[Establishing an Ambulatory Health-Care Centre (AHCC) at a University Hospital]. / Gründung eines Medizinischen Versorgungszentrums (MVZ) an einem Universitätsklinikum.

BACKGROUND: Since January 2004 hospitals have the opportunity to establish an ambulatory health-care centre (Medizinisches Versorgungszentrum - MVZ) as a result of the introduction of the Health-care Modernisation Act (Gesetz zur Modernisierung der gesetzlichen Krankenversicherung - GMG). After about a half-year preparatory phase, the UKE, in September 2004, began operation of the "Ambulanzzentrum des UKE GmbH" (a limited liability company) as the first MVZ at a university hospital in Germany. We report here on the establishment of the MVZ and the experience made. MATERIALS AND METHODS: In the initial phase, only the medical fields of radiation therapy and nuclear medicine were represented. Both disciplines, especially radiation therapy, were existentially threatened by the extensive loss of ambulatory patients. The central motive for the establishment of the ambulatory health-care centre was to secure the survival of both disciplines and to preserve existing jobs. After it was put into operation, the referrals from practice-based colleagues to both radiation therapy and nuclear medicine increased quickly. The positive developments caused other departments of the UKE to express their interest in supplementing their outpatient activities with facilities in the MVZ. RESULTS: Over the following years, the ambulance centre grew steadily. Now 24 departments are represented in the MVZ, and the centre has a total of 49 positions for physicians contracted by and registered within the German public health insurance system. The number of salaried doctors has risen to 85, although many of these only work part time in the MVZ. Also more than 83 non-medical staff members were hired over the years. These were mostly physiotherapists, radiographers, and medical assistants. With the growing number of departments in the MVZ, the number of treated cases grew steadily. Currently approximately 20 000 cases are treated in each quarter of a year. CONCLUSIONS: The experience made while establishing an ambulatory health-care centre is very positive. Better cross-sectoral medicine, support of referring practice-based colleagues, content of centre-physicians and a strengthening of research and teaching summarise the experience of the last 7 years accurately. The outpatient centre of UKE GmbH will strive to continue to expand its range of medical services into other medical fields whenever it makes sense.

[Central interdisciplinary emergency department. Organization of emergency medicine from the perspective of hospital management]. / Interdisziplinäre zentrale Notaufnahme. Organisation der Notfallmedizin aus Sicht des Krankenhausmanagements.

The treatment of emergencies in a hospital should be organized in a central interdisciplinary emergency department (ER). It is the main entrance for all patients with acute illness or injuries. There are multiple advantages of such a central unit. Quality of treatment and economic efficiency is improved. The interdisciplinary diagnostics and treatment at one place prevents time-consuming and unnecessary transport. The fact that more complex diseases and injuries need specialized doctors in specific disciplines should be considered in personnel planning of the ER. To reinsure that the entire medical staff of the hospital is familiar with the daily routine and clinical pathways of the ER, doctors from other departments of the hospital should always be part of the ER team.

[The role of university hospital executive board members]. / Die Rollen der Vorstandsmitglieder in einem Universitätsklinikum.

Demographic changes and medical progress in combination with vastly altered regulatory and economic environments have forced considerable change in the structure of German university hospitals in recent years. These changes have affected medical care as well as research and medical school training. To allow for more flexibility and a higher level of reactivity to the changing environment German university hospitals were transferred from state agencies to independent corporate structures. All but one remains wholly owned by the respective state governments. The governing structure of these independent medical hospitals consists of an executive board, generally made up of a medical director, a financial director, a director for nursing, and the dean of the medical faculty. In most hospitals, the medical director serves as chief executive officer. The regulations governing the composition and responsibility of the members of the executive board differ from state to state. These differences do affect to some degree the interactive effectiveness of the members of the executive boards. Modalities that stress the overall responsibility for all board members seem to work better than those that define clear portfolio limits. Even more than organizational and regulatory differences, the effectiveness of the work of the executive boards is influenced by the personality of the board members themselves. Success appears to be a clear function of the willingness of all members to work together.

Magnetic resonance colonography for the detection of inflammatory diseases of the large bowel: quantifying the inflammatory activity.

INTRODUCTION: The purpose of this study was to assess the diagnostic accuracy of magnetic resonance colonography (MRC) for its ability to detect and quantify inflammatory bowel disease (IBD) affecting the colon. Endoscopically obtained histopathology specimens were used as the standard of reference. MATERIALS AND METHODS: Fifteen normal subjects and 23 patients with suspected IBD of the large bowel underwent MRC. Three dimensional T1 weighted data sets were collected following rectal administration of water prior to and 75 seconds after intravenous administration of paramagnetic contrast (gadolinium-BOPTA). The presence of inflammatory changes in patients was documented based on bowel wall contrast enhancement, bowel wall thickness, presence of perifocal lymph nodes, and loss of haustral folds. All four criteria were quantified relative to data obtained from normal subjects and summarised in a single score. This MRC based score was compared with histopathological data based on conventional endoscopic findings. RESULTS: MRC correctly identified 68 of 73 segments found to reveal IBD changes by histopathology. All severely inflamed segments were correctly identified as such and there were no false positive findings. Based on the proposed composite score, MRC detected and characterised clinically relevant IBD of the large bowel with sensitivity and specificity values of 87% and 100%, respectively, for all investigated colonic segments. CONCLUSION: MRC may be considered a promising alternative to endoscopic biopsy in monitoring IBD activity or assessing therapeutic effectiveness.

Real time high resolution magnetic resonance imaging for the assessment of gastric motility disorders.

BACKGROUND: The aim of this study was to evaluate whether patients with increased or decreased gastric motility can be differentiated from healthy volunteers by means of real time magnetic resonance imaging (MRI). PATIENTS AND METHODS: Ten healthy volunteers, 10 patients with gastroparesis, and 10 patients with functional pylorospasm/peptic pyloric stenosis underwent real time MRI. All patients were examined on two separate days; once prior to therapy and once after adequate therapy. Antral motility was quantified by calculating the gastric motility index. RESULTS: Patients with gastroparesis showed a lower motility index compared with the reference volunteer group while the mean motility index of the patient group with pylorospasm was more than three times higher than that of the reference value of the volunteer group. However, the gastric motility index in the patient group with gastroparesis increased, and in the group with functional pylorospasm/peptic pyloric stenosis it decreased significantly after therapy. CONCLUSION: Real time MRI is a reliable tool for assessment of gastric motion. Furthermore, differences in gastric motility index in patients with increased or decreased gastric motility could be evaluated and quantified. Due to the non-invasive character of MRI, this imaging modality may be an attractive alternative to conventional invasive diagnostic tools for gastric motility disorders and therapeutic monitoring.

Value of (124)I-PET/CT in staging of patients with differentiated thyroid cancer.

The aim of this study is to evaluate the clinical significance of (124)I positron emission tomography (PET) using a combined PET/CT tomograph in patients with differentiated thyroid carcinoma and to compare the PET/CT results with (131)I whole-body scintigraphy (WBS), dedicated PET and CT alone. Twelve thyroid cancer patients were referred for diagnostic workup and entered complete clinical evaluation, including histology, cytology, thyroglobulin level, ultrasonography, fluorine-18 fluorodeoxyglucose (FDG)-PET, FDG-PET/CT and CT. Lesion-based evaluation showed a lesion delectability of 56, 87 and 100% for CT, (124)I-PET, and combined (124)I-PET/CT imaging, respectively. Lesion delectability of (131)I-WBS was 83%. We conclude that (124)I-PET/CT imaging is a promising technique to improve treatment planning in thyroid cancer. It is particularly valuable in patients suffering from advanced differentiated thyroid cancer prior to radio-iodine therapy and in patients with suspected recurrence and potential metastatic disease.

[Magnetic resonance imaging in the diagnosis of benign and malignant pelvic tumors]. / Magnetresonanztomographie benigner und maligner Tumoren des weiblichen Beckens.

Magnetic resonance imaging (MRI) is an accepted imaging method for diagnosing diseases of the female pelvis. This review article describes the role of MR imaging for the diagnosis of benign and malignant pelvic tumors. Sagittal T2-weighted fast spin echo sequences can be effectively applied to diagnose leiomyomas of the uterus and provide exact pretreatment measurements of size and localization. In the diagnostic work-up of endometrial carcinoma, fat-saturated, T1-weighted gradient echo sequences make it possible to determine precisely how deep myometrial infiltration extends and what tissue should be included in preoperative treatment planning. In cervical cancer staging, MRI permits both assessment of local tumor extent and determination of tumor volume for planning and monitoring radiotherapy. The usefulness of MRI in cervical cancer staging is, however, limited since not all early-stage cancer (FIGO stage IA and small stage IB tumors) can be detected. Hence, it appears that the use of MRI as a screening method for cervical cancer cannot be recommended. MRI can distinguish between benign and malignant ovarian tumors with high sensitivity and specificity. Standard and fat-saturated T1-weighted sequences usually can diagnose teratomas with a specificity of 100 %. Axial fat-saturated, contrast enhanced T1-weighted spin echo sequences are useful in the staging of malignant ovarian tumors since they facilitate evaluation of their internal structure and will disclose peritoneal metastases. Besides staging of ovarian cancer, MRI can be applied for localization and for monitoring treatment response.

High spatial resolution whole-body MR angiography featuring parallel imaging: initial experience.

PURPOSE: To combine whole-body multi-station three-dimensional contrast enhanced magnetic resonance angiography (3D CE MRA) using a self-developed rolling table platform with parallel imaging strategies (PAT) in order to increase the spatial resolution of the 3D MRA data sets. MATERIALS AND METHODS: Whole-body multi-station MRA was performed with a rolling table platform (AngioSURF) on 5 volunteers in two imaging series: 1) standard imaging protocol, 2) modified high-resolution protocol employing PAT using the generalized autocalibrating partially parallel acquisitions (GRAPPA) algorithm with an acceleration factor of 3. For an intra-individual comparison of the two MR examinations, the arterial vasculature was divided into 30 segments. Signal-to-noise ratios (SNR) and contrast-to-noise ratios (CNR) were calculated for all 30 arterial segments of each subject. Vessel segment depiction was qualitatively assessed applying a 5-point scale to each of the segments. Image reconstruction times were recorded for the standard as well as the PAT protocol. RESULTS: Compared to the standard protocol, PAT allowed for increased spatial resolution through a 3-fold reduction in mean voxel size for each of the 5 stations. Mean SNR and CNR values over all specified vessel segments decreased by a factor of 1.58 and 1.56, respectively. Despite the reduced SNR and CNR, the depiction of all specified vessel segments increased in PAT images, reflecting the increased spatial resolution. Qualitative comparison of standard and PAT images showed an increase in vessel segment conspicuity with more detailed depiction of intramuscular arterial branches in all volunteers. The time for image data reconstruction of all 5 stations was significantly increased from about 10 minutes to 40 minutes when using the PAT acquisition. CONCLUSION: The implementation of PAT into the concept of whole-body MRA enabled to increase the spatial resolution in all examined territories, which resulted in more detailed MR angiograms.

Dark-lumen MR colonography.

Magnetic resonance colonography (MRC) has been shown to be an appropriate diagnostic tool for the detection of colorectal pathologies. Recently, dark-lumen MRC has been introduced. This technique is based on the acquisition of a T1-weighted sequence after the administration of water enema and the intravenous administration of paramagnetic contrast. This report describes the underlying techniques of dark-lumen MRC concerning data acquisition and image interpretation. Furthermore, it points out the advantages of this approach as compared with conventional endoscopy or other MR methods. Possible improvements in the future such as the implementation of fecal tagging strategies to avoid bowel cleansing are discussed.

FDG-PET/CT in re-staging of patients with lymphoma.

The aim of this study was to evaluate the clinical significance of combined fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography (FDG-PET/CT) in patients with lymphoma, and to compare the FDG-PET/CT staging results with those of FDG-PET and CT alone. Twenty-seven patients were studied. Each patient had clinical follow-up for >12 months and entered complete follow-up evaluation. Patient-based evaluation showed a sensitivity of 78% for CT alone, 86% for FDG-PET alone, 93% for CT and FDG-PET read side by side, and 93% for combined FDG-PET/CT imaging. Region-based evaluation showed a sensitivity for regional lymph node involvement of 61%, 78%, 91% and 96% respectively. FDG-PET/CT imaging is superior to CT alone ( P=0.02) and has additional benefit over FDG-PET alone due to exact anatomical localisation. We conclude that FDG-PET/CT imaging is accurate in re-staging lymphoma and offers advantages over separate FDG-PET and CT imaging.

Dark lumen magnetic resonance colonography: comparison with conventional colonoscopy for the detection of colorectal pathology.

BACKGROUND: The purpose of this study was to assess the feasibility and usefulness of a new magnetic resonance (MR) colonography technique for the detection of colorectal pathology in comparison with conventional colonoscopy as the standard of reference. PATIENTS AND METHODS: A total of 122 subjects with suspected colorectal disease underwent "dark lumen" MR colonography. A contrast enhanced T1w three dimensional VIBE sequence was collected after rectal administration of water. The presence of colorectal masses and inflammatory lesions were documented. Results were compared with those of a subsequently performed colonoscopy. RESULTS: MR colonography was found to be accurate regarding detection of clinically relevant colonic lesions exceeding 5 mm in size, with sensitivity and specificity values of 93%/100%. CONCLUSION: Dark lumen MR colonography can be considered as a promising alternative method for the detection of colorectal disease. In addition, it allows assessment of extraluminal organs.

Diagnosis of labia metastasis by F-18 FDG PET and CT fusion imaging in sarcoma follow-up.

ABSTRACT A 32-year-old woman with a history of pelvic sarcoma underwent whole-body fluorine-18 fluorodeoxyglucose positron emission tomography (PET) and computed tomographic (CT) fusion imaging for restaging after primary surgery and adjuvant combined radiation and chemotherapy. Interpreting the PET images alone showed an area of focal tracer accumulation in the pelvic floor and was interpreted as being secondary to urine contamination. Image fusion with fully coregistered CT scans showed a localized site of increased uptake from a metastasis to the labia, which was confirmed by biopsy. The presented case illustrates the usefulness of combined PET/CT fusion imaging to overcome some pitfalls of PET imaging alone (eg, differentiating malignant tumor from pooling of tracer in the genitourinary tract or contamination).

[Magnetosomes as biological model for iron binding: relaxivity determination with MRI]. / Magnetosomen als biologisches Modell der Eisenbindung: Messung der Relaxivität in der MRT.

PURPOSE: In vitro characterization of iron-containing bacterial particles (magnetosomes) as superparamagnetic contrast agents for MRI. MATERIAL AND METHODS: Different concentrations of magnetosomes were examined with a 1.5 T clinical whole-body MR system at 21 degrees C using the transit/receive extremity coil. Both longitudinal and transversal relaxivities (R1 and R2) of the magnetosomes were determined by an inversion recovery snapshot gradient recall echo (IR FLASH) with various inversion times and a multi echo spin echo sequence. Atomic absorption spectrometry (AAS) and electron microscopy were used as reference standard. RESULTS: Longitudinal and transverse relaxivities of the magnetosomes were calculated to be R1 = 7.688 mmol -1 s -1 and R2 = 147.67 mmol -1 s -1, respectively. The corresponding iron concentrations were determined in all dilutions using AAS, while the magnetosomes were morphologically delineated by electron microscopy. CONCLUSION: Magnetosomes represent a new and interesting class of iron-containing contrast agents warranting further evaluation in cellular cultures and animal models. Magnetosomes may be suited for displaying the vector distribution and gene expression of new molecular therapies.

Virtual magnetic resonance colonography.

Colorectal cancer screening has vast potential. Beyond considerations for cost and diagnostic accuracy, the effectiveness of any colorectal screening strategy will be dependent on the degree of patient acceptance. Magnetic resonance (MR) colonography has been shown to be accurate regarding the detection of clinically relevant colonic polyps exceeding 10 mm in size, with reported sensitivity and specificity values exceeding 95%. To further increase patient acceptance, strategies for fecal tagging have recently been developed. By modulating the signal of fecal material to be identical to the signal characteristics of the enema applied to distend the colon, fecal tagging in conjunction with MR colonography obviates the need for bowel cleansing. The review will describe the techniques underlying MR colonography and describe early clinical experience with fecal tagging techniques.

[State of the art of MR colonoscopy]. / Aktuelle Standards der MR-Kolonographie.

MR colonoscopy is suitable for colorectal cancer screening. This imaging modality is non-invasive, has no harmful side effects and provides a high diagnostic accuracy. MR colonoscopy has been found to be highly sensitive and specific in detecting colorectal lesions > 10 mm in size. Since colonic polyps are difficult to differentiate from residual stool, colonic cleansing has been unavoidable but reduces patient acceptance. Cleansing of the bowel can be avoided if the signal of stool is rendered different from its surrounding. This can be achieved by adding an agent to the food that tags the feces (fecal tagging). This article describes current techniques of MR colonoscopy as well as first results with fecal tagging.

Gadobenate dimeglumine (MultiHance) for magnetic resonance angiography: review of the literature.

Although limited in number, reports describing the use of Gd-BOPTA for 3D CE-MRA reveal that this agent is safe, well tolerated and effective for CE-MRA at doses up to 0.3 mmol/kg bodyweight. The use of Gd-BOPTA leads to additional diagnostically relevant information comparable to that attainable with conventional DSA and superior to that on non-enhanced MRA in most arterial territories. In studies in which Gd-BOPTA is compared at equal dose with other gadolinium-based MR contrast agents, Gd-BOPTA has consistently shown significantly better quantitative and qualitative performance. Thus, Gd-BOPTA can be considered to have a very favorable risk/benefit ratio for MRA. In summary, it is likely the documented superiority of Gd-BOPTA for MR angiography will lead to its broad usage for this indication wherever the agent becomes available.

Combined PET/CT with iodine-124 in diagnosis of spread metastatic thyroid carcinoma: a case report.

Iodine-124 positron emission tomography (PET) is a useful 3D imaging technique for diagnosis and management of thyroid diseases. The difficulty in interpretation of the PET scans with highly selective tracers, such as iodine-124, is the lack of identifiable anatomical structures, so an accurate anatomical localization of foci presenting abnormal uptake is problematic. Consequently, a combined PET/CT scanner can resolve these difficulties by co-registering PET and CT data in a single session allowing a correlation of functional and morphologic imaging. A case is presented where iodine-124 produced by a clinical cyclotron and FDG were used to acquire images with a combined PET/CT scanner for clinical staging. On the basis of the PET/CT exams the treatment of the patient was modified.