PORTFOLIO A revolution in healthcare... Open Source solution for medical imaging

PORTFOLIO
Open Source solution for medical imaging
A revolution in healthcare...
1
OsiriX
INTRODUCTION
The increasing role of medical images in
medical decision-making and treatment
monitoring has lead to an increased demand for image display and visualization
tools in clinical practice. The complexity
and large volume of image data generated
by today’s imaging modalities call for more
sophisticated rendering techniques that allow users to better grasp physiological and
anatomical findings. While these advanced
imaging platforms are gradually available in
radiology departments, they still lack in
other clinical environments. The high cost of
commercially available solution is the most
limiting factor for wide spread implementation of advanced medical imaging workstations in clinical environment. The emergence of Open Source solutions provides
attractive and cost effective alternatives
that can easily be tailored to specific needs
and clinical tasks.
We adopted the Open Source paradigm for
the development of multimodality image
display and analysis software called OSIRIX.
This platform is designed for handling large
sets of images in three, four and five dimensions. Special attention was given to design
a user interface tailored for physicians that
are not necessarily familiar with image
processing tools. The user has full control on
customizing the user interface and adding
or removing tools as needed. The software
program allows easy addition of plug-in
components. The success and wide adoption of OSIRIX around the world has confirmed our belief in Open Source as an alternative to traditional commercial software
distribution. It helped us bring together a
2
community of users and developers that
largely contributed to the improvement and
extension of this program.
Short history...
A
2004 / UCL
The OSIRIX project started in 2004 when Dr.
Antoine Rosset joined the lab of Professor
Ratib at UCLA for a research fellowship. Dr.
Ratib was the vice chair of the department of radiology in charge of information technology and deployment of imaging informatics. With the rapid
growth of new imaging modalities
and emergence of new hybrid imaging techniques such as PET/CT, he was
challenged with an increasing demand for high-end image processing
and analysis workstations. Most
2006 / HCUGE
commercial solutions were very expensive and did not quite provide
adequate solutions for complex clinical requirements. With Dr. Rosset they decided to develop a new platform for advanced 3D and multi-modality image display and processing that can be easily used
by clinicians and radiologists without special
training. Their goal was to go beyond 3D
volume rendering of images that are commonly available, but to provide an integrated “navigation” platform for exploring
large sets of multidimensional image data.
The code name was “navigating the fifth
dimension”.
What is Osirix?
A fully interactive image
navigation and visualization
software designed for display and analysis of large
sets of three dimensional
medical images. The program
is specifically designed to handle new
3
generations of multi-modality imaging data
combining anatomical and metabolic images such as PET/CT. It also provides dynamic display for time-varying images such
as cardiac motion or metabolic functional
studies. Designed by a team of radiologists it
provides an intuitive and user friendly user
interface tailored for physicians that are not
familiar with complex image processing and
manipulation techniques.
OSIRIX platform was also designed to support peer-to-peer technology as an alternative to centralized Picture Archive and
Communication Systems (PACS) architecture for the increasing requirements for wide
access to images across the enterprise. The
infrastructure implemented allows fast and
efficient access independently from the actual physical location of the data with a
performance 10 to 20 x faster than central
PACS archive. It is particularly suitable for large hospitals and academic environments where clinical conferences, interdisciplinary
discussions and successive sessions of image
processing are often part of complex workflow or patient management and decision
making.
OsiriX software is distributed free of charge
as an open-source software under the GNU
licensing scheme.
Why Open Source?
The concept of Open Source Software
promotes the development and sharing of
software source code under special licensing agreements that protects author’s copyrights while maintaining the distribution of
free and open derivative work based on the
original code. The most successful example
of Open Source development is Linux Operating system. Numerous other Open Source
software products have been widely
4
adopted such Apache web server software
that has exceeded by far the number
of implementation sites of competing
commercial products.
The rationale behind open source is
very simple: When programmers can
read, redistribute, and modify the
source code for a piece of software,
the software evolves. People improve
it, people adapt it, people fix bugs. And this
can happen at a speed that, if one is used
to the slow pace of conventional software
development, seems astonishing. The rapidly growing open source community has
realized that this rapid evolutionary process
produces better software than the traditional closed model, in which only a very
few programmers can see the source code
and everybody else must blindly use an
opaque set of software tools.
It is important to acknowledge that not all
the free software programs are Open
Source. Numerous software packages are
distributed as “shareware” by which the
software is provided free of charge or in exchange for a voluntary token contribution,
but the source code is kept property of
its main author. While shareware software benefit from broad distribution and
feed back from users they lack the ability of improvement from input and enhancement provided by other developers and users.
Impact of Open Source in Medicine
Numerous recent reports showed that the
evolution and adoption of electronic medical records (EMR) in medicine have significantly lagged behind expectations due to
three major barriers: excessive cost, the
transience of vendors, and the lack of
common data standards. Many authors
suggested however that Open Source Soft5
ware reduces barriers to EMR adoption, first
by reducing EMR ownership and development costs. Open Source offers
freedom from software licensing
costs. With reduced cost software
upgrades, and no license expiration. The medical informatics
community welcomes OSS, which
fits naturally its scientific model of shared,
peer-reviewed knowledge in medicine.
Vendors of Open-source applications can
share development costs with
the users community and focus
on implementation and support
services. The resulting paradigm
shift is that open-source medical
system vendors can become
professional service providers,
competing on service quality rather than on
the basis of software secrets.
The impact of open source is even greater
in specialized areas of medicine such medical imaging. These vertical markets have
always been a challenge for vendors and
manufacturers due to the small size of specialized users and high expectations in terms
of complexity and performance of the tools
that users need. This has naturally driven the
market to high-end and high-cost developments and marketing strategies that also
try to cope with very rapid evolution of
computer technologies and software developments that make most products obsolete in very short time interval, which does
not allow the manufacturers to
generate sustainable return on investment. In very specialized niches
such as in medical imaging it is almost impossible to maintain profitable business models that are selfsustained. Most manufacturers will cover the
cost through revenues from other business
avenues such as sales of imaging modalities, scanners and imaging devices, or by
6
providing expensive global solutions and
charging high costs for implementation and
support and maintenance contracts of
complex integrated information systems.
OSIRIX in the world
In our project of development and wide distribution of OSIRIX we experienced the tremendous potential of Open Source
paradigm inside a community of specialists and professional users that were extremely supportive and instrumental in making the
success of this initiative go
beyond our wildest expectations. The rapid growth of
OSIRIX features and tools
was driven by the large
community of users that
contributed to its con20'000
stant improvement in
response to real practi17'500
cal needs. It is a perfect
example of software
application develop15'000
ment directly driven by
users and tailored for
12'500
their specific needs. The
most challenging task
10'000
for our development
team was to keep the
7'500
pace and coordinate
the development of
5'000
new tools while maintaining the robustness
Oct Nov
and stability of the
whole program. Thanks
to the wealth of feed
back and input from thousands of users
around the world it was possible to release
software updates and new features at a
Unique IPs / month
March April
May
June
July
August Sept
7
rate that exceeded by far the rate of software updates in industry. This was even
more challenging on the Macintosh platform due to the extremely rapid evolution of
the computer operating system and hardware platforms that were updated by Apple
at a rate of major enhancements of the
operating system every six months and a
change in the architecture and performance of the hardware platforms twice or
three times a year.
Besides the development of new processing
and analysis tools that will continue, it is our
plan is to extend the OSIRIX platform to become more than just a visualization and image processing software. A prototype of a
server version of OSIRIX using the core database and communication features of OSIRIX
to manage a large capacity storage volume provides a simple solution for building
the main component of a min-PACS that
can serve a network of imaging devices
and processing workstations. By supporting
all standard DICOM communication features, it provides a cost effective solution
when used with new raid storage technology like the ones released by Apple computer allowing to set up over 7 Terabytes of
storage capacity for less than $10’000.-. In
our institution we implemented such a solution to provide an extension to our commercial PACS for storage of very large datasets generated by multidetector scanners
generating extremely large number of thin
images slices used for generating 3D image
and volume rendering of anatomical structures. Usually these large data sets (of over
hundreds of Gigabytes) cannot be stored
on the clinical PACS due to their size and
the impact on image communication that
they generate on a conventional PACS.
Such an addition to existing PACS can provide an elegant solution for temporary storage of those large volumes of images with
List of institutions officially using OSIRIX for
clinical and research applications
8
impacting the performance and workflow
of existing PACS.
Furthermore we
joined a larger consortium of Open
Source developer in
medical imaging to
contribute to the development of a larger
range of software tools that will support image and data management in clinical and
multicentric research projects. The first kik-off
meeting of this new initiative was held during a two day workshop in Las Vegas in
March 2006 called “Open Source Strategy
for Multi-Center Image Management”
(http://www.mcim.georgetown.edu). The
consortium is currently extending its efforts in
Open Source development under a common framework called Image Management
Tool Kit (IMTK).
List of commercial companies implementing and supporting OSIRIX-based products
9
OsiriX
A success story...
OSIRIX was presented
at numerous international meetings and
scientific conferences and received numerous awards. It also
received awards from Apple for excellence in software design
and the authors were invited at several Apple events to present their work to the Apple developer and user community.
Dec 2004: Magna Cum Laude Radiological Society of North America (RSNA)
March 2005: 1st Price at the European Society of Radiology (ECR)
June 2005: Apple award of best Open Source software design
Dec 2005: Cum Laude award RSNA
Dec 2006: Certificate of Merit award RSNA
10
OsiriX in the News
OSIRIX in the press
Imaging Informatics, March 2004
First interview where the concept of Open Source imaging software as alternative to
traditional PACS software was mentioned.
Health Imaging and IT, November 2004
Article published in a special issue on the annual Radiological Society of North America (RSNA) annual meeting in November 2004.
11
Tages Anzeiger (Zurich Newspaper), March 2005
TA
GES
INFO
45 07.03.2005
10.03.05 13:10:53
DIGITAL
Tages-Anzeiger · Montag, 7. März 2005
45
Swisscom baut das
schnellere VDSL aus
Bis 2007 soll die Hälfte der Schweizer Bevölkerung mit VDSL surfen
(Very Highspeed Digital Subscriber
Line). Die auf dem Glasfasernetz basierte Technologie soll Surfgeschwindigkeiten von bis zu 50 Mbit
pro Sekunde ermöglichen, allerdings
nur, wenn man nahe genug an einem
Glasfaserknoten wohnt. Die Verteilung auf die Haushalte erfolgt per
Kupferdraht, je länger diese Leitung
ist, desto langsamer wird VDSL.
Steigen die Preise für
Musikdownloads?
Die Musikbranche macht offenbar
Druck bei den Online-Musikdiensten, die Preise pro Song zu erhöhen.
Anfangs hat man niedrigen Preisen
zugestimmt, weil man dachte, nur so
das Geschäft zum Laufen zu bringen.
Unterdessen hat alleine Apples
iTunes 300 Millionen Songs verkauft
– das weckt die Gelüste der Musikverlage auf mehr Geld. Steve Jobs sei
Berichten zufolge «wütend».
Erste Runde an Apple
In einem umstrittenen Verfahren gegen drei so genannte Gerüchte-Sites
hat Apple die erste Runde für sich
entschieden. Die Betreiber der Websites müssen demnach ihre Quellen
preisgeben, wollen aber an die
nächsthöhere Instanz appellieren.
Ritter Bill Gates
BILDER JEAN REVILLARD/REZO
Antoine Rosset ist Radiologe am Universitätsspital Genf. Sein Programm erzeugt u. a. 3-D-Modelle von Organen, die sich auf dem iPod betrachten lassen.
Ein günstiger Blick in den Körper
Digitale Bilder spielen in der
Medizin eine wachsende Rolle.
Um sie effizient auszuwerten,
schreibt ein Genfer Radiologe
eigene Software, die bereits
weltweit eingesetzt wird.
Von Roger Zedi
Mit Antoine Rosset Schritt zu halten, fällt
dem angereisten Journalisten nicht ganz
leicht. Durch die vom Tageslicht nur
knapp erreichten, weitläufigen Gänge des
ersten Untergeschosses des Universitätsspitals Genf führt der Radiologe den Besucher flink an den Ort des Geschehens: die
Radiologie-Abteilung, wo in gleich mehreren Computertomografen (CT) Patienten
in unbequem wirkenden Positionen liegen, Medizinerteams gebannt auf ihre
Bildschirme blicken und die resultierenden Aufnahmen diskutieren. «Hier entstehen täglich rund 6000 Bilder, im Jahr sind
es mehrere Millionen», erzählt Rosset, der
sich in seiner Welt sichtlich wohl fühlt.
Den Besucher beschleicht hingegen ein
leises Gefühl, in die Intimsphäre anderer
Leute eingedrungen zu sein, und nimmt
gerne Rossets Einladung ein, das Gespräch
in einem ruhigen Büro fortzusetzen.
Computertomografen und andere bilderzeugende Systeme sind aus der Medizin
nicht mehr wegzudenken. Rosset schätzt,
dass jedes Jahr rund 20 bis 30 Prozent
mehr Bilder produziert werden. «Wir setzen heute CT für viel mehr Dinge ein als
noch vor zehn Jahren, vieles davon wäre
damals noch undenkbar gewesen», sagt
Rosset. Sogar in der Genfer Notaufnahme
steht mittlerweile ein CT bereit, jederzeit
ins Innere der Patienten zu blicken. «Für
eine gute Diagnose ist es essenziell, dass
die Bilder rasch und präzise ausgewertet
werden können», erzählt er. Und genau zu
diesem Zweck hat er ein Computerprogramm geschrieben: Osirix.
Viewer. Und die mitgelieferten Anwendungen beinhalten oft nur die absoluten
Grundfunktionen, will man etwa aus den
Querschnitt-Bildern eines CT ein 3-D-Modell eines inneren Organs erstellen, kostet
das extra. «Früher hatten wir hier genau
einen Computer, der das konnte», sagt
Rosset, «dank Osirix können wir das nun
auf jedem unserer Macs machen.»
Seine Software hat es in sich, wie Antoine Rosset bei aller Professionalität mit
sichtlichem Spass demonstriert. Auf einen
Mausklick lädt er schwarzweisse CTQuerschnitte und generiert daraus innert
Sekunden farbige 3-D-Modelle etwa eines
menschlichen Herzens, kann das Knochengewebe ausblenden oder ganz nah an
bestimmte Kranzgefässe zoomen. Selbst
Animationen sind für Osirix kein Problem,
auf Wunsch schlägt das 3-D-Herz auch.
Zudem lassen sich Bilder verschiedener
Systeme einfach kombinieren, die man
früher nur auf verschiedenen, dafür speziell ausgestatteten Computern anschauen
konnte. Und all diese Möglichkeiten gibt
es zu einem unschlagbaren Preis: umsonst.
Das Sparpotenzial von Osirix ist enorm.
Open Source von zentraler Bedeutung
Ins Leben gerufen wurde Osirix 2003
während eines Forschungsaufenthaltes an
der University of California in Los Angeles unter der Leitung des Radiologen Osman Ratib. «Es war für uns von Anfang an
klar, dass unser Dicom-Viewer allen gratis
zu Verfügung gestellt werden soll», sagt
Rosset, der bereits Erfahrung im Programmieren mitbrachte.
Wenn schon Open Source, warum dann
Mac OS X und nicht gerade Linux? Linux
findet Rosset eine gute Sache, aber die Benutzeroberfläche von OS X ist einiges ausgefeilter, dazu kommen die enormen grafischen Möglichkeiten der Plattform. Und in
vielen Kliniken stehen eher Macs als Linux-PCs. Osirix darf auch als Befreiungsschlag aus der Diktatur der kommerziellen
CT-Hersteller verstanden werden. Zu denen gehören Philips, Siemens, General Electric,
LG, Toshiba und andere
mehr.
Rosset entschied sich
aber auch noch aus anderen Gründen für das
Open-Source-Modell, bei
dem alle den Bauplan eines Programms (genannt
Source-Code) einsehen
und ändern dürfen. «Mit
einem gesponserten oder
gar kommerziellen, proprietären Programm wäre es uns nie gelungen, seitens der Forschung und von den
Radiologen in den Kliniken so viel Feedback und Input zu erhalten», ist er überzeugt. Zudem zieht ein solches Projekt
keine Leute an, die nur des Geldes wegen
mitmachen. «Wenn von Anfang an klar ist,
dass niemand damit etwas verdient oder
für seine Arbeit entlöhnt wird, dann ma-
Erdumspannende Zusammenarbeit
Und die hat Rosset gefunden. Heute arbeiten zwei weitere Radiologen an der
Weiterentwicklung, einer lebt in Colorado
(USA), der andere in Neuseeland. So ist
fast rund um die Uhr jemand damit beschäftigt, neue Funktionen einzubauen.
«Ich hätte nie gedacht, dass ich mal mit
Leuten so gut zusammenarbeiten kann, die
ich weder kenne noch je
getroffen habe», sagt Rosset. Der 32-jährige Vater
eines 2-Jährigen versucht,
nicht mehr als zehn Stunden seiner Freizeit pro
Woche Osirix zu widmen.
Am meisten hat ihn jedoch das riesige Echo
überrascht, das er von
den
Anwendern
bekommt. Rund 5000 davon
hat Osirix heute, Tendenz
steigend. Die allermeisten
sind Radiologen an Kliniken aus aller Welt
(unter anderem am Universitätsspital Zürich), Ärzte, Forscher und Studenten.
Nur als OpenSource-Projekt war
es möglich, so viel
Feedback und Input
zu bekommen.
Osirix ist gratis und kann mehr
Wie kommt ein Radiologe dazu, selber
Software zu schreiben, liefern die CT-Hersteller so was nicht mit? Schon, aber zu einem sehr hohen Preis. Alleine die Software für eine einzelne Workstation, auf
der man CT-Bilder ansehen kann, kostet
zwischen 30 000 und 200 000 Dollar zusätzlich zu den bereits millionenteuren
Geräten. Die Bilder werden zudem in einem Format ausgegeben (Dicom), das gängige Bildbearbeitungsprogramme, etwa
Photoshop, nicht lesen können. Es braucht
also einen teuren, so genannten Dicom-
chen nur Leute mit, die sich wirklich für
die Sache interessieren.»
BILD PD
Per Video-Chat können die Bilder mit Kollegen besprochen werden.
Selbst Patienten nutzen Osirix
Über den Kreis der Radiologen hinaus
bekannt wurde Osirix, als Rosset und
seine Kollegen begannen, ihre iPods als
mobile Speicher für die Bilder zu benutzen. Das machte rasch im Internet die
Runde. «Es geht weniger darum, die Bilder
auf dem iPod photo anzuschauen. Wir
brauchten einen einfachen Weg, die Bilder
von einem Mac zum anderen zu bringen»,
sagt Rosset, den die ganze Aufregung um
Osirix und den iPod sichtlich amüsiert.
Eine CT-Aufnahmeserie ist rasch einmal
mehrere GB gross.
Selbst Patienten nutzen mittlerweile
Osirix. Seine eigenen CT-Bilder erhält
man auf CDs mit nach Hause, wenn man
dies wünscht. «Es kann für jemanden ein
wichtiger Teil der Auseinandersetzung
mit seiner Krankheit sein, das erkrankte
Organ oder einen Tumor am Bildschirm
zu betrachten», sagt Rosset. Gewisse Patienten gehen dann gleich mit ihrem Laptop zum Hausarzt und zeigen ihm die 3-DBilder. «Einige der Ärzte sind baff, was die
Patienten ihnen da zeigen, da ihre eigenen
Computer dieselben Daten nicht so darstellen können.»
Und wie lustig finden eigentlich die CTHersteller Osirix? Es gibt viel Neugier, wie
Rosset und seine Kollegen das so rasch
und günstig hingekriegt haben. «Bis jetzt
hat niemand versucht, uns zu stoppen.»
Die Queen hat Bill Gates zum Ehrenritter ernannt. Verdient hat er sich
die Ehre nicht als Softwareentwickler, sondern mit seinem Engagement
im Gesundheitswesen in armen Ländern des Commonwealth.
Zehn Jahre Yahoo
Die Suchmaschine Yahoo ist seit einer Dekade im Netz. Zwei Studenten
starteten den Dienst zunächst unter
dem Namen «Jerry’s Guide to the
World Wide Web». Heute arbeiten
7600 Leute bei Yahoo.
Intel mini
Der Chiphersteller Intel hat auf seiner Entwicklerkonferenz einen Kon-
BILD PD
Bloss Attrappe: Intel mini.
zept-PC fürs Wohnzimmer vorgestellt, der dem Mac mini zum Verwechseln ähnlich sieht. Wer so einen
PC bauen würde und ob das überhaupt passiert, ist noch offen.
Abo-Musikdienst
scheint erfolgreich
Bei Napster lassen sich Songs mieten. So lange das Abo läuft, dürfen
die US-Kunden unbeschränkt Musik
herunterladen, jedoch nicht auf CD
brennen. Das Modell scheint besser
zu laufen als erwartet, Napster hob
die Gewinnprognosen an, genaue
Zahlen sind noch nicht verfügbar.
Firefox gebremst
Der Webbrowser Firefox gewinnt
weiter Marktanteile, allerdings langsamer als bisher. «Spiegel online»
schätzt, dass Firefox in Europa beliebter ist als in Übersee. (TA)
«Digital-Sushi»
Im Gadget-Weblog
des «Tages-Anzeigers» schildern Redaktoren aus verschiedenen
Ressorts ihre Erfahrungen mit diversen
Gadgets. Leserkommentare und Anregungen sind willkommen.
www.tagesanzeiger.ch/
digitalsushi
12
l’HEBDO, july 2005
Article published in the July issue of the Swiss HEBDO magazine.
NyTeknik, November 2005
Article in the Swedish newspaper in the technical section just after an article about
Bill Gates.
13
Medical Futures, Spring 2006
Medical Futures is a specialized magazine for hospital managers, investors and CEOs.
FEMINA, March 2007
General article on new imaging technology with a special emphasis on OSIRIX and
Open Source
14
Radiology Today, February 2007
Cover story on Open Source mentioning OSIRIX on the cover with an Apple logo as
an example of successful Open Source imaging software.
REFLEX, June 2007
Article published in the official public magazine of the EPFL technical university in
Lausanne.
15
PULSATIONS , 2006-2007
OSIRIX was mentioned in several articles were published in PULSATIONS, the official
newsletter of the university hospital of Geneva (HUG)
European Cardiovascular Disease, July 2007
Review article on new trends in software developments for cardiac imaging with
emphasis on open source alternatives that provide advanced imaging tools developed by the community of developers and users.
16
White paper published by Apple October 2007
Article relating the advantages of implementing OSIRIX in clinical practice with a
practical example of the University of Manheim
Article in the Swiss Engineering journal November 2007
Article reporting on the practical utilization of OSIRIX and its 3D rendering capabilities
for treatment planning in orthopedic surgery
17
Article in the Japanese Surgical Journal November 2007
Article among a series of article published by a Japanese surgeon on the use of
OSIRIX in operating rooms for virtual navigation in images generated in 3D in the context of minimal invasive surgical procedures
Article in the Swiss newspaper Le Temps November 2007
18
Article published by Apple on Prof Pe%erin November 2007
Article relating the clinical utilization of OSIRIX by Professor Pellerin and his team at
the hospital of Lille for planning complex congenital repair surgery procedures
Article published by Apple on OSIRIX PACS January 2008 (in press)
In depth article published in collaboration with Dr. Roger Katon on the value and advantages of Open Source solutions such as OSIRIX in clinical settings
19
OSIRIX on the Web
Apple home Page (multiple events in 2004/2006)
Apple
(UK
and
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On CNN.com
20
Articles published by Apple on their web site
Dr. Osman Ratib
UCLA Department of Radiological Sciences
The challenge
“The G5 has such high-end power compared
to the rest of the market, the support for
OpenGL is fantastic, and the development
environment is just what we need.”
Bring expensive, compute-intensive 3D
medical visualization out of high-end
research labs and into the hands of
doctors, care givers, and patients
everywhere.
G5 Power in Science
Affordable 3D Medical Visualization
Dr. Osman Ratib: UCLA Department of Radiological Sciences
At UCLA, doctors have been working on advanced 3D medical visualization techniques.
Modern medical scanners (MRI, CT, and PET) produce GB-size images. Sets of these images combine to form
3D volumes that can be analyzed from any point of view or any angle. The ability to view medical data as a
real-time 3D volume provides researchers and doctors with an invaluable perspective on their work. Imagine
the benefits of making a diagnosis based upon an interactive 3-dimensional model versus a static 2dimensional image. These medical volumes consist of 100s or even 1000s of images, and in the past, only
doctors with access to expensive imaging workstations could make use of the huge data sets. The high costs
have placed these powerful tools out of reach of many of the doctors and caregivers who would benefit
most; consequently there have been few clinical applications for 3D medical visualization.
•! Powerful solution G5
at 10%
Power
of the cost
•! Workstation performance,
ease-of-use of a Mac
•! Out of the lab and into
the point of care
Dr. Osman Ratib, Professor and Vice Chair of Information Systems
UCLA Department of Radiological Sciences
in Science
Dr. Osman Ratib, professor and vice chair of information systems at the UCLA Department of Radiological
Sciences, and his colleagues have been working on a solution to bring compute-intensive 3D medical
visualization out of high-end research institutions and into the hands of doctors, care givers, and patients
everywhere.
G5 Power in Science
[Note to speaker: for more information see the online story at http://developer.apple.com/business/
macmarket/osirix.html]
Affordable 3D Medical Visualization
Dr. Ratib and his colleagues have developed the next-generation real-time 3D medical visualization solution.
The application is called OsiriX and it runs on a dual processor Power Mac G5. The 64-bit processing power
and affordability of today’s Power Mac G5 allows more doctors and hospitals access to this advanced medical
tool.
OsiriX is incredibly processor-intensive and is perfect for dual G5 processing. It is a multi-threaded
application that takes full advantage of the dual 64-bit G5 processors in a Power Mac G5, and is optimized for
the Velocity Engine. The Power Mac G5 and Mac OS X are also ideal because of the large 64-bit memory
addressing, reliable UNIX-based operating system, great OpenGL support and powerful developer tools.
Dr. Ratib has taken a powerful tool that was previously available only at the upper reaches of science and
made a solution that the average care giver can acquire and is comfortable using. This incredible solution
will result in better diagnosis, better treatment and better medicine.
21
American Medical News June 2007
2 PM
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Medicine on
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received a call
from a fellow
radiologist at
UCLA Medica
the San
l Center who nee
ded a second opin ta Monica
case.
ion on a tough
Dr. Zaragoza,
associate clinical
director at the
professor and
radiology clin
center, was able
ical
to view CT ima
and consult with
ges of the pati
his
ent
without ever leav colleague within a matter
of minutes, and
ing his home.
This scenario
much differen
would have bee
t a few years ago
n
,
than 10,000 use
before UCLA
became one of
rs of OsiriX soft
more
ware.
OsiriX was dev
eloped at UCLA
from Geneva,
by Dr. Osman
who
Rat
Dr. Antoine Ros was on staff at UCLA in the ib, a radiologist
early 2000s, and
set, who is also
research fellows
from Geneva
and was doing
hip at UCLA
a
during Dr. Rat
ib's tenure ther
The idea for Osi
e.
riX occurred to
using his iPod
the doctors afte
to transport larg
r Dr. Ratib star
ted
e radiological
computer to ano
files from one
ther. The softwar
expedites the
e recognizes the
downloads of
iPod and
images much
an iPod when
like iTunes reco
it is plugged in.
gnizes
But the iPod feat
part of the pro
gram.
ure is only a sma
ll
OsiriX, which
is compatible
only with App
physicians to
le computers,
view and navigat
allo
ws
e the data just
workstations cos
as effectively
ting upwards of
as
Borelli, MD, cha
$150,000, acc
ording to Joe
ir of the Americ
Accreditation
Committee, and an College of Radiology MR
I
a regular OsiriX
user.
"It's an amazing
era that we live
so ridiculously
in now, becaus
easy and so rob
e the technolo
gy is
ust," said Dr.
president and
Zaragoza, who
medical director
is also
of MRI of Bel
fair in Bluffto
Dr. Borelli has
n, S.C.
become such a
fan of OsiriX
every available
that he now use
opportunity to
s
eva
minutes with a
radiologist, they ngelize. "If you give me five
will be using Osi
riX," he said.
His enthusiasm
earned him the
starring -- alth
in a OsiriX We
ough unpaid -b seminar pro
role
duced by App
through the com
le, and availab
pany's Web site
le
.
The software
is continually
changing, as use
Dr. Rosset. It
rs make sugges
is available as
tions to
an open-source
Apple. A vers
download thro
ion of the soft
ugh
ware,
earlier this yea
r, is also availab which received FDA approv
al
le thro
a technology com
pany that develop ugh Aycan Medical System
s,
s software for
radiologists.
Conve
Med
://w
http
Apple news on UCLA radiologists
Appl
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ce Profile
Cutt
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LA
Radi
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, p.1
Sant
a Mo
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Med
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agin
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Cent
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By Jo
seph
Lo
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05/0
6/20
06
Scie
nce
07:5
0 AM
Apple - Science - Profile - UCLA Radiology, p.1
Why
05/06/2006 07:50 AM
Mac
for
Scie
digital age by allowing theHadisplay, transmission,
and storage of digital
nce
rdwar
e foUCLA
medical images. In addition, former
r Re radiologists Dr. Antoine Rosset and
sear
Soft
Dr. Osman Ratib were responsible
ch OsiriX, a free, open source
ware for creating
fofor
r Reradiologists for multimodal and
program designed by radiologists
se
arch
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multidimensional visualization.
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archAvailable only
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advantage of the platform’s
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Pr
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Imag
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X
As a result, standard Re
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lated
Link
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A br
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Home > Science > Profiles > UCLA Radiology
Page
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http://www.apple.com/science/profiles/ucla/
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22
Another success story published by Apple
Podcast on Apple web site of a conference in Boston, Nov 2005
Conference on OSIRIX given by Dr. Ratib at the Mass General Hospital in Boston and
recorded by Apple team that was posted on Apple web site
23
Online course on OSIRIX sponsored by Apple, May 2007
Apple uses OSIRX as a promotional tool for Apple hardware
24
Apple profiles on OSIRIX clinical implementations
25
OSIRIX news was also replicated in numerous web sites
26
OSIRIX on TV
Telejournal TSR1 , Mars 2005
First interview of Antoine Rosset and his project after returning from UCLA
Telejournal TSR1 , April 2006
Interview on OSIRIX for evening news on Swiss national TV
27
Telejournal TSR1 , Mars 2007
Interview on National TV during the official opening of the biomedical imaging center at EPFL technical university in Lausanne.
Pulsation - Leman Bleu , Aug 2007
Special reportage on innovations at the University Hospital of Geneva (HUG) with a
special feature on OSIRIX and Open Source
28
OSIRIX screen-shots
Examples of images and tools )om OSIRIX software
29
Scientific and peer-reviewed articles
Reference articles published by the OSIRIX team
1.
Rosset A, Spadola L, Pysher L, et al. Informatics in radiology (infoRAD): navigating the fifth dimension: innovative interface for multidimensional multimodality
image navigation. Radiographics. Jan-Feb 2006;26(1):299-308.
2.
Rosset A, Spadola L, Ratib O. OsiriX: an open-source software for navigating in
multidimensional DICOM images. J Digit Imaging. Sep 2004;17(3):205-216.
3.
Rosset C, Rosset A, Ratib O. General consumer communication tools for improved image management and communication in medicine. J Digit Imaging.
Dec 2005;18(4):270-279.
4.
Ratib O. PET/CT image navigation and communication. J Nucl Med. Jan
2004;45 Suppl 1:46S-55S.
5.
A Rosset, L Spadola, L Pysher, O Ratib - Navigating the Fifth Dimension: Innovative Interface for Multidimensional Multimodality Image …RadioGraphics, 2006 RSNA
6.
A Rosset, L Pysher, L Spadola, O Ratib - OSIRIX: open source multimodality image navigation software -Proceedings of SPIE medical Imaging Conference,
2005 -
7.
O Ratib, A Rosset - IOpen-source software in medical imaging: development of
OsiriX, International Journal of Computer Assisted Radiology and Surgery, 2006 Springer
Articles with references to OSIRIX
*obtained from Google Academic
High function PACS utilizing Osirix, an open source software
Y Katakura - No Shinkei Geka, 2006 - ncbi.nlm.nih.gov
Medical Images: Open Source Software
R Dreesen - wwwcs.uni-paderborn.de
Open source software for medical images R Dreesen - wwwcs.uni-paderborn.de
Peer-to-peer architecture for multi-departmental distributed PACS A Rosset, J Heuberger, L Pysher, O Ratib - Proceedings of SPIE, 2006 PET/CT image registration: Preliminary tests for its application to clinical dosimetry in
MC Baños-Capilla, MA García, J Bea, C Pla, L … - Medical Physics, 2007 -
30
Clinical and diagnostic imaging of bisphosphonate-associated osteonecrosis of the jaws S Chiandussi, M Biasotto, F Dore, F Cavalli, MA … - Dentomaxillofacial Radiology, 2006 - Br Inst Radiology
Cited by 6
Hexapod-Supported Instrument Control at the Temporal Bone
T Klenzner, F Knapp, CC Ngan, J Raczkowsky, H … - Skull Base, 2006 - thieme-connect.com
3D MRI in multiple sclerosis: a study of three sequences at 3 T RJ Mills, CA Young, ETS Smith - Br J Radiol, 2006 - Br Inst Radiology
Cited by 1 Incidence of Pulmonary Embolism After Non-Cemented Total Hip Arthroplasty in Eleven Dogs: Computed … AV Specialists, FL Maitland - Veterinary Surgery, 2007 - Blackwell Synergy
Spatial Analysis Tools for Virtual Reality-based Surgical Planning B Reitinger, D Schmalstieg, A Bornik, R Beichel - Proc. IEEE Symp. 3D User Interfaces doi.ieeecomputersociety.org
Cited by 1 Optimization of cardiac cine in the rat on a clinical 1.5-T MR system K Montet-Abou, JL Daire, MK Ivancevic, JN … - Magnetic Resonance Materials in Physics, Biology and
…, 2005 - Springer
Cited by 1 Apparent Diffusion Coefficient Mapping of Salivary Gland Tumors: Prediction of the Benignancy and … S Eida, M Sumi, N Sakihama, H Takahashi, T … - American Journal of Neuroradiology, 2007 - Am Soc Neuroradiology
The validity of estimating quadriceps volume from single MRI cross-sections in young men
CI Morse, H Degens, DA Jones - European Journal of Applied Physiology, 2007 - Springer
Recent Advances in Small Animal Cardiac Magnetic Resonance Imaging
M Nahrendorf, WR Bauer - Current Cardiology Reviews, 2006 - ingentaconnect.com
PARALLEL COMPUTING FOR MAGNETIC RESONANCE IMAGING (MRI)
VQ Garcia - 2005 - faculty.ed.umuc.edu
References and Reading Lists for Imaging Informatics Professionals: Preparing for Certification J Honeyman-Buck - Journal of Digital Imaging, 2006 - Springer
Decompressive Hemicraniectomy for the Treatment of Intractable Intracranial Hypertension After … CM Schirmer, DA Hoit, AM Malek - Stroke, 2007 - Am Heart Assoc
Cited by 6 Age-related quantitative MRI changes in healthy cartilage: Preliminary results - all 4 versions »
JC Goebel, A Watrin-Pinzano, I Bettembourg-Brault, … - Biorheology, 2006 - IOS Press
Listeria hijacks the clathrin-dependent endocytic machinery to invade mammalian cells E Veiga, P Cossart - Nature Cell Biology, 2005 - nature.com
Cited by 28 Delayed Enhancement Magnetic Resonance Imaging Predicts Response to Cardiac Resynchron JA White, R Yee, X Yuan, A Krahn, A Skanes, M … - Journal of the American College of Cardiology, 2006
- Elsevier
Cited by 3 Application of magnetic resonance imaging in developmental neurotoxicity testing: A pilot study. K Johnson, L Ryan, J Davis, A Elmore, B Guenther, … - NeuroToxicology, 2006 - Elsevier
Multimodal visualization interface for data management, self-learning and data presentation S Van Sint Jan, X Demondion, G Clapworthy, S … - Surgical and Radiologic Anatomy, 2006 - Springer
Cited by 1 Localization of Intestinal Bleeding Using a Fusion of Tc-99m-Labeled RBC SPECT and X-ray CT N Yama, E Ezoe, Y Kimura, M Mukaiya, K Fujimori, Y … - Clin Nucl Med, 2005 - nuclearmed.com
Cited by 1 -
31
General consumer communication tools for improved image management and communication in
medicine OM Ratib, A Rosset, JM McCoy - Proceedings of SPIE, 2005 - link.aip.org
Anisotropic Diffusive Image Filtering to Improve Stroke CT JJ Hargreaves, I Dzialowski, C Sivakumar, S … - imaginginformatics.ca
Sagittal craniofacial growth evaluated on children dry skulls using V 2 and V 3 canal openings as …
JC Harnet, T Lombardi, JC Lutz, P Meyer, JL Kahn - Surgical and Radiologic Anatomy - Springer
Three Dimensional Imaging and Virtual Endoscopy for Difficult Airway Evaluation in Children B Marciniak, P Fayoux, A Hébrard, C Weinachter, R … - asaabstracts.com
Segmentation of Costal Cartilage in Abdominal CT Data using Watershed Markers
AB Holbrook, KB Pauly - AIP Conference Proceedings, 2007 - link.aip.org
Comparison of Four Freely Available Frameworks for Image Processing and Visualization That Use ITK I Wolf, JM Kuhnigk - IEEE Transactions on Visualization and Computer Graphics, 2007
doi.ieeecomputersociety.org
-
SHORT CONTRIBUTION
SD JOHNSTON, C MADDEN, V NICOLSON, G COWIN, M PYNE … - Aust Vet J, 2006 - Blackwell Synergy
Hierarchical storage of large volume of multidector CT data using distributed servers - all 3 versions »
O Ratib, A Rosset, J Heuberger, D Bandon - Proceedings of SPIE, 2006 - link.aip.org
In vivo imaging of T cell delivery to tumors after adoptive transfer therapy
MJ Pittet, J Grimm, CR Berger, T Tamura, G … - Proceedings of the National Academy of Sciences, 2007 National Acad Sciences
Informatics in Radiology (info RAD) Free DICOM Image Viewing and Processing Software for the … EJ Escott, D Rubinstein - 2004 - RSNA
Cited by 2 Clinical aspects and management of bisphosphonates-associated osteonecrosis of the jaws M Biasotto, S Chiandussi, F Dore, A Rinaldi, C … - Acta Odontologica Scandinavica, 2006 - Taylor &
Francis
MAGNETIC RESONANCE MICRO-IMAGING OF XYLEM SAP DISTRIBUTION AND NECROTIC LESIONS IN TREE
STEMS …
K Kuroda - IAWA Journal, 2006 - cse.ffpri.affrc.go.jp
Multimod Data Manager: A tool for data fusion
M Viceconti, F Taddei, L Montanari, D Testi, A … - Computer Methods and Programs in Biomedicine,
2007 - portal.acm.org
High-resolution Myocardial Perfusion Imaging in Mice with High-frequency Echocardiographic Detection …
CA Preparation, A Preparation, I Micrososcopy, S … - Journal of the American Society of Echocardiography, 2007 - Elsevier
Brain of the African elephant (Loxodonta africana): neuroanatomy from magnetic resonance images AY Hakeem, PR Hof, CC Sherwood, RC SWITZER III, … - The Anatomical Record Part A, 2005 doi.wiley.com
Cited by 4 Model-Based Improvements in the Treatment of Patients with Strabismus and Axial High Myopia R Hoerantner, T Kaltofen, S Priglinger, CM Fock, M … - Investigative Ophthalmology & Visual Science,
2007 - ARVO
Magnetic resonance imaging of Klebsiella pneumoniae-induced pneumonia in mice
F Password, ISI View, C Microbiology - Cellular Microbiology, 2006 - Blackwell Synergy
Multimodality Molecular Imaging Identifies Proteolytic and Osteogenic Activities in Early Aortic … E Aikawa, M Nahrendorf, D Sosnovik, VM Lok, FA … - Circulation, 2007 - Am Heart Assoc
Cited by 4 A new approach towards volumetric assessment of left ventricular function with MSCT
S Yamamoto, S Hamada, M Miyamoto, J Masumoto, M … - biij.org
32
2D and 3D 3-tesla magnetic resonance imaging of the double bundle structure in anterior cruciate …
H Steckel, G Vadala, D Davis, FH Fu - Knee Surgery, Sports Traumatology, Arthroscopy, 2006 - Springer
Cited by 3 Body Diffusion-Weighted MR Imaging Using High b-Value for Malignant Tumor Screening: Usefulness and
…Y Tsushima, A Takano, A Taketomi-Takahashi, K Endo - Academic Radiology, 2007 - Elsevier
Establishing a Cardiac MRI Program: Problems, Pitfalls, Expectations MK Atalay - Journal of the American College of Radiology, 2005 - Elsevier
Assessment of the accuracy of dental enamel thickness measurements using micro-focal X-ray computed … AJ Olejniczak, FE Grine - Anat Rec: Part A, 2006 - doi.wiley.com
Cited by 3 Activity-Dependent PSD Formation and Stabilization of Newly Formed Spines in Hippocampal Slice …
Y Zuo… - Cerebral Cortex - Oxford Univ Press
Activity-Dependent PSD Formation and Stabilization of Newly Formed Spines in Hippocampal Slice … M De Roo, P Klauser, P Mendez, L Poglia, D Muller - Cerebral Cortex, 2007 - Oxford Univ Press
Knowledge management and the internet R Dieng - Intelligent Systems and Their Applications, IEEE [see also …, 2000 - ieeexplore.ieee.org
Cited by 40 Isotropic MRI of the Knee with 3D Fast Spin-Echo Extended Echo-Train Acquisition (XETA): Initial … GE Gold, RF Busse, C Beehler, E Han, ACS Brau, PJ … - American Journal of Roentgenology, 2007 - Am
Roentgen Ray Soc
Ferumoxtran-10 enhancement in orthotopic xenograft models of human brain tumors: an indirect
marker … S Kremer, S Pinel, PO Védrine, A Bressenot, P … - Journal of Neuro-Oncology, 2007 - Springer
Effect of size and charge on pharmacokinetics and in vivo MRI contrast enhancement of biodegradable … Y Zong, J Guo, T Ke, AM Mohs, DL Parker, ZR Lu - Journal of Controlled Release, 2006 - Elsevier
Ultrastructural characterization of the giant volcano-like virus factory of Acanthamoeba polyphaga … all 3 versions »
M Suzan-Monti, B La Scola, C Fraisier… - PLoS ONE, 2007 - pubmedcentral.nih.gov
Cited by 1 International Journal for Computer Assisted Radiology and Surgery
MW Vannier, HU Lemke - International Journal of Computer Assisted Radiology and …, 2006 - Springer
Spatial relational learning persists following neonatal hippocampal lesions in macaque monkeys - all 4
versions »
P Lavenex, PB Lavenex, DG Amaral - Nature Neuroscience, 2006 - nature.com
Cited by 1 Spatial relational learning persists following neonatal hippocampal lesions in macaque monkeys A Potential, NN Blog, N Conferences, D Discovery - 2006 - nature.com
ARF6 GTPase controls bacterial invasion by actin remodelling ME Balana, F Niedergang, A Subtil, A Alcover, P … - Journal of Cell Science, 2005 - jcs.biologists.org
Cited by 10 Workflow in the operating room: A summary review of the Arrowhead 2004 Seminar on Imaging and …
HU Lemke, OM Ratib, SC Horii - International Congress Series, 2005 - Elsevier
Single breath-hold whole-heart MRA using variable-density spirals at 3T JM Santos, CH Cunningham, M Lustig, BA Hargreaves, … - Magn Reson Med, 2006 - doi.wiley.com
Cited by 3 Patchy Organization and Asymmetric Distribution of the Neural Correlates of Face Processing in … S Zangenehpour, A Chaudhuri - Current Biology, 2005 - Elsevier
Cited by 7 -
33
High-resolution imaging of murine myocardial infarction with delayed-enhancement cine micro-CT M Nahrendorf, C Badea, LW Hedlund, JL Figueiredo, … - American Journal of Physiology- Heart and
Circulatory …, 2007 - Am Physiological Soc
Magnetic resonance imaging of Klebsiella pneumoniae-induced pneumonia in mice R Tournebize, BT Doan, MA Dillies, S Maurin, JC … - Cellular Microbiology, 2006 - ingentaconnect.com
Repetitive Transcranial Magnetic Stimulation of Broca's Area Affects Verbal Responses to Gesture … M Gentilucci, P Bernardis, G Crisi, RD Volta - Journal of Cognitive Neuroscience, 2006 - MIT Press
Cited by 1 Ultrastructural Characterization of the Giant Volcano-like Virus Factory of Acanthamoeba polyphaga …
ONE PLoS, B Subject, C Guidelines, S Map, F … - plosone.org
Dual-Modality PET-CT Visualization using Real-Time Volume Rendering and Image Fusion with … J Kim, W Cai, D Feng - Engineering in Medicine and Biology Society, 2005. IEEE-EMBS
A Cooperative Switch Determines the Sign of Synaptic Plasticity in Distal Dendrites of Neocortical … PJ Sjöström, M Häusser - Neuron, 2006 - Elsevier
Cited by 9 A203 Distribution of ABO Blood Types in Patients with Congenital Heart Defects
KC Odegard, PC Laussen, D Zurakowski, SJ … - asaabstracts.com
DURGA: A HEURISTICALLY-OPTIMIZED DATA COLLECTION STRATEGY FOR VOLUMETRIC MAGNETIC RESONANCE IMAGING
CK ANAND, AT CURTIS, R KUMAR - LMS J. Comput. Math - cas.mcmaster.ca
Use of gene expression profiling to direct in vivo molecular imaging of lung cancer J Grimm, DG Kirsch, SD Windsor, CFB Kim, PM … - Proceedings of the National Academy of Sciences,
2005 - National Acad Sciences
Cited by 10 CAR Posters
D Chen - International Journal of Computer Assisted Radiology and …, 2006 - Springer
DICOM Structured Reporting and Cancer Clinical Trials Results DA Clunie - Cancer Informatics, 2007 - la-press.com
Subtemporal Approach to the Tentorial Incisura: Normative Morphometric Data Based on Magnetic …
S Approach, M Measurements - neurosurgery-online.com
Otoferlin, Defective in a Human Deafness Form, Is Essential for Exocytosis at the Auditory Ribbon … I Roux, S Safieddine, R Nouvian, M Grati, MC … - Cell, 2006 - Elsevier
Cited by 7 Technologist Abstracts M Schmidt - Journal of Cardiovascular Magnetic Resonance, 2007 - Taylor & Francis
Technologist Abstracts
A Options, TOC Latest - Journal of Cardiovascular Magnetic Resonance, 2007 - ingentaconnect.com
Page 1. Journal of Cardiovascular Magnetic Resonance (2007) 9, 477–491
Human Immunodeficiency Virus Type-1 Infection Impairs the Formation of the Immunological Synapse MI Thoulouze, N Sol-Foulon, F Blanchet, A Dautry- … - Immunity, 2006 - Elsevier
Cited by 11 Activity-Dependent Adjustments of the Inhibitory Network in the Olfactory Bulb following Early … A Saghatelyan, P Roux, M Migliore, C Rochefort, D … - Neuron, 2005 - Elsevier
Cited by 12 Cytoskeleton/stretch-activated ion channel interaction regulates myogenic differentiat …
L FORMIGLI, E MEACCI, C SASSOLI, R SQUECCO, D NOSI … - Journal of cellular physiology, 2007 doi.wiley.com
Cited by 2 The mTOR pathway is regulated by polycystin-1, and its inhibition reverses renal cystogenesis in …
JM Shillingford, NS Murcia, CH Larson, SH Low, R … - Proceedings of the National Academy of Sciences,
2006 - National Acad Sciences
Cited by 27 -
34
Análise e interpretação de imagem médica com o apoio de agentes de software
F Marreiros - 2006 - repositorium.sdum.uminho.pt
O3-DPACS Open-Source Image-Data Manager/Archiver and HDW2 Image-Data Display: An IHEcompliant … P Inchingolo, M Beltrame, P Bosazzi, D Cicuta, G … - Computerized Medical Imaging and Graphics,
2006 - Elsevier
Cited by 1 Single-Photon Emission Computed Tomography/Computed Tomography in Abdominal Diseases O Schillaci, L Filippi, R Danieli, G Simonetti - Seminars in Nuclear Medicine, 2007 - Elsevier
Proceedings of the 150th meeting of the society of British Neurological Surgeons
O PRESENTATIONS - British Journal of Neurosurgery, 2007 - informaworld.com
PACS WORKSTATION SOFTWARE
SC HORII - Springer
Page 1. PACS WORKSTATION SOFTWARE STEVEN C. HORII BACKGROUND AND DEFINITIONS
Atlas Of PET/CT Imaging In Oncology
J Czernin - 2004 - books.google.com
Page 1. with CD-ROM Atlas of PEET/CT Oncolo Johannes Czernin Magnus Dahibom Osman Ratib Christiaan Schlepers Imaging in gy Spi inger Page 2. ...
Cited by 2 9 thInternational Conference on Cochlear Implants and Related Sciences
B Wilson - WMW Wiener Medizinische Wochenschrift, 2006 - Springer
RTI and Duke University Medical Center, North Carolina, USA ...
Effect of the needle tip shape on fall of force after puncture in epidural anesthesia
K Naemura - International Journal of Computer Assisted Radiology and …, 2006 - Springer
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