascaused by capillary contractions. Hisevaluation of molecular transportacross the arterial wall was limited bycurrent knowledge of blood structureand composition, but he noted theimpossibility that fluids can besqueezed directly through the arterialwall by arterial blood pressure. It wasan uncompromising work, givingrational scientific arguments to try toexplain physiological phenomena.

MEDICINE OR TECHNOLOGY?Pelletan was back in the mainstream ofmedicine in Paris. He obtained a postat the Val-de-Grace (a military hospital).He received the honorary title médecinordinaire to King Louis XVIII (figure 3).But he could not keep away from hisfirst love, technology and invention.Recalling his soda days, he publiciseda new method for making sulphuricacid, a necessary chemical in theLeblanc process. In 1817 he visitedLondon to gather information on thenewly-installed gas lighting in the city.

FIGURE 1.Pierre Pelletan c.1790: attributedto Greuze (© Coll.Musée Hist MédParis).3

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Thenext fewyears setthe stagefor thetensionsthatwoulddominatehis life

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Back in Paris, Pelletan reported severaltimes to l’Académie Royale des sciences in1816/17 on lighting systems using bothcoal-gas and hydrogen. The first coal-gas lighting system in Paris wasinstalled in the Hôpital Saint Louis and,given Pelletan’s medical position, hemust surely have been involved.

FAILURE AND SUCCESSHowever, a poignant and revealingletter written in 1819 by Pierre’s father3

gives a glimpse of the waning familyfortunes at this time. He explains to hisson why he is no longer able to helphim financially, because ‘intrigues andill-will have blighted my career, so Icannot even afford to marry off mydaughter and may be unable to ensureprovision for my widow’. He adds that‘you would have reached the peak ofreputation and comfort if you hadfollowed a sensible career’. Pierre hadstill not achieved this happy state and,for his father, things were about to get alot worse.

The circumstances that caused theclosure of the Faculté de Médecine in1822 following Desgenette’s eulogy forHallé were described in part 2 of thisseries.1 Phillippe-Jean Pelletan wasamongst the 11 faculty members wholost their positions and their pensionrights, leaving him, it was said, nobetter off than when he was a student.

On the other hand, for his son, now40, this was his big break. On 30thNovember 1822, Pierre Pelletan wasappointed to be one of the interimadministrators to the faculty. Hallé’schair of Medical Physics and Hygienewas split, and, on 2nd February 1823,Pelletan was nominated by royalcommand as professor of medicalphysics. The next few years wereastonishingly productive, as if todemonstrate that he was as good as hisnewly acquired, better-establishedacademic colleagues.

TRAITÉ DE PHYSIQUE Pelletan was already working on adictionary of medical chemistry,published in two parts in 1822/3. Thefirst edition of his Traité de Physique4

appeared a year later. In three volumesand 994 pages he had written a physicstextbook for his first-year medicalstudents, including sections onproperties of matter, statics, mechanics,heat, optics, acoustics, electricity andmagnetism, supported by 168 figures.Two further editions followed (in 1829and 1838) in which he updated thesection on electrodynamics, and added


FIGURE 4.[CENTRE]Detail from Traitéde Physique, 2ndedition. The twotrolleys are joinedby a spring-loadedsilk thread.Pelletan designedand used thisequipment todemonstrate therelationshipbetween force,mass and velocity.

FIGURE 5.[BOTTOM LEFT]Certificate signedby Pelletandeclaring thatHenry Powellattended hismedical physicscourse in thesummer of 1831(WellcomeInstitute, London).

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FIGURE 6.[BOTTOM RIGHT]Detail from UKPatent 9068.Pelletan:Propelling Fluidsand Vessels, 1841.

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Laplace’s wave description of light tothe Newtonian corpusculardescription of the first edition. He alsoresponded to other criticisms. It wasobjected that mechanics was reallypart of mathematics, and had no placein a physics text. Pelletan’s responsewas to add a further section on themechanics of animal movement.Doctors wanted more medicalapplications. Pelletan added sectionson endo-osmosis, animal heat and thecirculation. He also described his ownresearch into acupuncture and the flowof heat (caloric) in the body. Here hisscientific contributions were lesseffective. He observed thatacupuncture needles becameelectrically charged on insertion, anddeveloped a theory of galvanicacupuncture. Claude Pouillet(1790–1868), then professor of physicsin Paris, pointed out that the chargewas absent when gold or platinumelectrodes were used, identifying thesource as electrode oxidation. Oncaloric, Pelletan states his law that ‘lifeonly exists under the influence of aflow of caloric (heat)‘. This theorydepended on the prevalent view in the1820s that oxidation in the lungs wasthe only source of body heat, fromwhich caloric flowed to all other partsof the body.

Pelletan was a clear and eloquentspeaker. He designed equipment todemonstrate mechanical principles,once more showing his inventive mind(figure 4). Sometimes he contributed tocourses with Pouillet and Gay-Lussac,professors from the physicsdepartment, and occasionally overseasstudents attended his course whilststudying in Paris, because of its worldreputation for excellence in medicaltraining (figure 5).

THE 1830 REVOLUTIONThe French had another revolution inJuly 1830. Charles X was replaced byLouis-Philippe I, ‘the citizen’s king’,and, as always happens with a changeof administration, appointments fromthe previous regime were scrutinised.Pelletan, now 48, had to re-apply forhis own post as Professor of MedicalPhysics. The other shortlistedcandidate was Charles Person, a bright28-year-old physicist who had recentlygained a medical degree. Examinationwas in public (the concours). Theinterview included two presentations,one on evaporation in vacuum and inair, and a second on the determinationof refractive index, with special

reference to eye tumours. Finally, thecandidates had to prepare, with 3hours’ notice, a lesson to ‘describe anddiscuss the phenomena associated withthe production of dew’. Writing later tothe Lancet,5 a correspondent who waspresent considered that these topicswere ‘of the most abstruse and tryingnature … ably handled by bothcandidates’, even though Pelletan wasat the time suffering with arthritic pain.

The selection committee wascomposed of eight professors from theFaculty of Medicine and four from theInstitute of Science. The decision wentin favour of Pelletan and againstPerson, the preferred candidate of theInstitute members. They weresufficiently annoyed by the selectionprocess that they successfullypetitioned the Ministry to take nofurther part in future selection of chairsof physics, chemistry or natural history.

THE DAUPHIN’S HEARTThe other strange story from thisperiod has to do with the Dauphin’sheart. At the end of the previouscentury, following the execution ofLouis XVI, his young son Louis washeld in prison where he died.Pelletan’s father conducted theautopsy, and removed and preservedthe boy’s heart. By the late 1820s, thisrelic was held by the Bishop of Parisand, under threat during the 1830revolution, it was passed back to thefamily, either to Pierre or his half-brother Gabriel. After many changes ofownership, the tissues were geneticallyevaluated in 2000, and a match wasestablished with the mitochondrialDNA of Marie Antoinette, so endingtwo centuries of speculation on theDauphin’s death.6

A PHILOSOPHY FOR MEDICALPHYSICSPelletan lost his father in 1829, and hiswife Sophie died in 1832. Thereafter hislife changed emphasis. The onlysubsequent medical publication wasthe third edition of the Traité dePhysique, which adds little more ofscientific substance to earlier editions.In it, however, Pelletan added adiscussion of the philosophy ofmedical physics. He states thatPhysique Médicale had been used as anofficial title for a number of years. Heis scathing about vitalism inphysiology, saying that it revives theoccult characteristics of the ancients,and argues that the rational approachused in physics is the only way to

FIGURE 2.[TOP LEFT]Title page fromPierre Pelletan’sdoctoral thesis .

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FIGURE 3.[TOP RIGHT]Pierre Pelletan(© Coll. MuséeHist Méd Paris).

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determine truth in physiology andmedicine. He imagines, perhaps for thefirst time, that there will be those whowill occupy themselves with medicalphysics, at least until all possibleconnections between physics andmedicine have been determined.

PELLETAN AND THE INDUSTRIALREVOLUTIONMeanwhile, Pelletan pursued hisindustrial interests. He was fascinatedby steam propulsion for both boats andlocomotives, and worked on a numberof possible engine designs, usingcompressed air or steam. Pelletan iscredited with encouraging the leadingFrench railway engineer Seguin to usea blast-pipe steam-jet to enhance boilerdraft, as Stephenson had done in hisRocket in 1829. By January 1833Pelletan was carrying out trials atCherbourg on boat propulsion using asteam-jet, subsequently obtaining bothFrench and British patents (figure 6).He devised machines for the newsugar-beet industry, which haddeveloped in France following theearlier British blockade of sugarimports from the Caribbean. At thebeginning of the 1840s he visitedLondon several times, obtaining Britishpatents for a new means of gaslighting, and launching his owncompany. An advertisement, dated23rd August 1844 in the LondonMorning Chronicle, advises that ‘ThePatent Pelletan Light Company(temporary offices 248 Regent Street) isoffering for sale 4,000 shares of £20each, applications before 31st inst.’.

The evidence from this periodshows Pelletan devoting his talents toFrench industry, trying to stop hiscountry from slipping too far behindBritain. He was frustrated, however, bya French establishment that still had

one foot in the pre-industrial era, andacademics that emphasisedphilosophy and theory of science,rather than its applications.

A SAD END TO A CAREERAt the same time, Pelletan was stillemployed by the university to work inthe medical school. Given his extra-curricular activities, it is not surprisingthat he became increasingly isolatedfrom his colleagues. He applied tobecome a member of the Academy,both in physics and in medicine andsurgery, but was not even shortlisted.Things finally came to a head on 20thJuly 1843, when Pelletan was forced toresign from his post in the faculty,following ‘des spéculationsmalheureuses’.7 Feeling rejected by hiscountrymen, he went into self-imposed exile in Belgium, settling inBrussels with his second wife, Louise,where he gave physics lectures at theConservatoire des Arts.8 He died oftuberculosis in August 1845. Noeulogy was spoken for Pierre Pelletan.There was no published obituary. Laterbiographies are quite short.7 A briefcomment by a senior physician in anaddress to medical students comparedPelletan unfavourably with anotherrecently-deceased professor.9 Damningwith faint praise, he said that Pelletanwould be ‘remembered for his unusualtalents, for his lively mind and hiswide knowledge, and because he wasa friend to all his colleagues’.However, the doctor went on to tell hisaudience that they must love scienceabove talent and intelligence, andparticularly to love medicine, which hedescribed as the greatest of thesciences. Pelletan was neverunconditionally committed tomedicine, and so was considered to bea failure.

PELLETAN’S CONTRIBUTIONS Pelletan aspired to establish a newdiscipline of medical physics. Whilst hemade the first steps in this direction, henever achieved the academic status togain independence from his parentdisciplines. There is almost noreference to Pelletan’s work bycontemporary medical scientists ordoctors. Abandoned by his colleaguesin physics and from his own faculty,his isolation led inevitably to hisrejection. At his death, his colleaguesassigned him to obscurity, a false,harsh and ultimately prematurejudgement.

Both medical physics and Pelletan’sinitiatives and ideas had longevity. Hisabsolute conviction, declared in 1813,that physics and chemistry must formthe only basis for physiology, emergedas mainstream thinking by the middleof the century, particularly in theGerman universities. Courses inmedical physics slowly becameestablished throughout Europe andacross the Atlantic, together withtextbooks to support them. One suchbook in Spain explicitly declared theauthor’s debt to Pelletan.10 And anyconflict between physics and medicinearose from politics and personalities,and not from science. This remains astrue today as it was in Pelletan’s time.

REFERENCES

1 Duck F. A history of medical physics. Defining medicalphysics: 1794–1822. Scope 2011; 20(2): 50–4.

2 Young T. The Croonian Lecture. On the functions of theheart and arteries. Phil Trans 1809; 99: 1–31. See also PhilTrans 1808; 98: 164–86.

3 Sonolet J, Poulet J. La dynastie médicale des Pelletans.Sem Hop Paris 1972; 48: 3513–20.

4 Pelletan F. Traité Élémentaire de Physique Générale etMédicale. Paris: Gabon, 1824.

5 Ballot. French medical concours. Lancet I 25th October1834: 159–60.

6 www.france-pittoresque.com/spip.php?article3542

7 Hoefer JCF. Pelletan, Pierre. In Nouvelle biographiegénérale depuis les temps les plus reculés jusqu’a nosjours. Paris: Firmin Didot, 1862; 39: 498–9, and Wikipedia.

8 Pelletan P. Douze leçons de physique générale. Brussels:Mertens, 1845.

9 Anon. Avis aux abonnés de la Presse. La Presse, 7thNovember 1845.

10 Ribero Serrano A. Tratado elemental de fisica general ymedica, estractado de las obras de MM. Pelletan Despretz,etc. Madrid: Hortelano, 1845.

ABOUT THE AUTHORFrancis Duck is Honorary ConsultantMedical Physicist in the Department ofMedical Physics and Bioengineering atthe Royal United Hospital Bath NHSTrust and visiting professor at theUniversity of Bath. Email: [email protected]

ACKNOWLEDGEMENTI am greatly indebted to Estelle Lambert, ofthe Bibliothèque interuniversitaire desanté, Paris, for providing copies ofPelletan documents, currently held in theMusée d'Histoire de la Médecine, Paris.

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Theevidencefrom thisperiodshowsPelletandevotinghis talentsto Frenchindustry

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