Service quality Benchmarking new systems

SCOPE
INSTITUTE OF PHYSICS AND ENGINEERING IN MEDICINE | www.ipem.ac.uk | Volume 24 Issue 1 | MARCH 2015
Service quality
Benchmarking
new systems
Delivering sonographic
education and training
Person-centred care
Quality measure?
ISO 15189 with peer review and accreditation
ISO 9001 certificated + peer review
ISO 14971 certificated
ISO 9001
certificated
No system
– do your
best
Image processing and
analysis using ImageJ
Quality management systems
P08 JOB SATISFACTION LEVELS
Staff work–life balance in the
radiography and physics workforce
P32 NEWS ON POLICY UPDATES
Keeping you up-to-date on
IPEM’s work to influence policy
P50 FROM THE BES TO IPEM
The discipline gains recognition
and merges with the IPEM
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CONTENTS
THIS ISSUE
FEATURES
14
Cover feature: Benchmarking service quality
Accreditation or certification? How do we assess quality
and how will new healthcare systems fit?
19
Delivering sonographic education and training
Promoting better standards in ultrasound education
through an innovative accreditation partnership
21
Person-centred care: health technology management
The process of care from the patient and carer perspective
with relevance for health technology management
26
ImageJ: image processing and analysis in Java
Software offering basic tools and processing techniques
required to view and manipulate medical images
35
MEETING REPORTS
35
38
42
42
7th World Congress of Biomechanics and a research visit
George Adams
IEEE Engineering and Medicine in Biology Conference
Claire Tarbert
Medical Physics and Engineering Conference
Laura Moran
OBITUARY
49
Dr Jonathan Whybrow
HISTORICAL FEATURE
50
Part 5: From the BES to the IPEM
Concluding our historical series as the discipline gains
recognition, develops journals and merges with the IPEM
REGULARS
36
04
05
06
07
32
33
44
President’s letter Charity is close to home
CEO’s column Public Engagement Panel
Editor’s comment Delivering news
Journal club news An interesting article on job satisfaction
Policy update Recent issues and work on policies
Technologist news Dosimetric effects of tissue swelling
Book reviews Latest books, reviews, reports and newsletters
40
SCOPE | MARCH 2015 | 03
PRESIDENT’S LETTER
Charity is close to home
Stephen Keevil is keen for members to know more about how IPEM
functions as a charity and hopes that more members will have their say
t comes as a surprise to some people to discover
that IPEM is a charity, a term that usually brings to
mind organisations that support people in need, or
perhaps care for our heritage or the environment.
The RSPCA and RSPB, amongst the largest charities
in the UK, provide a different kind of support again.
IPEM seems very different to these examples, but under
law any organisation that exists for the public benefit
and meets any of a wide range of criteria can register as
a charity, not just those that rattle tins and run shops in
the high street!
Like any charity, IPEM is ultimately governed by its
Board of Trustees. Most of IPEM’s trustees are members
of the Institute: the President and honorary officers,
and three others representing the broader membership.
There are also two independent trustees who are not
members, bringing a wider range of skills and
perspectives. The Board recently agreed to expand this
broader input, and to recognise the degree of financial
strategic planning needed by a growing organisation,
by appointing for the first time an Honorary Treasurer
who is not a member. David Ellis combines a first
degree in physics with a long and successful career in
engineering and technology, including 12 years of
board-level experience. David succeeds our previous
Honorary Treasurer, Paul Robbins, and it is a great
tribute to Paul that we have had to look to someone
with experience of this kind to replace the expertise
that he has developed over the past 5 years.
I
“
“
STEPHEN
KEEVIL
President
Trustees monitor progress
against this plan at each
Board meeting
The Charity Commission website has a very clear
and succinct statement about the role of charity
trustees: they ‘have overall control of a charity and are
responsible for making sure it’s doing what it was set
up to do’. In the case of a relatively large organisation
like IPEM, trustees largely discharge this duty by
ensuring that we have an appropriate mix of expertise
amongst our volunteers and staff to deliver the work of
the Institute in a way that is effective, efficient and
compliant with the law. But the trustees cannot avoid
or delegate the ultimate legal responsibility that they
have, and so the Board meets four times a year to
provide oversight, scrutiny and, very importantly,
strategic direction.
04 | MARCH 2015 | SCOPE
The overall strategy adopted by the Board can be
found at:
http://www.ipem.ac.uk/Portals/0/Documents/Profess
ional%20Matters/Strategy/IPEM%20strategic%20obj
ectives%202012%20-%2014.pdf. This document sets
out IPEM’s charitable purpose and seven key strategic
objectives flowing from this. Each year, the Institute’s
various committees are asked to contribute to an
action plan based around these objectives, and
trustees monitor progress against this plan at each
Board meeting.
Keen-eyed members will object that a strategy
document dated ‘2012–14’ is overdue for review! In
fact, trustees decided that the 2014 review should
focus on four key areas highlighted in the last
member survey: regional structures, volunteering,
policy work and public engagement. A more
comprehensive review is planned for later in 2015.
The results of this focussed review were
considered by the Board in January. A summary will
be made available to members via the website. There
were a number of very helpful suggestions, which
will either be acted on or referred to the relevant
committee for further consideration and
development. However, there was a disappointing
level of engagement from the membership, and some
of the actions proposed are things that the Institute is
already doing. It is encouraging that members
approve of work that is already underway, but
worrying that they are not aware that this is the case!
Now that new membership rules are in place, it is
timely to develop a new membership strategy. This
will include plans for recruiting new members of
course, but it is clear that we also need better ways of
engaging members in activities like the strategy
review, and also communicating with members so
that they are more aware of what we are doing.
One particularly significant way of engaging is to
stand for office in IPEM. Several positions fall vacant
in September, and it would be great to have a strong
field of candidates for members to choose between.
Vacancies will be advertised soon through the
newsletter and website. We would welcome
applications from members from all backgrounds and
at all stages of their careers. It is not true that
members have to be approached before they can
apply! If you are interested but need more
information about the nature of the work or the
commitment involved, feel free to contact current
office holders or me directly via
[email protected]
CEO’S COLUMN
Public Engagement Panel
Rosemary Cook CBE provides a recap on IPEM’s initiative to involve
‘lay’ people in its activities and deliver its charitable objectives
ince the Trustees decided in July last year to set
up a Public Engagement Panel (PEP) for IPEM,
work has been going on to make this a reality.
However, responses to the recent strategy
review show that some members would like to
know more about the initiative – so here is a quick recap.
As a charity with public benefit as its main purpose,
IPEM has long involved ‘lay’ people – people from outside
of the membership professions – in its structures. We have
had ‘independent’ trustees for many years, bringing a
different perspective to the Board’s decision-making than
that of the officers and member trustees, as well as
additional skills to add to the expertise of members: skills
such as marketing, communications, governance and legal
knowledge. IPEM also has lay people involved in its
professional conduct committee, in line with good practice.
S
“
“
It will help deliver IPEM’s
charitable objective to advance
public education
ROSEMARY
COOK CBE
Chief Executive
Officer
▼
The Public Engagement Panel is designed to go a step
further, by involving lay people proactively in a wider
range of IPEM’s activities. This has been partly stimulated
by the need to involve lay people in the management of
the Register of Clinical Technologists, in order to meet the
good practice requirements of the Professional Standards
Authority. But it will also help to deliver on IPEM’s
charitable objective to advance public education about
physics and engineering applied to medicine.
The PEP’s Terms of
Reference, approved by
the Trustees in October,
can be found on the
website: follow the link
on the home page
under Public
information. The Panel
has four main aims:
n To help ensure that
IPEM’s strategy and
activities are focussed
on achievement of its
charitable objectives.
n To improve IPEM’s
engagement and
communication with public
audiences.
n To bring a public perspective to inform IPEM’s policy
responses, regulatory activities, etc.
n To link with other public engagement bodies in the
fields of healthcare and science, as appropriate.
The PEP will be chaired by an independent trustee,
and Danielle Ross has agreed to be the first incumbent.
Members will also include a member trustee, plus a
number of lay people who volunteer to become involved.
The Panel will meet twice a year, but members will be
engaged on different pieces of work by email between
meetings. Initially, PEP members may be asked to:
n Assess the content and accessibility of the website or
publications from a public perspective.
n Review strategic plans to check that they will help
achieve our charitable objectives.
n Advise on our public engagement programme and
activities.
n Help judge awards for public–scientist partnership
work.
n Suggest new ways to present members’ work to
enhance patients’ and the public’s understanding of
healthcare science.
n Help recruit volunteers to assist with our work.
n Help target our careers and outreach work to new
audiences.
n Input into national consultations or initiatives from a
public perspective.
n Comment on course documentation from a lay
perspective.
n Provide an individual to join a specific working group
or committee when required, to bring a lay perspective to
its work.
IPEM has been recruiting to the Panel since January,
via many local,
regional and national
networks. We have
stressed that this is not
a patient involvement
panel, and the panel
will not be asked to
comment on specific
services. We aim to
hold an initial
information workshop
for volunteers to learn
more about IPEM and
about the kind of
activities they might be
involved in, after which
the membership of the Panel will
be finalised.
Members can
keep up with
developments via
the PEP pages on
the website. If
you would like
the panel to
assist with any
specific work of a
group you are
involved in for
IPEM, don’t
hesitate to
contact the office
to arrange this
SCOPE | MARCH 2015 | 05
EDITOR’S COMMENT
Delivering news
very warm welcome to all! We have another spectacular issue of
Scope incorporating a new section on policy work undertaken by
the IPEM. This new section was added in response to the general
IPEM survey (2013). CEO Rosemary Cook compiled this section to
keep you up-to-date. You asked; we delivered!
During a major clear-out at home earlier this year, I stumbled upon a
glossy old issue of Scope. Remarkably, the magazine has undergone a number
of significant changes in the last couple of decades. The increase in
submissions and improvement in general design is thanks to all your
contributions, that of the previous Editors and the publishing house. In light
of our recent Scope survey, we hope to make many more enhancements to the
magazine. To kick-start this process, we will soon be publishing the survey
results, so please watch this space!
In a thought-provoking article, Edwin Claridge talks about the new
quality management systems (QMS) for medical physics and clinical
engineering services, providing a personal view of the development of UK
healthcare science quality systems. His discourse covers differences between
old vs new, certification vs accreditation and the scope of the QMS. Those
with an appetite for anything ImageJ or working in nuclear medicine will
want to read the stimulating article written by Gregory James. In addition to
covering the basics, he considers benefits and need and compares ImageJ to
other software packages, its use in the clinical context and the availability of
curve-fitting tools and plugins.
Is recruitment and retention of staff a problem in your department? We
have a great journal club article on job satisfaction levels of the physics and
radiography workforce in radiotherapy. A survey stressed the importance of
professional development, staff support and prevention of burnout. All these
aspects must certainly contribute to improvements in patient safety. Good
management practices outlined may benefit medical physics and clinical
engineering departments in general. Definitely, a must read.
David Stange highlights an interesting article in the Journal of Applied
Clinical Medical Physics on the dosimetric effects of tissue swelling during
helical tomotherapy breast irradiation. A study looked at quantifying underand over-dosage and surface doses during the treatment of breast carcinoma
– these are important considerations at the radiotherapy replanning stage.
Once again, we have an exciting mix of book reviews and medical physics
newsletters. Kirsten Hughes presents three engaging travel bursary reports,
covering the 7th World Congress of Biomechanics, the IEEE Engineering and
Medicine in Biology conference and the Medical Physics and Engineering
Conference and Biennial Radiotherapy Physics Meeting.
Those looking forward to Stanley Salmon’s biomedical engineering
historical series will find the final installment in this issue. He concludes this
inspiring article by talking about the Biological Engineering Society and its
integration into what is now known as IPEM! I am really thankful to Stanley
for his quality contributions over the last five issues of Scope.
We hope you thoroughly enjoy this issue!
A
Scope is the quarterly
magazine of the Institute
of Physics and Engineering
in Medicine
IPEM Fairmount House,
230 Tadcaster Road,
York, YO24 1ES
T 01904 610821
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E [email protected]
W www.ipem.ac.uk
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EDITOR-IN-CHIEF
Usman I. Lula
Principal Clinical Scientist,
1st Floor, Radiotherapy,
Building, Medical Physics University, Hospitals
Birmingham NHS
Foundation Trust, Queen
Elizabeth Hospital, Queen
Elizabeth Medical Centre,
Birmingham, UK B15 2TH
T 0121 371 5056
E [email protected]
ASSISTANT EDITOR
Dr Hazel Starritt
Consultant Clinical Scientist
Head of Diagnostic Imaging
Physics, Medical Physics
and Bioengineering
Royal United Hospital Bath
NHS Trust, Combe Park,
Bath BA1 3NG
T 01225 824085
E [email protected]
MEETING REPORTS EDITOR
Kirsten Hughes
Trainee Clinical Scientist
Radiotherapy, North Wales
Medical Physics, Glan Clwyd
Hospital
T 01745 445113
E [email protected]
nhs.uk
NEWS EDITORS
Usman I. Lula
Principal Clinical Scientist,
1st Floor, Radiotherapy
Building,Medical Physics,
Queen Elizabeth Hospital,
Queen Elizabeth Medical
Centre, University Hospitals
Birmingham NHS
Foundation Trust,
Birmingham, UK B15 2TH
T 0121 371 5056
E [email protected]
and
Richard A. Amos
Operational Lead for Proton
Beam Therapy Physics,
Radiotherapy Physics
Department, University
College London Hospitals
NHS Foundation Trust,
1st Floor East – 250 Euston
Road,London NW1 2PG
T 0203 447 2369
E [email protected]
BOOK REVIEW EDITOR
Usman I. Lula
Principal Clinical Scientist,
1st Floor, Radiotherapy,
Building, Medical Physics University, Hospitals
Birmingham NHS
Foundation Trust, Queen
Elizabeth Hospital, Queen
Elizabeth Medical Centre,
Birmingham, UK B15 2TH
T 0121 371 5056
E [email protected]
ACADEMIC EDITOR
Professor Malcolm Sperrin
Director of Medical Physics
Royal Berkshire NHS,
Foundation Trust, London
Road, Reading, RG1 5AN
E [email protected]yal
berkshire.nhs.uk
‘ ERRATUM
In my last hardcopy editorial, it was Angela Cotton who had stepped down
as Meeting Reports Editor. Thanks to Angela Newing for highlighting this!
USMAN I. LULA EDITOR-IN-CHIEF
06 | MARCH 2015 | SCOPE
INTERNATIONAL EDITOR
(Developing countries)
Andrew Gammie
Clinical Engineer, Bristol
Urological Institute, BS10 5NB
T +44(0)117 950 5050
extension 2448 or 5184
E [email protected]
INTERNATIONAL EDITOR
(North America)
Richard A. Amos
Operational Lead for Proton
Beam Therapy Physics,
Radiotherapy Physics
Department, University
College London Hospitals
NHS Foundation Trust,
1st Floor East – 250 Euston
Road,London NW1 2PG
T 0203 447 2369
E [email protected]
CLINICAL TECHNOLOGIST
NEWS EDITOR
Position vacant
Trevor Williams and Dave
Stange
Senior Clinical
Technologists,1st Floor,
Radiotherapy Building,
Medical Physics, Queen
Elizabeth Hospital, Queen
Elizabeth Medical Centre,
University Hospitals
Birmingham NHS
Foundation Trust,
Birmingham, UK B15 2TH
T 0121 371 5051
E [email protected]
E [email protected]
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system and safety positions
REGULATION AND SAFETY
The way the MHRA handles
adverse incidents involving
medical devices is changing.
The agency is setting up an
integrated and simplified system
of reporting with NHS England.
This means you can report
incidents once, through a single
route instead of reporting to
several organisations. Crucial to
the development of this system is
a network of Medical Device Safety
Officers (MDSO) and Medication
Safety Officers (MSO). These have
widened and replaced the Medical
Device Liaison Officer (MDLO)
network.
What this means for you?
n Continue to report incidents
separately to MHRA and NRLS
(National Reporting and Learning
System) until your organisation is
verified for single route reporting.
n There are better-defined
reporting criteria for you to use,
described in the patient safety
alert ‘Improving medical device
incident reporting and learning’,
published in March 2014. This also
gives details of the new system
and how healthcare organisations
should nominate an MDSO.
n Find out who the MDSO is in
your organisation.
The MHRA and NHS
England are:
n Asking larger healthcare
organisations in the NHS and
independent sector to nominate
MDSOs and MSOs.
n Testing the system at several
sites for each of the major local
risk management system
providers to develop toolkits.
n Running conferences. Details
will be available on the MHRA
website.
n Running monthly online
seminars for MDSOs.
n Encouraging the use of the
Patient Safety First website for the
exchange of medical device safety
information, including recordings
of online seminars.
‘ Louise Mulroy is a Senior
Medical Device Specialist at the
MHRA Imaging, Acute and
Community Care Unit which is
part of the Agency’s Devices
Division. She works in the device
areas covering anaesthetic,
breathing and vascular devices
MHRA – unique device identifiers for medical
devices based on barcodes
UDI COMPLIANT LABEL: What a UDI looks like on a manufacturer’s
product label: human readable (under the barcode) and AIDC format
REGULATION AND SAFETY
Unique device identifiers (UDIs)
for medical devices are being
introduced in Europe and the USA
to unambiguously identify specific
medical devices. UDIs will be
based upon established
labelling/barcoding systems –
most commonly GS1 Global Trade
Identification Numbers (GTINs) or
HIBCC Labeller Identification
Codes (LICs). UDIs applied to
devices (and in particular
implants) or their labels,
documented in a UDI database,
and used consistently throughout
distribution and use, should
facilitate a number of patient
safety benefits, including:
n traceability of devices;
n the identification of devices in
adverse events reports and other
postmarket safety surveillance
activities;
n recalls and other field safety
correction, and
n reducing medical errors.
In order to establish a national
system for recording and
analysing UDI information for
implants the MHRA and key
partners will need to develop:
n local systems for inputting
implant barcodes – in the form of
UDIs – into existing hospital
patient electronic record systems
and storing the information
locally;
n national standards and systems
for transferring local patient
electronic records incorporating
UDIs into a national database –
HES or care.data, and
n systems and associated
governance frameworks for
analysing the national data using
the MHRA Clinical Practice
Research Datalink (CPRD).
The MHRA is currently
undertaking a project to establish
the feasibility of the first point
above. This will look at the
practicalities of incorporating the
information contained in the
barcodes which manufacturers
are currently placing on implant
labels into existing hospital patient
electronic record systems. The
information will be collected in
real time in real clinical
environments and stored locally,
ensuring that it will be readily
retrievable from the hospital
record system for onward
transmission and further analysis.
The MHRA has already had
discussions with a number of
potential pilot sites, but thus far
none of them have been able to
move forward on this work, mainly
because of issues around
integration of existing electronic
record systems within hospitals
and around engagement of clinical
staff. The Agency is currently
working with Portsmouth
Hospitals with the aim of
establishing them as a beacon
centre to collect UDIs as part of
their existing hospital patient
electronic record systems. MHRA
would welcome the assistance of
IPEM members in promoting the
introduction/development of such
systems within their Trusts. If you
are interested, please contact Mike
Peel ([email protected]
uk) or Andy Crosbie
([email protected])
at MHRA.
‘ Andy Crosbie is Head of the
MHRA Biosciences and Implants
Unit, which is part of the
Agency’s Devices Division. He has
a particular interest in medical
device post-market surveillance
and implant registries and he
currently leads work within the
Agency on the use of unique
device identification (UDI) to
improve patient safety
SCOPE | MARCH 2015 | 07
JOURNAL CLUB NEWS BY USMAN I. LULA AND RICHARD AMOS
Job satisfaction levels in UK radiotherapy centres:
radiography and physics workforce
MANAGEMENT
Staff work–life balance can be
impacted by workload pressures
such as evening, weekend and
bank holiday working. Employers
need to give consideration to the
Flexible Working Regulations
effective from April 2014.
Increased provision and
appropriate interventions are
required to achieve the aim of
delivering world-class
radiotherapy. Retaining and
developing an adequate
resourced, skilled and committed
workforce will be a key factor in
future success.
The UK Francis report (2013)
highlighted the tragic
consequences of systems failure
coupled with health
professionals suffering from the
effects of compassion fatigue.
Healthcare is hugely rewarding,
and paradoxically emotionally
strenuous. The combination of
associated individual,
interpersonal and organisational
challenges are primary drivers
for burnout. The subsequent
Berwick report (2013) highlighted
that good people can fail to meet
patients’ needs when their
working conditions do not provide
them with the conditions for
success. A strong relationship
exists between employee
satisfaction and patients’
perceptions of the quality of their
care. Organisations and leaders
can significantly influence an
individual’s satisfaction.
Obtaining an understanding of
the work experiences of
radiotherapy professionals will
support the development of
strategies to increase job
satisfaction, productivity and
effectiveness. In this recently
published work, a quantitative
survey was conducted assessing
job satisfaction, attitudes to
incident reporting, stress and
burnout, opportunities for
professional development,
workload, retention and turnover.
All questions were taken from
validated instruments or adapted
from the UK NHS survey.
The survey yielded 658
completed responses (16 per
cent response rate), from the
public and private sectors (see
table 1). Responses were
received from 74 of the 75 sites
(NHS and private providers)
delivering radiotherapy in the
UK. Over a third of respondents
were classified as satisfied for
job satisfaction with 11 per cent
dissatisfied and the remaining 53
per cent ambivalent. A significant
proportion of clinical staff (38 per
cent) reported high emotional
exhaustion and low professional
accomplishment. Presenteeism
was an issue with 42 per cent
attending work despite feeling
unable to fulfil their role. A
significant proportion (42 per
cent of respondents) felt they
didn’t get the recognition they
deserved for doing a good job. A
statistically significant difference
was also evident between
departments. In the non-clinical
group over a quarter of
respondents reported high levels
of cynicism. The majority of
respondents stated an increase
in the intensity and pace of work
in the past 12 months. The
increase was attributed to a
combination of factors such as
staffing levels, lack of resources
and administrative support.
Significant workload was
frequently preventing staff from
undertaking learning and
development opportunities.
TABLE 1 [TOP LEFT]: Response
by professional group
TABLE 2 [BOTTOM LEFT]: Job
satisfaction survey (JSS) data with
scoring key compared with a
comparative norm of nurses
All tables kindly supplied by
Daniel Hutton, The Clatterbridge
Cancer Centre, NHS Foundation
Trust, England, UK. © The British
Institute of Radiology 2014.
Hutton D, Beardmore C, Patel I,
Massey J, Wong H, Probst H. Audit
of the job satisfaction levels of the
UK radiography and physics
workforce in UK radiotherapy
centres 2012. Brit J Radiol 2014;
83: 20130742
08 | MARCH 2015 | SCOPE
JOURNAL CLUB NEWS BY USMAN I. LULA AND RICHARD AMOS
National targets were cited as
impacting on workload,
particularly the managers, e.g.
the radiotherapy dataset, Trust
and national waiting time
standards (see tables 2 and 3).
Job satisfaction is
multifaceted; it is dependent on
the individual, context of work
and environment. The remaining
facets of supervision, contingent
rewards, operating conditions,
co-workers, nature of work and
communication can be
significantly influenced by
service leaders and
organisations and this is where
energy and effort should be
focussed. Professional
development is a key area to
focus energy and organisational
effort to positively influence job
satisfaction. Individuals have a
responsibility to themselves and
to their colleagues as their
behaviours and attitudes
influence job satisfaction.
Supporting staff and preventing
burnout will have a positive effect
on absenteeism, team
performance and reduce the
prevalence and severity of
incidents.
Managers and service
providers should be encouraged
to use existing forums, such as
the National Radiotherapy
Service managers and the heads
of radiotherapy physics network,
to discuss and share best
practice and enhance learning
across organisations. Sharing
challenges with the national
professional bodies also enables
intelligence and evidence to be
gained in order to enable these
matters to be promoted to key
national stakeholders and policy
makers. It is recommended that
service managers conduct
regular local surveys to monitor
job satisfaction levels within
centres and so highlight and
action any local issues to work
towards improving job
satisfaction levels.
TABLE 3 [LEFT]:
Maslach Burnout
Inventory (MBI) human
services (clinical) and
general (non-clinical)
showing percentage of
respondents scoring
low, moderate and
high levels, with
scoring key
Free download for a
limited period of 6
weeks:
http://www.birpublic
ations.org/doi/full/1
0.1259/bjr.20130742
1
Cooper T, Williams
MV. Implementation
of intensitymodulated
radiotherapy:
lessons learned and
implications for the
future. Clin Oncol
2012; 24: 539–42.
‘ MORE INFORMATION
The work was published in Brit J
Radiol 2014; 83: 20130742.
http://dx.doi.org/10.1259/bjr.201
30742
‘ NEWS EDITOR’S COMMENT:
This work provides an excellent
insight into the job satisfaction
levels of the UK radiotherapy
physics and therapy radiography
workforce. Furthermore, the
paper is full of management tips
and an essential read for any
service manager. It breaks down
problematic areas and
consequently proposes possible
solutions to issues on both local
and national levels.
The increasing ‘intensity’ of
work demand is cited as a factor
in the article in reducing levels of
satisfaction and creating difficulty
in maintaining a good work–life
balance. This is in the context of
the Department of Health UK/NHS
drive to greater 7-day service
delivery, and advice in some
regions from commissioners that
new capacity developments (i.e.
more linacs) will not be supported.
With a growing demand for
radiotherapy, these factors mean
that Trusts will need to find ways to
deliver increased ‘intensity’ (i.e.
fractions per linac) whilst engaging
with and supporting staff and
investing in technologies which
enable higher workflow rates.
Seven-day working brings
inevitable challenges for a good
work–life balance so staff
engagement is crucial. As an added
bonus, indications so far are that
key radiotherapy tariffs will be
reduced substantially in 2015–16 so
the flexibility for Trusts to make
much needed efficiency and quality
improvements will be limited.
(Private communications with
Professor Stuart Green, Director of
Medical Physics, University
Hospitals Birmingham, UK.)
It is also important to note that
although professional development
reviews are taking place, there still
appears to be a practice of getting
the review completed without the
required support for staff to action
the approved plan. The authors
highlight in this work that a
structured framework comprising
a personal development plan,
competency framework, mentoring
and planned rotations underpinned
by a culture of CPD and reflective
practice can benefit the workforce.
They further add that the
framework acknowledges the
inherent link between CPD, PDRs,
job satisfaction and service
development.
Additionally, long-term
departmental strategy meetings
could engage with staff at all
levels. This level of involvement
would allow an understanding of
infrastructure and resource
priorities and generally benefit
all staff.
With the expansion of
radiotherapy services such as
IMRT beyond 24 per cent, with
experts1 considering an optimal
level of IMRT delivery more likely
to be around 50 per cent of
radical patients, there needs to
be further service provisions.
The funding for further
provisions is currently decided
by both national and local
commissioning groups. With
further funding, there is
potential scope for thousands
more patients to benefit
annually from advanced
radiotherapy.
Any comments? Email:
[email protected]
SCOPE | MARCH 2015 | 09
Radiation Dose Management
in Radiological Institutes – a clinical example
Sebastian Schindera, M.D.
Clinic of Radiology and Nuclear Medicine, University of Basel Hospital, Switzerland
FOREWORD BY
Mary Cocker
Consultant Clinical Scientist,
Oxford University Hospitals
Radimetrics dose management system can significantly cut the time and effort required
to comply with our legal obligations to optimise all processes involved in the use of medical
X-rays. Dr Schindera provides some excellent clinical examples where Radimetrics assists in
the management and optimisation of CT protocols; reduces dose; enhances dose awareness
through alerts and action levels; and provides effective and efficient benchmarking as an aid to
compliance with ‘As Low As Reasonably Practicable’.
The Royal College of Radiologists 2014 Annual Scientific Meeting
in London hosted the Bayer lecture: Radiation Dose Management
in Radiological Institutes – a clinical example. Mary Cocker
chaired the meeting and introduced internationally-renowned
radiologist, Sebastian Schindera M.D. to present his experience
in state-of-the-art dose management within computed
tomography, with reference to data published from his work.
USE OF COMPUTED TOMOGRAPHY
The number of computed tomography (CT) examinations has
dramatically increased both in the UK and US over the past 20
years.1 Schindera attributed the increase to a combination of
technical advancement, the increased rate of CT installations and
the medico-legal aspect, whereby physicians may request a CT
examination to exclude unlikely possibilities simply to prevent any
legal ramifications.
The rise in the use of CT has caused an increase in the per-capita
medical exposure. Schindera presented findings from a US study
which found that medical exposure due to CT examinations
increased 6-fold between 1980 and 2006.2
RADIATION INDUCED CANCER
The World Health Organisation (WHO) classify ionising radiation as
a carcinogen, and an increasing number of published retrospective
cohort studies directly attribute cancer to the use of medical
X-rays.3,4 One study found that patients younger than 22 years
old have a slight increase in the risk of cancer following one CT
scan.4 The risk was similar to that estimated by the International
Commission on Radiological Protection (ICRP) who estimated the
lifetime fatal cancer risk from ionising radiation to be 5% per Sievert
(Sv) for the entire population, including children.5
STATUS QUO OF RADIATION PROTECTION
IN CT
Many effective technical advances have been introduced by CT
manufacturers to improve patient safety by minimising radiation
exposure, including automatic tube current and voltage modulation;
iterative reconstruction; and novel, dose-efficient detectors.
Similarly, radiologists have advanced practice through optimising
CT protocols.
Schindera posed the question: How are we doing with CT radiation
protection?
He suggested that the practice of CT dose protection substantially
differs from the theory and that compliance may be an issue. A
study that looked at the dose of CT in renal colic, which should be
of a low dose due to its accuracy and use in children, found that not
one institution averaged a low dose.6 Schindera concluded that the
collection of comprehensive data on CT radiation doses is vital in
order to overcome compliance issues and identify potential problems
in radiation exposure to minimise any adverse effects.
STATE OF THE ART RADIATION DOSE
MANAGEMENT
Schindera and his team concluded there was a need to improve
processes to maximise patient safety, so looked to source suitable
software that would offer both dose tracking, to provide a
complete picture of the CT dose through automatic, continuous and
comprehensive documentation of every CT examination; and
dose benchmarking, to compare CT scanners within the same
institution, other institutions or with national diagnostic reference
levels. In 2013 Schindera proceeded with the installation of the
RadimetricsTM system at the University of Basel Hospital (UBH). Both
retrospective and prospective dose tracking were conducted by the
team, focussing upon dose level and productivity management.
DOSE LEVEL MANAGEMENT
The team at UBH adopted a specific approach to addressing dose
level management (Figure 1). The dashboard of the RadimetricsTM
system (Figure 2) promptly provided users with comprehensive data
showing the 20 most frequent CT protocols at the UBH; the total
number of examinations per protocol in that year; and the CT Dose
Index measured in CTDIvol or size-specific dose estimate (SSDE),
dose length product (DLP) and effective dose calculation by the ICRP
(minimum, average and maximum).
Identification and collection of
20 most frequently used CT protocols
Benchmark with national
diagnostic reference levels
Compare average dose values
of different CT scanners
Monitor protocol
optimisation efforts
Figure 1: Dose level management approach
Schindera’s team compared their results with the national diagnostic
reference levels, and found that CT of the head examinations were
within the expected range stipulated by the national regulations.
mSv to 4.7 mSv). This valuable information took only 5 minutes to
obtain. The team also monitored their protocol optimisation efforts
by looking at the overall average effective dose per CT scan, and they
were able to reduce the effective dose (in mSv) by 32%.
DOSE MANAGEMENT ON AN EXAMINATION
LEVEL
Figure 2: RadimetricsTM dashboard showing results from all
CT of the head examinations in the year 2013
This was repeated for the 20 most frequently performed CT protocols
at UBH. For CT of the chest, the data also looked at size-specific dose
estimates (SSDE), taking into account the patient´s body habitus.
The calculation of the effective dose is useful because it allows
the radiologist to communicate the CT doses with the referring
physicians rather than using CTDI, SSDE or DLP.
Using RadimetricsTM, it is also possible to compare the average
SSDE of different scanners. This information can be passed onto
technicians to help them comply with specific recommendations that
encourage younger patients to be scanned using the more doseefficient scanners.
MONITORING OF PROTOCOL OPTIMISATION
EFFORTS
Schindera et al. conducted
a study using a phantom,
customised kidney 7
(Figure 3) to assess the
detectability and material
characterisation of renal
stones with a dual-energy
CT protocol at various
radiation doses. The results
showed that the radiation
dose could be reduced by up
to 57% whilst maintaining
detectability and diagnostic
accuracy.
The research team then
used the RadimetricsTM
system to establish the
Figure 3: Customised kidney
degree by which the dose
had been reduced overall. Compared to the default CT protocol, they
found that the effective dose had been reduced by 45% (from 8.6
The team also looked at patient dose records and automatic alerts
of dose outliers. Schindera cited an example of a patient who had
received 14 CT scans within 6 months for a non-malignant disease
which led to a cumulative dose of almost 270 mSv. Had the system
been installed earlier, an alternative scanning technique would have
been recommended.
The RadimetricsTM system is able to demonstrate the effective dose
for each CT scan according to the ICRP to aid compliance. The data
includes the effective dose; the DLP; the SSDE; and a comparison with
other patients who had the same type of CT. Schindera also presented
information on installing dose alerts using RadimetricsTM whereby
specific thresholds can be applied to protocols, and also to specific
patients’ cumulative dose, with a notification email being sent to the
radiologist and technician if the dose has been exceeded.
MANAGEMENT OF PRODUCTIVITY
The RadimetricsTM system provides easy access to the number and
types of CT scans performed by each scanner within a specified time
frame. (Figure 4)
Scanner B
Scanner A
Scanner C
Scanner D
Productivity of scanners in 12
months
Productivity by day within one month
Figure 4: Productivity of four CT scanners at University
Hospital Basel
CONCLUSION
Schindera concluded that comprehensive radiation dose tracking has
been widely neglected. Dose tracking and dose benchmarking are
the two major components of radiation dose management which will
play an important role in ensuring patient safety through greater
compliance of radiation protection within CT in the near future. Due
to the large amount of data that needs to be collected, a software
solution is preferable for systematic and comprehensive radiation
dose management.
To arrange an evaluation of your current approach to radiation dose management or to receive further
information, please email: [email protected] or telephone: 01635 563480.
The symposium and this article were both initiated and funded by Bayer HealthCare.
REFERENCES
1. Hall EJ, et al. Cancer risks from diagnostic radiology. Br J Radiol. 2008;81(965):362-378.
2. Mettler FA, et al. Radiologic and Nuclear Medicine Studies in the United States and Worldwide: Frequency, radiation dose and comparison with other radiation sources - 1950-2007.
Radiology. 2009;253(2).
3. Mathews J, et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. British Medical Journal.
2013;346:2360.
4. Pearce MS, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012;380:499-505.
5. International Commission on Radiological Protection website http://www.icrp.org/docs/rad_for_gp_for_web.pdf (accessed 14 October 2014).
6. Lukasiewicz MS, et al. Radiation dose index of renal colic protocol CT studies in the United States: A report from the American College of Radiology National Data Registry. 2014;271(2).
7. Pansini M & Schindera S, et al. Low-dose dual-source dual-energy CT for urolithiasis: feasibility study. European Society of Urogenital Radiology 2013 (poster presentation).
L.GB.10.2014.8585 January 2015
JOURNAL CLUB NEWS BY USMAN I. LULA AND RICHARD AMOS
Small-field tissue phantom ratio data
generation methods: a comparison
RADIOTHERAPY PHYSICS
Tissue-phantom ratios (TPRs)
are a common dosimetric
quantity used to describe the
change in dose with isocentric
depth in tissue with
megavoltage photon
treatments. Published linear
accelerator data for field sizes
of 4 × 4 cm2 and greater are
widely available and often used
as a reference data check for
data determined within an
individual radiotherapy
department. These data are
usually tabulated as a function
of depth and field size at the
isocentre for a given beam
quality index (TPR20/10 ratio).
Stereotactic and intensitymodulated treatments require
data for field sizes smaller
than 4 cm2. TPR can be
challenging and time
consuming to measure. The
conversion of percentage
depth dose (PDD) data using
standard formulae (developed
by Dutreix et al.) is widely
employed as an alternative
method to generating TPR
(also see table B.1 in BJR S17,
1983). However, the
applicability of these formulae
for small fields has been
called into question in the
literature. Guidance in the
IPEM Report 103 on Small
Field Dosimetry does not
recommend the use of
‘ MORE INFORMATION
The work was published in Med
Dosim 2014; 39: 60–63.
http://dx.doi.org/10.1016/j.me
ddos.2013.09.008
‘ NEWS EDITOR’S COMMENT:
This work provides valuable
information about the validity
of extrapolated TPR data and
the use of standard formulae
for small-field dose
calculations.It can prove
useful to those intending to
measure or use PDD-
12 | MARCH 2015 | SCOPE
standard formulae for TPR
calculation from PDD.
Functional representation has
been proposed for small-field
TPR production.
This work compared
measured TPR data for small 6
MV photon fields against that
generated by conversion of
PDD using standard formulae
to assess the efficacy of the
conversion data.
By functionally fitting the
measured TPR data for square
fields greater than 4 cm in
length, the TPR curves for
smaller fields are generated
and compared with
measurements. TPRs and
PDDs were measured in a
water tank for a range of
square field sizes. The source
to detector distance was set to
a constant 100 cm and the
water level was softwarecontrolled by means of a water
gauge fitted to the detector’s
support arm. Data were
measured using a parallel
plate microchamber aligned to
the central axis of the beam.
Each TPR dataset was
normalised at a depth of 10 cm
in water. The PDDs were
converted to TPRs using
standard formulae. TPRs for
fields of 4 × 4 cm2 and larger
were used to create functional
fits. The parameterisation
coefficients were used to
construct extrapolated TPR
curves for 1 × 1 cm2, 2 × 2 cm2
and 3 × 3 cm2 fields.
The TPR data generated
using standard formulae were
in excellent agreement with
direct TPR measurements. The
TPR data for 1 × 1 cm2, 2 × 2
cm2 and 3 × 3 cm2 fields
created by extrapolation of the
larger field functional fits gave
inaccurate results. The
corresponding mean
differences for the three fields
were 4.0 per cent, 2.0 per cent
and 0.9 per cent with
maximum differences between
generated and measured TPRs
of 12.0 per cent, 5.3 per cent
and 2.0 per cent.
Generation of TPR data
using a standard PDDconversion methodology has
been shown to give good
agreement with our directly
measured data for small fields.
It would be suitable for clinical
use in independent monitor
unit check calculations.
However, extrapolation of TPR
data using the functional fits to
fields of 4 × 4 cm2 or larger
resulted in generation of TPR
curves that did not compare
well with the measured data.
Specifically, the dose just
beyond the buildup region and
dose falloff with depth beyond
10 cm was overestimated.
Therefore, this method of data
generation could not be
recommended.
converted TPR data for small
fields. As a note, the authors
highlight that functional fitting is
an extremely useful tool for
smoothing measured data and
producing TPR data for
intermediate field sizes and
depths not measured.
With TPR data, there is no
divergence or distance
dependence though there is
dependence on depth, energy and
shape and size of the field
(Sibtain A, Morgan A, MacDougal
N. Physics for Clinical Oncology.
OUP, 2012: 100–101).
Independent MU calculations
using TPR data are thus easier
to perform for isocentric
treatments as it avoids the
application of the Mayneord F
factor to correct for changes
to the focus-to-skin distance.
If you have a comment on
this news article, or would like
to share your experiences with
the medical physics
community, then please get in
touch with me via email:
[email protected]
n TUBERCULOSIS DRUGS
PET/CT imaging of the lungs can
reveal whether a drug can treat
tuberculosis, according to a
study. The challenge is to find
more effective treatments that
work in a shorter time period,
but the standard preclinical
models for testing new drugs
have occasionally led to
contradictory results when they
are evaluated in human trials
(Sci Transl Med 6: 265ra167).
n PHOTOACOUSTICS
Researchers have shown the
potential of photoacoustic
imaging as a rapid non-invasive
method for detecting and
staging cervical cancer with high
accuracy. Photoacoustic
imaging can detect regions of
abnormal angiogenesis due to
their high haemoglobin
concentration, which causes
such regions to exhibit higher
optical absorption than normal
tissues at certain wavelengths.
(Biomed Opt Express 6: 135).
n TEN-YEAR DATA
Cleveland Clinic researchers
have reported on 10 years of
experience using stereotactic
body radiotherapy to treat
medically inoperable early-stage
lung cancer patients. At 5 years
post-treatment, overall survival
was 18.3 per cent and 20.3 per
cent for patients with central and
non-central tumours,
respectively (Chicago
Multidisciplinary Symposium in
Thoracic Oncology, 2014).
n COGNITIVE DECLINE
Arterial spin labelling, an MRI
technique that measures brain
perfusion without requiring
contrast agent injection, can
detect signs of cognitive decline
even before symptoms appear.
The technique has the potential
to serve as a biomarker in very
early diagnosis of preclinical
dementia (Radiology doi:
10.1148/radiol.14140680).
JOURNAL CLUB NEWS BY USMAN I. LULA AND RICHARD AMOS
Figure 1: Measured and generated tissue-phantom ratio data from conversion of percentage depth doses using the equation of Dutreix et al. Measured
data are shown as symbols and generated data as lines. Figure kindly supplied by Neil Richmond MSc, Medical Physics Department, James Cook
University Hospital, Middlesbrough TS4 3BW, UK. © Elsevier 2014. Richmond N, Brackenridge R. A comparison of small field tissue phantom ratio
data generation methods for an Elekta Agility 6 MV photon beam. Med Dosim 2014; 39: 60–63
Figure 2: Measured and generated tissue-phantom ratio data created by functional fitting of measured values for field sizes 20 × 20 cm2 to 4 × 4 cm2.
The coefficients of the functional fits were extrapolated to smaller field sizes to create 3 × 3 cm2, 2 × 2 cm2 and 1 × 1 cm2 TPR curves. Measured data
are shown as symbols and functionality fit data as lines. Figure kindly supplied by Neil Richmond MSc, Medical Physics Department, James Cook
University Hospital, Middlesbrough TS4 3BW, UK. © Elsevier 2014. Richmond N, Brackenridge R. A comparison of small field tissue phantom ratio
data generation methods for an Elekta Agility 6 MV photon beam. Med Dosim 2014; 39: 60–63
SCOPE | MARCH 2015 | 13
Quality measure?
ISO 15189 with peer review and accreditation
ISO 9001 certificated + peer review
ISO 14971 certificated
ISO 9001
certificated
No system
– do your
best
Quality management systems
Benchmarking service quality:
accreditation or certification?
Edwin Claridge (University Hospitals Birmingham) explains how new
quality management systems have evolved and what issues they bring
his article was stimulated by discussions
about new quality management systems
(QMS) for MP&CE services, noting the work in
hand in the AHCS/IPEM1 project. My intention
is to present a personal review of the
development of UK healthcare science quality systems
and to explain my understanding of the newer initiatives,
so putting them into perspective. There are several
important issues for IPEM. One concerns the means by
which assessment of the overall competence of services
can be judged. This is complicated through the use of the
terms ‘certification’ and ‘accreditation’, applied to the
formal recognition of QMS. Another is to consider
whether the scope of QMS is best applied to service
provision across managerial boundaries, which I will call
‘horizontal’ systems, or best applied to more limited and
defined sections of activity, or ‘vertical’ systems. The fact
that some areas of MP&CE have no QMS and others have
well-established systems raises additional problems. It is
important that these issues and their implications are
T
COVER IMAGE:
How do we
assess quality
and how will
new healthcare
systems fit?
14 | MARCH 2015 | SCOPE
understood when considering, designing and introducing
new systems.
Some 15 years ago there was much activity within the
oncology community concerning QMS, largely stimulated
by the Bleehen report2 that called for radiotherapy
services to have such systems. The requirement was
commonly met through the use of the ISO 9000:1998
family of standards. The application of the standards and
the scope of the systems were defined locally, so it was
possible to embrace an oncology service, covering
radiotherapy, chemotherapy and the radiotherapy physics
branch of a medical physics service. This could happen
even if medical physics was managed separately from the
clinical services. It was also possible to include
‘constructive’ activities such as treatment planning and
clinical decision making. These QMS can be described as
‘horizontal’. The systems are certified by organisations
such as BSI that, in turn, are accredited by the United
Kingdom Accreditation Service (UKAS). UKAS is
recognised and monitored both internationally and by the
SERVICE QUALITY FEATURE
government as the focus for UK accreditation work,
defined as ‘the procedure by which an authoritative body
gives formal recognition that an aspirant body or person is
competent to carry out specific tasks’.
The ISO 9000 approach was sometimes criticised as
simply validating the fact that ‘what was said to be done
was actually done’, with no regard to quality. However, by
adopting a positive attitude, it is clearly possible to
include features that embrace quality. For example, the
procedures for the use of the National Physical Laboratory
primary standards and regional secondary standards for
dosimetry, local training practices, local competency
requirements, CPD records and feedback monitoring can
all be included. The regular ISO system external audit
arrangements check that procedures are being followed.
Further checks through interdepartmental audit, external
clinical peer review and external clinical trials audits can
be also be referenced in the procedures and contribute to
an assessment of competence. ISO 9001:2008 systems, in
use within oncology, have come to be regarded as
worthwhile. With the further checks described they can
certainly be argued to confirm competence.
ISO 9001:2008 systems have been adopted in other
areas of MP&CE, notably clinical engineering and
radiation protection. The world of international standards
evolves slowly but the ISO approach to quality and risk
management is alive, well and dealing with current issues
relevant to MP&CE. Appendix 1 indicates part of the
range of international standards and technical reports that
involve MP&CE activity. These documents are frequently
used in defining and demonstrating the ‘good practice’
needed to meet the requirements of the EU Medical Device
Directive (MDD). Together with the ionising radiation
documentation, these developments help us maintain our
links with the wider scientific world. The MDD is
currently subject to consultation3 and when relaunched as
the Medical Device Regulations may require appropriate
QMS compliance for elements of MP&CE. This topic
perhaps deserves another article.
Moving beyond ISO 9001:2008
I have indicated that constructive use of the ISO 9001:2008
quality standard can go far beyond a simplistic and
somewhat meaningless compliance. However, over the
years, a requirement for something more than ISO 9000
has been recognised. Consider the production of vacuum
cleaners. Retailers offer many models. We expect them all
to be CE marked and manufactured within an appropriate
ISO certified system. However, there are consumer advice
labs which test the products and produce league tables
and ‘best buy’ suggestions to provide additional help to
the consumer. Such quantification of ‘product’
characteristics stimulated developments going beyond the
ISO 9000 certification concept. Perhaps the first example
was ISO/IEC 17025:1999, ‘General requirements for the
competence of testing and calibration laboratories’.
Current ISO 17025:2005 systems embrace ISO 9000
requirements and the scheme works well because it is
relatively easy to subject laboratories to both technical
audits and test measurement schemes.
The audit/assessment processes for ISO 9001:2008 and
ISO/IEC 17025:2005 are quite different. For ISO 9001:2008
systems, certification is defined as ‘written assurance by a
third party that a product, process or service conforms to
or complies with specified requirements’. The external
auditing and certification of QMS is performed, using
generalist auditors, by a UKAS accredited company. For
ISO 17025:2005 the work is done directly by UKAS and it
involves technical experts. The laboratory is accredited,
not certificated.
A similar concept was adopted in 1992 when Clinical
Pathology Accreditation (UK) Ltd, or CPA, was formed to
compare and ensure standardisation of the output of
clinical laboratories and grant accreditation. Initial
planning for the scheme involved labs from Australia,
Canada and the UK. This was an example of the use of the
term ‘accreditation’, outside the aegis of UKAS. CPA
continued to be involved in international collaboration
and the work eventually led to the publication of ISO
15189:2003, ‘Medical laboratories – particular
requirements for quality and competence’.
In 2009 CPA was acquired by UKAS. CPA continued its
international collaboration and a revised standard
document, ISO 15189:2012, has been published that
embodies the requirements of ISO 9001:2008. Medical
laboratories are now in a well-organised evolution from
accreditation through CPA to accreditation with ISO
15189:2012, through UKAS.
A further complication is that UKAS is not the sole
body offering QMS accreditation in the UK. Other
organisations, accredited with UCAS, can offer
certification of ISO 9001:2008 systems and supplement
this by granting accreditation using their own standards,
which have been approved by the International Society
for Quality in Health Care (ISQua).4
Further developments in UK healthcare science
So far I have considered the two long-established QMSs in
healthcare science: the medical laboratories’ ISO 15189
approach, with UKAS accreditation, and the MP&CE
departments using ISO 9001 certified systems, often
referencing and augmented by peer review, etc. In recent
years an alternative approach to QMS has emerged. In
both Europe and America similar initiatives have been
developed. In 2009 the Imaging Services Accreditation
Scheme (ISAS)5 was introduced in the UK. It was
developed by the Royal College of Radiologists (RCR)
and the College of Radiographers (CoR) with Department
of Health (DoH) support. It uses UKAS as the
accreditation body and assessor teams involving technical
experts, RCR clinical experts and a lay person. It
combines self-assessment with separate external
assessment/peer review visits. Assessment is conducted
against ISAS published standards and criteria. The
applicant department defines the scope. In November
2014 only 18 services were listed as accredited. To gain
insight into the work involved and to access a larger
bibliography on health sector accreditation see Hiorns.6
A similar scheme, closely modelled on ISAS, called
Improving Quality in Physiological Services (IQIPS),7 was
launched with pilots in 2011. The IQIPS accreditation
framework was developed to improve, promote and
recognise good-quality practice across eight physiological
disciplines. In November 2014 there are 22 listed ‰
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SCOPE | MARCH 2015 | 15
SERVICE QUALITY FEATURE
‰ accredited services. Accreditation is awarded by
‘ Edwin
Claridge
was a Consultant
Clinical Scientist
based at the
Queen Elizabeth
Hospital, UHB
NHS Foundation
Trust,Birmingham,
UK
UKAS under a contract with the Royal College of
Physicians (RCP). Both ISAS and IQIPS are available to
NHS and private providers.
The common model used in the ISAS and IQIPS
schemes involves firstly a list of domains, then a list of
standards. Each standard then acquires a list of criteria.
These documents are published and available online.
After departments enrol they gain access to a selfassessment and improvement tool (SAIT) and a
knowledge management system (KMS). Departments
establish documentation to indicate that they satisfy the
criteria and undertake self-assessment against the
criteria. Progress is logged electronically with the
scheme’s central office. When reasonably confident,
departments apply for accreditation – if the remote
assessment is considered satisfactory then a formal
assessment visit takes place and accreditation can be
granted. Thereafter annual web-based self-assessment
follows. Formal visits occur every two years for ISAS
and every four years for IQIPS. ISAS and IQIPS have no
formal connection with ISO 9001 but the criteria clearly
share many common themes.
Attention to the importance of quality management
in healthcare science was highlighted in November 2013
by Professor Sir Mike Richards CBE, who stated that
‘accreditation and peer review already play an
important role in quality improvement in areas such as
mental health, diagnostics and cancer and I strongly
believe that such schemes have a key role to play in the
future of hospital inspection’. Soon after that the AHCS/
IPEM project was launched, to design an accreditation
system for MP&CE. The project is currently called
Improving Quality in Clinical Engineering and Physical
Science Services (iCEPSS).1 This title seems somewhat
pejorative; would not CEPSSAS or CEMPAS be better,
following the ISAS precedent?
iCEPSS documentation indicates that existing QMS
systems need to be recognised and accommodated. This
is easier said than done, because most are certified,
rather than accredited, meaning that different auditing
bodies, contracts and philosophies are involved. The
consultation on standards and criteria, produced by the
AHCS/IPEM project group and in progress at the time
of writing in early November 2014,8 clearly concentrates
solely on a new system. It did not seem to stimulate
much lively conversation in MP&CE common rooms but
the underlying issues are of considerable importance.
The proposal involves a top level generic scheme with
five domains:
n patient and service user experience – five standards,
27 criteria;
n management, facilities and resources – 11 standards,
34 criteria;
n workforce and training – six standards, 46 criteria;
n safety and risk management – six standards, 37
criteria, and
n clinical scientific service – six standards, 38 criteria.
Departmental arrangements are so different that it is
unlikely that all departments will find all the criteria
relevant but this problem will already have been faced
within IQIPS.
16 | MARCH 2015 | SCOPE
Options for MP&CE: comparing the old and
the new
The scope of the ISO 9001:2008 systems can easily be
defined to cover clinical services, as described in the
introduction above. A major benefit of ISO 9001 is that it
does not impose a ‘vertical ’implementation. We can
argue that there are greater benefits for an oncology
service (which includes radiotherapy) to use a
‘horizontal’ ISO 9001 system than for the radiotherapy
physics service to have its own separate ‘vertical’ iCEPSS
system. This is because the ‘horizontal’ system helps to
formalise relationships and handovers between
clinicians, radiographers, clinical scientists and
practitioners, IT staff and company supplier staff.
Another significant feature of ISO 9001 is that the
external auditors for the core system are ‘generalists’ or
‘laymen’ and they visit frequently. With separately
organised peer review and intercomparisons, having
services monitored in this way is surely reassuring for the
public at large.
The ISAS and IQIPS systems use a ‘vertical’
approach. IQIPS covers eight disciplines: audiology,
cardiac physiology, gastrointestinal physiology,
neurophysiology, ophthalmic and vision science,
respiratory and sleep physiology, urodynamics and
vascular science. ISAS includes, for example,
radiography, mammography, ultrasound and MRI in the
list of accreditable activities. If iCEPSS also uses this
approach it is faced with the challenge of dividing
MP&CE activities into a workable range of ‘vertical’
topics. This is likely to expose overlaps with ISAS and
IQIPS. There is also, of course, ‘horizontal’ sharing within
MP&CE, e.g. clinical computing, clinical measurement,
electronic and mechanical workshops, therapeutic
nuclear medicine and radiation protection. Do vertical
systems cover relationships with all colleagues as well as
‘horizontal’ ones?
Overall competence is really only assessed through the
analysis of output. In healthcare this can involve clinical
assessment of diagnosis and of treatments, sometimes
involving a long period of time. In oncology this has
already been recognised and we have clinical peer
review, interdepartmental dosimetry audits and various
audits associated with national and international clinical
trials. These complement the frequent external audits
required with ISO 9001:2008 systems and which are
conducted by generalist auditors from the certifying
company. It seems that within ISAS and IQIPS this
generalist auditing is replaced by self-assessment partly
monitored through electronic submissions to a central
office. The external audit visits are less frequent and
incorporate peer review assessments that are integral to
the QMS.
Building peer review into a UKAS QMS for healthcare
science service groups usually requires UKAS to associate
with a partner able to provide appropriate potential
auditors. With ISO 15189 this was achieved early, when
UKAS acquired CPA. For ISAS the natural partners were
the RCR and the CoR. The Royal College of Physicians
runs the accreditation office for IQIPS and contracts
assessment work to UKAS. A new iCEPSS scheme will
need an appropriate partner – should IPEM take this on?
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SCOPE | MARCH 2015 | 17
SERVICE QUALITY FEATURE
‰ Developing and managing QMS
Those who already have QMS will know that the staff
input needed in their development is considerable and
after systems are established it continues to be significant.
Paper-based systems exist but many systems benefit from
QMS organisational software that makes logging events,
controlling documents and flagging actions more
practical. Whilst iCEPSS would require a central agency
with online systems for collecting reports, it seems
unlikely that this will remove the need for local QMS
management software. There may even be a need to create
middleware to link the two.
As well as possible local software systems, the ISAS/
IQIPS model requires a central back office which deals
with enrolment, payments, online services, advice services
and links with UKAS. This office will build up a
centralised information resource within the subject areas
and that is not supplied through individual ISO 9001:2008
system certification bodies.
Conclusions
First let us look at the semantics. The distinction between
the terms ‘certification’ and ‘accreditation’, used in the
context of QMS assessment, is actually quite fuzzy. The
term ‘accreditation’ means different things to different
people and even in the world of healthcare QMS it is not
unique to UKAS. The core issue is that our masters want
further assurance of our competence and appear to favour
UKAS accreditation as the method through which it can
be achieved.
The evidence from the timescales outlined above
suggests that creating new and effective QMS takes a long
time and that systems based on ISO standards work well.
Beyond ISO 9001:2008, both ISO 17025:2005 and ISO
15189:2012 assess competence mainly through quantitative
means. What is more difficult is to determine how to
assess competence with regard to clinical outcomes.
It is a pity that the AHCS/IPEM project consultation
concentrates on fine detail without setting out
explanations and options. Hopefully members will have
made good use of the free text opportunity! Incidentally,
good examples of consultation come from the Law
Commission9 and the MHRA.3 DoH asked IPEM to join
ACHS in this work because of its wide-ranging MP&CE
involvement. Additionally, within IPEM, there is access to
much MP&CE experience of ISO 9001:2008, together with
an understanding of risk assessment, option appraisal,
project management and business case planning. These
strengths need to be brought to bear on the problems.
The AHCS/IPEM project is encouraged to quickly
produce a new accreditation system. Whilst that would be
helpful to the Care Quality Commission (CQC), the
material presented here suggests that the process is not
usually quick. Clearly departments or sections of
departments without quality systems could benefit from
having them but at this stage iCEPSS seems to place too
much confidence in a model that is not well understood
within a MP&CE context and has a limited NHS pedigree.
A particular challenge is to consider the best way to
conduct assessment of service competence in MP&CE
areas, or the service areas they support. Perhaps there is
scope for an evolutionary approach using both ISO
18 | MARCH 2015 | SCOPE
9001:2008 systems and new iCEPSS systems? Services
with good QMS would avoid dramatic change and still
satisfy review requirements. In the much longer term
migration to an extended ISO system, parallel with ISO
15189, might be possible. An evolutionary approach
would follow the lead from Simon Stephens and the NHS
’Five Year Forward View’,10 which suggests, in a different
context, that we should question whether a ‘one size fits
all’ approach is best. It is possible that ISO 9001:2008
‘horizontal’ systems with appropriate peer review and
intercomparisons are best in some circumstances and
iCEPSS ‘vertical’ systems will fit other needs. In both
cases funded peer review and scheme support is needed.
In the new systems peer review is built into the
accreditation model but core activity is monitored mainly
by self-assessment. In certified systems core activity
monitoring is probably more robust and peer review is
arranged separately. Perhaps the key question is to ask
whether peer review is best organised within or
alongside QMS?
One of the IPEM core objectives is to promote the
interests of MP&CE for the benefit of the community at
large. To encourage more departments to use QMS is
clearly in line with this objective. Would it be best served
by seeking an evolutionary approach to the wider use of
QMS? This approach might deal better with interscheme
overlaps and potential unforeseen consequences. Peter
Jarritt, the iCEPSS Project Lead, and his team have a
difficult job to do. I hope that this article will encourage
IPEM members to engage with the team and contribute
to further discussions. n
‘ APPENDIX 1. THE SCOPE OF ISO STANDARDS IN
HEALTHCARE SCIENCE
The documents listed here indicate that there are many important
MP&CE-related issues now covered by ISO/IEC standards and
technical reports. The list is not inclusive and does not cover
ionising radiation material. MP&CE must continue to be aware of
these and similar documents in planning its QMS developments.
n The next revision of ISO9001 is due in 2015.
n ISO/IEC 27000:2014 Information technology – Security
techniques – Information security management systems –
Overview and vocabulary.
n ISO 27799:2008 Health informatics – Information security
management in health using ISO/IEC 27002.
n ISO 15189:2012 Medical laboratories – Requirements for
quality and competence.
n ISO 60601-1:2006 + Amendment 1:2013 Medical electrical
equipment. General requirements for basic safety and essential
performance (harmonised with the MDD).
n ISO 13485:2003 Medical devices – Quality management
systems – Requirements for regulatory purposes.
n ISO 14971:2007 Medical devices – Application of risk
management to medical devices.
n ISO/IEC 90003:2004 Software engineering – Guidelines for the
application of ISO 9001:2000 to computer software.
n IEC/TR 80002-1:2009 Medical device software – Part 1:
Guidance on the application of ISO 14971 to medical device
software.
n IEC 62304:2006 Medical device software – Software life cycle
processes.
n IEC 80001-1:2010 Application of risk management for ITnetworks incorporating medical devices – Part 1: Roles,
responsibilities and activities. This document is the first in a
series of eight that deal with the relationship between hospital IT
departments and medical device users in organising the sharing
of networks. This is of considerable relevance to MP&CE services.
Wireless networks are included and advice to hospitals on the
implementation of the standard is to be provided.
SONOGRAPHIC EDUCATION FEATURE
REFERENCES
Hyperlinks checked in November 2014
1 AHCS. iCEPSS project leaflet, 2014.
http://www.ahcs.ac.uk/wordpress/wpcontent/u
ploads/2014/06/iCEPSS-A4-leaflet.pdf
2 Bleehen NM. Quality Assurance in Radiotherapy.
Report of Standing Sub-committee on Cancer.
London: Department of Health, 1991.
3 MHRA. Changes to the Medical Device Directive.
http://www.mhra.gov.uk/Howweregulate/Device
s/Legislation/NewLegislationonMedicalDevices
4 The International Society for Quality in
Healthcare. http://www.isqua.org
5 ISAS. Imaging Services Accreditation Scheme.
https://www.isasuk.org/Library/Preapplication_
Page/ISAS%20Preparation%20Leaflet%20Med%
20res.pdf
6 Hiorns M. Radiology Accreditation in the UK: the
Theory and the Reality. http://www.isasuk.org/Library/Radiology%20in%20the%20UK%20
2011.pdf
7 Improving Quality in Physiological Services.
https://www.iqips.org.uk
8 AHCS. The iCEPSS consultation.
http://www.ahcs.ac.uk/2014/08/icepssconsultation-launched-have-your-say-in-shapingstandards-criteria-anddomains/?utm_source=VoxAug14
9 Law Commission. Regulation of Health and Social
Care Professionals.
http://lawcommission.justice.gov.uk/areas/Health
care_professions.htm
10 NHS England. Five Year Forward View, October
2014.
http://www.england.nhs.uk/wpcontent/uploads/20
14/10/5yfv-web.pdf
Delivering sonographic
education and training
Sally Hawking (CASE Co-ordinator) describes the
consortium that promotes best ultrasound practice
U
ltrasound is something the public are very
acquainted with – who hasn’t seen the
black-and-white image of an unborn baby in
the womb? But its use in healthcare
stretches far beyond obstetrics and its
application crosses many areas of medical physics, and
so it is right that this is a field in which IPEM should be
involved. This article explains how IPEM is helping to
promote better standards in ultrasound education,
through an innovative and successful accreditation
partnership known as CASE.
If you read the list of IPEM objectives you will see that
the top two are ‘Ensure and improve the quality, safety
and effectiveness of science and technology in healthcare’
and ‘Maintain high standards of professional
development for healthcare scientists, engineers and
technicians’. Just one of the ways IPEM is meeting these
objectives is by being a key member of the Consortium
for the Accreditation of Sonographic Education,
otherwise known as CASE. The consortium is made up of
five member organisations, the others being the Society
and College of Radiographers (SCoR), the British Medical
Ultrasound Society (BMUS), the British Society of
Echocardiography (BSE) and the Society for Vascular
Technology of Great Britain and Ireland (SVT). CASE was
established in 1993 with a common purpose to ensure
that the education and training of sonographers in the
UK is delivered at the highest level.
Promoting best ultrasound practice
CASE has been on something of a journey in the past 22
years as both people and technology have changed. The
arrival of high street sonography, the rise of short,
focussed courses and the encouragement of non-NHS
service providers have all had an impact on sonography
education and practice. In spite of this, CASE has recently
been enjoying a period of growth and success as its
reputation extends to higher education institutions and to
students, both in the UK and abroad.
CASE is governed by its member organisations, and
whilst they are each unique in their purpose and
commitments to their members, they are brought
together to provide a forum for exchanging ideas, ‰
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SONOGRAPHIC EDUCATION FEATURE
‰ sharing views and providing the governance, strategic
aims and financial decisions. A committee, made up of
two representatives from each of the member
organisations and supported by the CASE co-ordinator,
manages the actual accreditation process alongside other
fundamental tasks. The day-to-day activities include
approving new accreditor applications, organising study
days, producing a newsletter and maintaining data. For
both groups, it is key to consider the advances in clinical
procedures and in academic methods and reach
conclusions on how CASE should respond. It is vital to
everyone involved that the standards of service provision
and education are developed in parallel with increasing
demand and improving technology.
CASE’s philosophy has always been to promote best
ultrasound practice through the accreditation of
postgraduate training programmes that develop safe and
competent ultrasound practitioners. At its heart is a team
of 31 volunteer accreditors who ensure that the
programmes being run from currently 17 of the UK’s
universities meet the exacting standards that CASE has
set. The accreditors themselves come from a mix of both
academic and clinical backgrounds, some are universitybased whilst others are hospital-based, but many have
experience in both areas. Their skills cover a wide range
of ultrasound applications including gynaecology,
vascular, musculoskeletal, cardiac and emergency
medicine.
The accreditation process
‘ MORE INFO
To volunteer as a
CASE accreditor,
or for further
details, see
www.case-uk.org
Course leaders of MSc programmes and postgraduate
level focussed courses are required to apply to CASE for
accreditation, after which a team of accreditors will be
assigned to review and appraise every aspect of the
programme or course from documentation through
clinical assessment and staff competency to student
experience. A key element of the process is the feedback
that the accreditors give to the universities where,
alongside commendations and recommendations for
change, conditions can be applied which the university
must meet within a given timeframe in order to achieve
accreditation. A comprehensive annual performance
monitoring review (APMR) is carried out at the end of
each academic year and provides the APMR subgroup
with the opportunity to check on the courses being run
and to see if any adverse issues arise
between official CASE accreditation
visits to further safeguard standards.
Of the applications CASE receives
for accreditation, the main area to see
recent growth is the delivery of
focussed courses that meet a need for
training in a specialist area of
ultrasound application, whether that is
a niche skill or a subject matter that is
profession-specific. For such courses to
be successful at accreditation it is
important that they match up to the
same clinical practice standards as a
full programme would. The very fact
that these courses are growing in
popularity, however, reflects the
20 | MARCH 2015 | SCOPE
changing environment from an academic and service
perspective and how individuals go about advancing
their own career. There have also been a number of recent
approaches to CASE to request accreditation from other
providers of education, such as private training
companies or manufacturers. Whilst CASE is willing to
accredit these courses, the key requirement remains that
the clinical competencies are the equivalent of an ‘Mlevel’ course, albeit in a smaller, defined area of practice.
Plans for the future include encouraging the Royal
College of Midwives to return to the consortium, as
midwives are seen as a highly valuable and important
group that needs to be represented; persuading the few
remaining unaccredited courses to apply for CASE
accreditation, and developing a strategic plan for the
consortium that will ensure it can continue its essential
work into the future.
Through its involvement and influence with CASE,
IPEM is achieving its aim to ensure high standards for
the benefit of the public when it comes to sonographic
training. It is maintaining the Institute’s traditional role in
setting and maintaining standards which protect the
public, whilst being flexible and innovative in response
to a changing environment. For the IPEM members
involved with CASE, both as accreditors and committee
members, the role is an interesting and rewarding one.
Gill Dolbear, CASE Chair, November 2014:
‘The main aim of CASE has always been to protect the
public by ensuring consistently high levels of ultrasound
education and training throughout the UK. Alongside
this, CASE has strived to encourage creativity in the
design and delivery of ultrasound programmes and
courses, whilst at the same time ensuring the quality and
consistency of the student experience. The current
sonography workforce crisis is driving the need for
further innovation and, over the next few years, we will
see a new and exciting ultrasound education and training
landscape emerge as “new style” courses are developed
and delivered. The challenge presented to CASE is,
therefore, to make the best use of the extensive
knowledge and experience of its accreditors to guide
HEIs through this period of change to a successful
outcome.’ n
Person-centred care: health
technology management
John Amoore (NHS Ayrshire and Arran) and Patricia Brooks Young
(Edinburgh Napier University/NHS Lothian)
‘
erson-centred care’ has become a new slogan
in contemporary healthcare, with hospitals,
Trusts and other organisations adopting
strategies to support a greater focus on service
users, including patient representatives on
Boards and committees. But surely all healthcare is
focussed on patients? What does person-centred care
actually mean?
The answer lies in viewing the process of care from the
patient and carer perspective. Person-centred care is then
defined by service users as ‘planned with people who
work together to understand me and my carer(s), put me
in control, co-ordinate and deliver services to achieve my
best outcome’.1
P
Within rehabilitation engineering and other disciplines
of medical physics and engineering whose work routinely
involves direct patient and carer contact, the importance
of person-centred care is not difficult to appreciate.
Designing or adapting mobility aids for an individual
patient and their carer is inherently person-centred. But
does a person-centred approach have relevance for health
technology management (HTM), the technical details of
which can often seem remote from patients and carers?
The objective of medical devices and HTM goes beyond
functional technology, to the outcomes and experience for
the patients and carers whom the technology supports.
This objective must not be lost as HTM practitioners
concentrate on the necessary technical details. ‰
‘ FEEDBACK
Scope welcomes
your feedback!
@IPEMScope
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SCOPE | MARCH 2015 | 21
PERSON-CENTRED CARE FEATURE
‰
t
FIGURE 1. Engineering is built on pillars of people, money and technology, an
understanding of which is particularly appropriate for engineering applied to
healthcare whose focus is the people involved, in particular the patients and
their carers, professional and lay
Medical devices are not used in isolation. The
interactions between technology, patients and their carers
(professional and lay) should be understood by the clinical
engineer solving medical device problems. Focussing solely
on the technicalities of medical devices and their
management is not sufficient to meet contemporary
healthcare demands and national quality standards. White
and King emphasised this when discussing the selection of
enteral feeding pumps: ‘The accuracy and safety of feeding
pumps are, however, only a part of enteral pump system
evaluation. Assessment … is also required from patients and
their care givers’.2 Engineering is not simply about the
technical details of equipment, but is built on the pillars of
‘people’, ‘finance’ and technology (figure 1). This is
particularly true for health technology management where
people (patients and caregivers) are at the heart of the
process, the ‘keystone’ that holds the process together.3
If person-centred HTM is appropriate, what does this
mean in practice? The ECRI Institute, reflecting on the
transformation of healthcare from a ‘provider-based model to
one that recognises and incorporates the individual patient’s
needs and values’ questioned how to ‘transform the concept
from an amorphous ideal into a clearly attainable goal’,
suggesting the need to define the ‘elements that are
characteristic of patient-centered care’.4
Transformation from equipment focus to person
focus
FIGURE 2. Equipment-focussed health technology management
Traditional equipment management focussed on the devices
whilst acknowledging relationships between medical devices,
healthcare team, the patient and supporting infrastructure
(figure 2). Technical details are vitally important, ensuring
careful selection followed by maintenance to ensure efficacy
and safety during the equipment’s operational life. Equally,
the necessary technical attention should consider and not
obscure patient and carer requirements. Hence, personcentred equipment management transforms the focus from
the medical devices (figure 2) to include the patient and carer
(figure 3). Recognising the need for this transformation is
only the first step, however; how to turn this into a practical
reality is a key consideration. One approach is to review, from
a patient–carer perspective, the individual elements of the
traditional HTM pathway starting from identification of
need, through selection, procurement and management
during operational use to final disposal (table 1).
Transforming the ‘amorphous ideal into a clearly attainable
goal’4 requires analysing each element, identifying how each
should be developed to better support patient and carer
needs. The transformation does not neglect the technical
requirements, but adds the complementary person-centred
dimension.
t
Identifying the person-centred dimensions of the
HTM pathway
FIGURE 3. Patient- and carer-focussed health technology management
t
22 | MARCH 2015 | SCOPE
Table 1 summarises the HTM pathway with its three phases:
acquisition, operational and disposal. Incorporating the
person-centred (PC) approach involves looking at each phase
from the perspective of patient and carer.
The first phase, the acquisition of medical devices, begins
with the identification of need, from which the clinical and
technical specifications follow. These specifications provide
the basis for evaluating the technologies available to enable
PERSON-CENTRED CARE FEATURE
selection of the optimum device meeting the clinical,
technical and financial criteria. The MHRA, in its 2014
revised guidelines on ‘Managing Medical Devices’,5
recognises the importance of the PC approach, asking those
who select medical devices to explicitly consider the
patient perspective. Planetree and the Picker Institute
discussed evaluating equipment from a patient
perspective,6 adding that the patient perspective
complements and supports the traditional approach. Thus,
for example, when assessing the need for MRI scanning,
the PC approach will include maximising patient comfort
(noise and environmental aspects) and the needs of
particular patient groups (e.g. bariatric patients and
children). In community settings, the PC approach
considers how technology best supports and provides
confidence to patients and carers, supporting safety, clinical
therapeutics and quality of life. There is the need to
understand their perception of medical technology and its
day-to-day use in the home, with consideration of how
they can be supported by healthcare professionals should
problems occur.7
These considerations should lead to a specification that
explicitly considers patient and carer needs. This issue is
increasingly emphasised by the drive to shift the balance
of care from hospital to community setting and allow
more people to spend more time in a homely setting. In
addition, the progressing health and social care integration
agenda8 means that the professional carer may not be a
registered nurse or other healthcare practitioner. The
usability of devices may then have to match a range of
skill levels including social work carers and care home
staff. This wider pool of ‘users’ may also include the
greater numbers of patients with chronic conditions being
supported to self-manage their condition or to do so with
support from their family. This shift in care setting and
delivery, where well managed and supported, has
attractions both for patients and healthcare resources. It is
likely that medical devices will play an increasingly
important role.
Equipment specification should therefore encourage
those who design and construct medical devices to
incorporate patient–carer requirements by asking ‰
‘ FEEDBACK
Scope welcomes
your feedback!
@IPEMScope
TABLE 1
Phase
Traditional equipment management approach
Person-centric approach
1. Acquisition
1.1 What is the clinical need
and how can technology
support it?
Identify clinical need, linking to strategic plans and identify
the technology to support this
From the person perspective, can technology support care, and if so how and
what technology is available?
1.2 Transform the clinical
need into a clinical and
technical specification that
includes evaluation criteria
a. Clinical function
b. Governance and safety
c. Technical requirements
d. After-sales support
e. Financial – acquisition and operating costs
f. Evaluation criteria and scoring system
a. Location of use (e.g. home) and implications including support
b. Ease of use for non-professional: ergonomics, mistake-proofing
c. Robust, size, weight, portability
d. Aesthetics, shape, colour
e. Utilities required
f. Accessories, consumables
g. Cleaning
1.3 Evaluate, select
Look for what is not obvious
Evaluate and score
Evaluate and score from person perspective, with extra focus on ease-of-use by
non-professional
1.4 Procure
Comply with financial instructions
Do products and consumables need delivery to community?
1.5 Commission
Staff requirements, training, procedures
Locations of use
Physical installation, IT requirements, mounting
Configure, test
Documentation
Supply of accessories and consumables
Training, information for use (IFU) and guidance, procedures
Practicalities and risks of use in the community and home
Obtaining help if things go wrong
Logistics and control of accessories and consumables supply
2.1 Normal operation
Supply and disposal of consumables
Ongoing training
Documentation review
Routine scheduled testing
Continue to ensure patients and carers understand the purpose of the device
Update training
Manage patient–carer documentation
Are additional considerations for supply and disposal of consumables needed?
Manage routine maintenance, including any patient–carer maintenance required
2.2 Problems, faults
Fault reporting
Incident reporting
Responding to safety warnings
Ensure dialogue and communication
How are problems reported and resolved?
Incident reporting by patients – e.g. MHRA website
When to withdraw from use
Disposal compliance with waste regulations
Are special considerations required for disposal outwith healthcare
organisation?
2. Operation
3. Disposal
TABLE 1. The equipment management pathway. Note: the term ‘person’ in the table includes patient and lay carer
SCOPE | MARCH 2015 | 23
PERSON-CENTRED CARE FEATURE
t
FIGURE 4.
The patient and
carer
experience is
the focus, the
keystone,
integrating the
equipment and
patient
journeys
‰ questions such as: ‘Describe how the product has been
designed to enhance the patient experience’. Thus noise
reduction and minimising the sense of claustrophobia will
be considered for MRI scanners. A pump administering
medication for pain and symptom relief will be designed to
be intuitive to use with clear instructions, and attention
given to weight and size for mobile patients.2, 9
The specification and evaluation should question how
risks associated with the ‘environmental unpredictability’
of the care environment are managed and minimised by
the device design.10 To explore and encourage ‘designing
out risk’, evaluations should assess the extent to which
mistake proofing has been achieved. Methods may include
tamper-proof and child-proof protection measures.
Evaluation and selection requires a multidisciplinary
team approach with patient, clinician, clinical engineer,
procurement and finance each contributing their expertise.
The team approach must be managed to ensure sharing of
views, without domination by vested interests.
The acquisition phase will help direct the clinical
operational phase. For example, will patients or carers
operate the equipment? Patients will directly control some
medical devices, even in hospitals (e.g. patient-controlled
analgesia pumps). Patient care is enhanced when patients
understand the clinical reasons for the medical devices.11
This understanding can relieve anxieties of family and
friends seeing loved ones connected to medical devices. ‘It
was awful seeing mum connected to all those tubes and
wires.’ ‘Is it because I am about to die that you are
connecting me to that pump?’ These anonymous comments
echo surveys that show the need to address the emotional
needs of patients with infusion devices.12
Home-care equipment (home dialysis, home ventilation,
telemonitoring, infusion and feeding pumps) will typically
require direct patient–carer control. Device controls should
be logical and intuitive, with clear instructions for use in
non-technical language. Unfortunately, there is still poor
recognition of the importance of carer support and the
impact of technology in the home.13
Processes for supplying and disposing of consumables,
accessories and associated packaging should be
implemented which consider patient pathways within and
across relevant settings. Within the home-care
environment, special arrangements for scheduled
24 | MARCH 2015 | SCOPE
maintenance should be provided, including whether any
patient–carer maintenance is required. Clear problemsolving procedures are required, whether the problem is
equipment failure, consumable shortage or lack of
confidence in equipment operation. Procedures should exist
for reporting and providing feedback if an incident occurs.
patients and carers to directly report adverse events, but
this should be facilitated by local support systems.14 Greater
attention is required to involve patients and carers in the
safe and effective use of medical devices.
The third and final HTM phase is deciding when to
remove equipment from use. Procedures will be in place for
disposal of equipment used within healthcare organisations.
Procedures are required for equipment used within the
community and in patients’ homes.
An effective feedback loop to procurement and
commissioning is essential throughout the HTM process.
This ensures that future device development is informed by
clinical and patient need with equipment fully fit for
purpose rather than driven by manufacturers or solely by
advances in technology.
Discussion and conclusion
This article challenges health technology management to
focus on the needs of patient and carer, including everyone
in the decision-making process. Achieving person-centric
HTM requires implementation of practical steps that
transforms the focus from technology to people. Person
centeredness demonstrates the added value of a
participatory team approach that recognises the knowledge,
skills, competence and responsibilities of all involved; the
patient, carers, clinicians, clinical engineers and other
support staff. Practical application requires identifying the
elements of person-centred equipment management. Table
1 summarises some elements of the lifecycle pathway, but is
not exhaustive.
It is important to incorporate the PC approach without
losing sight of technological details, but rather see the two
approaches as complementary. It is the integrated attention
to the technology and the patient and carer that transforms
the engineer into a clinical engineer. The keystone model3
symbolises this integration of the technical and clinical
pathways and processes focussing on the patient and carer
(figure 4). n
‘ ACKNOWLEDGEMENTS
Supported by a grant from the Scottish Government Health
Innovation Patient Experience Fund
REFERENCES
1 National Voices.
http://www.england.nhs.uk/2012/12/11/narrativeintegrated-care (accessed 17th November 2014).
2 White H, King L. Enteral feeding pumps: efficacy,
safety, and patient acceptability. Med Dev Evid Res
2014; 7: 291–8.
http://dx.doi.org/10.2147/MDER.S50050
3 Brooks-Young P, Amoore JN. Subcutaneous
infusions for pain and symptom control in palliative
care: introducing the keystone model. 19th
PERSON-CENTRED CARE FEATURE
International Congress on Palliative Care, Montreal,
Canada, October 2012.
4 ECRI Institute. Patient-centered Care. Healthcare
Risk Control, Executive Summaries, Volume 2,
November 2012. www.ecri.org
5 MHRA. Managing Medical Devices: Guidance for
Healthcare and Social Services Organisations.
http://www.mhra.gov.uk/home/groups/dtsbs/documents/publication/con2025143.pdf
(accessed 17th November 2014).
6 Planetree and The Picker Institute. Patient-centred
Care Improvement Guide. Chapter 8: Patient
centred approaches to data and technology.
http://patientcenteredcare.org/chapters/chapter8.pdf (accessed
17th November 2014).
7 Smithard DG. Family carers/next-of-kin perceptions
of home-care technology: a review. Smart
Homecare Tech TeleHealth 2014; 2: 45–53.
http://dx.doi.org/10.2147/SHTT.S42675
8 Scottish Government. The Integration of Health and
Social Care 20:20 Vision.
http://www.scotland.gov.uk/Topics/Health/Policy/
Adult-Health-SocialCare-Integration (accessed
17th November 2014).
9 Hilbers ESM, de Vries CGJCA, Geertsma RE.
Medical technology at home: safety-related items in
technical documentation. Int J Technol Assess
2013; 29: 20–26.
10 Center for Devices and Radiological Health.
Medical Device Home Use Initiative, April 2010.
http://www.fda.gov/downloads/MedicalDevices/Pr
oductsandMedicalProcedures/HomeHealthandCon
sumer/HomeUseDevices/UCM209056.pdf
(accessed 17th November 2014).
11 Pelletier SD. Patients’ experience of technology at
the bedside: intravenous infusion control devices. J
Adv Nurs 1992; 17: 1274–82.
12 Quinn C. Infusion devices: understanding the patient
perspective to avoid errors. Nursing Times, October
2003. http://www.nursingtimes.net/infusiondevices-understanding-the-patient-perspectiveto-avoid-errors/199834.article
13 Bjuresäter K, Larsson M, Athlin E. Struggling in an
inescapable life situation: being a close relative of a
person dependent on home enteral tube feeding. J
Clin Nurs 2012; 21: 1051–9.
14http://www.mhra.gov.uk/Safetyinformation/Reporti
ngsafetyproblems/Devices/index.htm (accessed
17th November 2014).
‘ John Amoore
is Head of
Medical Physics,
NHS Ayrshire and
Arran.
He has a special
interest in health
technology
management,
safe use of
medical
equipment and
patient-centred
care.
‘ Patricia
Brooks Young
is Lead Nurse for
Palliative Care &
Clinical
Researcher NHS
Lothian/
Edinburgh Napier
University.
She has a special
interest in how
person-centred
care can be
achieved within
the realities of
healthcare
environments.
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SCOPE | MARCH 2015 | 25
IMAGEJ FEATURE
ImageJ: image processing
and analysis in Java
Gregory James (City Hospital, Birmingham) uses this open-source
software in his department and finds it versatile and easy to use
t
FIGURE 1.
Screen capture
of the ImageJ
toolbar interface
(Windows 7)
mageJ is free, open-source software used for image
processing. It can read many image formats
including TIFF, GIF, JPEG, BMP, DICOM and FITS.
ImageJ can run either as an online applet or as a
downloadable application through the website.1 The
ImageJ software is written in Java, which means it can be
installed on any of the three operating systems
(Windows, Mac OS or Linux) as long as the computer has
Java 1.5 virtual machine (or later). ImageJ is used in a
range of academic specialisms (biology, astrophysics, etc.)
and is growing in popularity amongst medical physicists,
especially those working in nuclear medicine. It offers
many image processing tools and functions that make it a
useful resource for medical image processing. The ImageJ
interface is very simple and shown in figure 1.
I
Why use ImageJ?
Being public domain open-source software, an ImageJ
user has the four essential freedoms defined by Richard
Stallman in 1986: (1) the freedom to run the program, for
any purpose; (2) the freedom to study how the program
works, and change it to make it do what you wish; (3) the
freedom to redistribute copies so you can help your
neighbour, and (4) the freedom to improve the program,
and release your improvements to the public, so that the
whole community benefits.
Apart from being free, ImageJ offers all the basic tools
and processing techniques required to view and
manipulate medical images. This includes region of
interest statistics, histogram analysis, profile analysis,
plot creation and many more. ImageJ also supports
standard image processing functions such as contrast
manipulation, sharpening, smoothing, edge detection
and spatial filtering. Simple processes like these can often
26 | MARCH 2015 | SCOPE
be difficult to perform in other software packages or
manufacturers’ own proprietary software. The data can
also be easily exported from ImageJ if the user wishes to
use other third party software, e.g. Microsoft Excel.
ImageJ has a large and knowledgeable worldwide
community with ‘more than 1,700 users and developers
subscribed to the ImageJ mailing list’.2 Extensive help and
documentation is available through the website,
including a detailed 198-page user guide explaining each
of the built-in features of ImageJ. There are specific
tutorials for the more abstract/complicated functions, e.g.
Fourier analysis. If issues are still unclear then questions
can be raised through the ImageJ mailing list.
For our department, it has provided a complete suite
of gamma camera QA software tools which are platformand manufacturer-independent. We also have a range of
standardised clinical analysis packages (e.g. renograms)
which are also independent of camera manufacturer. The
programs are also much easier to customise for any
change in technique or recommendations.
Programming in ImageJ
ImageJ has its own macro language with extensive help
and documentation provided on the website.3 In addition,
the ImageJ community has created excellent tutorials on
macro programming.4 The macro language is easy to
learn and use (with a syntax similar to that of C or Java),
making it ideal for beginners in computer programming.
For the more experienced computer programmers,
plugins are available where the power and magic of Java
is utilised. Plugins are implemented as Java classes,
which means that all the features of the Java language can
be used. In a similar way that apps can be downloaded
for a smartphone, a wide range of plugins are freely
IMAGEJ FEATURE
available through the ImageJ website.5 It is always worth
searching through the list of plugins to check that
somebody hasn’t already solved your problem before
embarking on writing your own solution. As powerful as
plugins are, the ImageJ macro language is not to be
dismissed as ‘too simplistic’. Some very powerful features
are still available in the macro language.
Image processing
When DICOM data is opened with ImageJ, the data is
presented in its raw, native format. For colleagues that are
used to viewing DICOM images on commercial software
this can be a bit of an unwelcome surprise. Most
commercial software packages will perform some sort of
cosmetic smooth to the images or interpolate the pixels
without the user realising it. However, this is one of the
advantages of ImageJ as it takes nothing away from the
user or the data. For this reason, ImageJ is an excellent
teaching platform for trainees and students to learn about
image processing techniques. This is a particularly
important skill to have in the field of nuclear medicine
where image processing is critical to the clinical
interpretation of the images. Such techniques include
smoothing filters, pixel interpolation and pixel truncation.
Region tools
One of ImageJ’s strengths is that it allows the user to
manipulate regions of interest. There are dozens of builtin functions available under [Edit > Selection > …] of the
ImageJ toolbar. As an example, using only two of the ROI
functions it is possible to write a simple macro to
automatically generate perirenal background regions of
interest in a kidney scan (see figure 2). To write this
functionality from scratch would be fairly complex,
especially on manufacturers’ proprietary software where
even simple tasks can be difficult to program. Using
ImageJ, this complex task can be performed in several
lines of code.
given the constant evolution of imaging and processing
techniques and the need to tailor programs to the needs
of the individual department.
Manufacturers’ nuclear medicine processing
platforms offer many image processing tools but where
there are shortfalls, ImageJ can be very useful in filling
in the gaps. To quote the ImageJ website: ‘user-written
plugins make it possible to solve almost any image
processing or analysis problem.8 In other words, as long
as you have the imagination and the programming
ability, anything is possible!
ImageJ was first used within the department to
address a requirement for vendor-independent gamma
camera QC analysis. The department was responsible
for gamma cameras from three different manufacturers,
each using their own software to analyse QC data to
their own specifications. Often, there was little
information available on how the results of such
analysis packages were derived. This made crosscomparison between systems impossible, and checks
against standard specifications very difficult. We
therefore saw the need for an independent platform to
analyse gamma camera QC data to ensure a consistent
approach between different systems. Since ImageJ was
free, accessible and easy to use, it was the obvious
choice. Initially, some very basic analysis programs
were written quite quickly (with sub-optimal
programming!). Over time, the programs evolved into a
complete gamma camera QC analysis suite that offers
automatic data archiving, trend analysis plots and
automatic QC results summaries. We now use these
programs routinely within the department and they
have detected problems that manufacturer’s own
software had missed. ‰
‘ FEEDBACK
Scope welcomes
your feedback!
@IPEMScope
Fourier analysis and convolution
t
One of ImageJ’s strongest and most impressive
functionalities is its ability to take the Fourier transform
of an image and display the frequency contributions
(power spectrum) in the form of a 2D image. This can be
particularly useful if the user wants to make high-pass or
low-pass filters for noise suppression or edge detection.
An example is given in figure 3 which has been taken
from the ImageJ user guide (available on the website).6
This technique of noise reduction is particularly useful
when removing sinusoidal noise patterns from images.
Such sinusoidal noise patterns manifest themselves as
‘spikes’ in the FFT image and so they can be masked out.
When the FFT image is transformed back into real space,
the noise is removed. Tutorials on this topic are available
on the ImageJ website.7
FIGURE 2. Image showing the automatic kidney and background regions
produced from a simple ImageJ macro
The evolution of ImageJ in our department
t
In the field of medical physics, it is often necessary to
write user-developed programs/software to perform
tasks that can otherwise not be performed by standard
packages. The culture of user-developed programs is
especially prevalent within the field of nuclear medicine,
FIGURE 3. Example of how the FFT image can be manipulated to pass or
exclude various frequency components
SCOPE | MARCH 2015 | 27
IMAGEJ FEATURE
‰
The gamma camera image uniformity program
shown in figure 4 is an excellent showcase for the
capabilities of ImageJ. The left half of figure 4 shows the
gamma camera flood images for detectors 1 and 2 of a
modern dual-headed gamma camera. The bottom two
images are duplicates of the top two except they have been
heavily windowed to exaggerate the non-uniformity of the
detectors. The right half of figure 4 shows the differential
uniformity histograms for detectors 1 and 2, for the useful
field of view (UFOV) and the central field of view (CFOV).
The method of analysis is defined by the National
Electrical Manufacturers Association (NEMA), which is an
industry standard method of analysing the uniformity of a
gamma camera flood field image. One of the conditions of
NEMA uniformity analysis is that the size of the pixels
within the image must be within a certain range. Most
gamma camera systems acquire a flood field image using
a much smaller pixel size. In order to use NEMA
quantitative uniformity analysis the pixel data must be
rebinned to achieve the required pixel size. This is a
standard image processing technique in nuclear medicine
where every 2 × 2 or 4 × 4 block of pixels are summed
together, presenting the image as if it were acquired on a
smaller imaging matrix, thus improving the signal to noise
and facilitating a more accurate quantitative measurement.
This process is sometimes referred to as ‘folding down’ the
image. Most commercial nuclear medicine workstations
will offer some form of ‘folding down’ process but their
methods vary, with some incorporating pixel interpolation
techniques. This is not the same as simply rebinning the
pixel data as the noise characteristics become destroyed.
Users should be vigilant to this and not be misled. Using
ImageJ it is possible to write a simple program to perform
this task properly in several lines of code.
Once the pixel size of the image is correct, NEMA then
states that the image must be smoothed using a specified
2D kernel. Most nuclear medicine workstations do not
offer this functionality, but this is standard with ImageJ
and can be achieved through the ImageJ toolbar [Process >
Filters > Convolve…] or in a single line of code. Once the
image has been smoothed, NEMA uniformity analysis
uses the maximum and minimum pixel values in the socalled ‘useful field of view’ (UFOV) of the gamma camera
detector. A simple ‘while’ loop can be used to detect the
UFOV, then ImageJ’s built-in functionality can measure
the minimum and maximum pixel counts to calculate the
‘NEMA uniformity’ index. These values can then be
written to a simple .txt file, allowing the data to be saved
and trend analysis plots to be produced; either within
ImageJ itself (figure 5) or within third party software (e.g.
Microsoft Excel) after export of the results.
Trend analysis plots like the ones shown above are a
vital tool in any department’s quality assurance
programme. It is rare for manufacturers’ own software to
offer this functionality.
Measuring spatial resolution using convolution
techniques
‘ FEEDBACK
Scope welcomes
your feedback!
@IPEMScope
ImageJ has the ability to perform a wide range of image
maths; for example, adding images together, subtracting
images, etc. One of the more impressive tasks is ImageJ’s
ability to convolve two images together. This can be useful
28 | MARCH 2015 | SCOPE
for research. Using convolution techniques it is possible to
measure the spatial resolution of an imaging system if a
‘contrast-type’ phantom is used. Typically a ‘contrast-type’
phantom would mean something with line-pairs, e.g. a
Huttner phantom for diagnostic x-ray systems or a fourquantrant bar phantom for gamma cameras. Given that the
object being imaged is discrete (i.e., black or white on a
representative image), if this is convolved with a Gaussian
point spread function (describing the spatial resolution of
the system) then the resulting image will give sinusoidal
pattern. The caveat to this is that the spatial resolution
should be comparable or greater than the object being
imaged. This is shown pictorially in figure 6.
Using this principle, it is possible to write a simple
program to get ImageJ to simulate specified object sizes
(line pairs), and then convolve the image with a theoretical
point spread function describing the spatial resolution of
the imaging system. If this process is repeated (using a
‘for’ loop) for various object sizes and point spread
functions, it is possible to generate a detailed lookup table
of spatial resolutions and image contrasts. When the
phantom is imaged, the contrast can be measured from the
plot profile. The contrast measurement can then be
converted into a full-width half-maximum (FWHM) for
the point spread function. Figure 7 shows this theory in
practice. Validation of the program shows that the spatial
resolution calculated using a convolution technique
matches very closely the resolution calculated directly
from an acquired point spread function.
Clinical use of ImageJ
The use of ImageJ within the department evolved from
gamma camera QC analysis to processing full clinical
studies for diagnostic purposes. This raises the interesting
question of whether this use of open-source software
becomes a clinical device as defined by the MHRA.9 Of
course, according to professional ethic at the very least, all
programs should be subject to standard QC software
procedures, e.g. verification and validation. Using ImageJ
it was possible to produce customised analysis programs
tailored to fit the specific requirements of the department.
The programs were written with due consideration given
to the needs of every staff group. Colleagues were given
the opportunity to contribute their own thoughts and
ideas on the font, colour scheme, layout, etc. which were
considered in the design. Special consideration was given
to the output being readable by non-nuclear medicine
staff, e.g. referring clinicians who review such cases at
MDT meetings. The final products are a testimony to how
programs can be written to the specifications of the staff
groups involved. Figure 8 is an example of a renogram
study that was processed using the ImageJ program.
For readers not familiar with renograms, the study
shows a normal right kidney (blue curve) and a poorly
functioning and obstructed left kidney (green curve).
ImageJ can produce quality outputs that are easy to
interpret for the reporting clinician. In the renogram study
above, this includes generating clear ‘activity-time’ curves
and displaying the results in large, bold text. The images
have also been annotated with the regions of interest so
that the reporter can check the quality of the region
drawing by the processor. This program offers several
IMAGEJ FEATURE
t
FIGURE 4. Example of the NEMA uniformity program written in ImageJ
t
FIGURE 5. An example of trend analysis plots that can be generated from a text file
SCOPE | MARCH 2015 | 29
IMAGEJ FEATURE
‰
advantages over other commercially available software;
specifically, the generation of curves that show the excretion
of tracer from the kidneys and the support of delayed
imaging (as in this example where the patient was imaged
again at 80 minutes post injection). In addition, we have
been able to implement the more detailed Rutland-Patlak
analysis technique, not commonly available. A second
screen generated in ImageJ has the details of the analysis
used by the operator, and this is available to the reporter.
Figure 9 shows the Rutland-Patlak plots for both
kidneys. These plots are critical to the quality of the study.
The user must define the ‘linear’ region of the plots which
are shown by the blue data points. The red data points
have been excluded from the ‘linear’ region. The relative
gradients of the lines of best fit give the relative kidney
functions (left: 29 per cent, right: 71 per cent in this case)
and the y-axis intercepts give the relative amount of
background to subtract from the raw kidney curves.
DICOM compatibility
t
FIGURE 6. Example of how the image is a result of the object convolved with
the spatial resolution of the imaging system
t
FIGURE 7. Example output from the ImageJ program used to measure spatial
resolution using a four-quadrant bar phantom
ImageJ accepts all kinds of image formats, including
DICOM which has relevance to the medical physics
community. ImageJ does not natively support saving
images in DICOM format, but the ImageJ community has
addressed this problem and there are plugins available
through the ImageJ website that allow this.
One plugin of interest is from the Institut für Telematik
in der Medizin (IFTM)10 and another plugin is the Tudor
DICOM plugin.11 The Java source code for both plugins is
freely available through both websites. Both plugins offer
different features and functionality with advantages and
disadvantages of each. The Tudor DICOM plugin saves as
‘explicit VR big endian’ whereas most commercial DICOM
workstations only accept data of ‘implicit VR (little)
endian’. Using this plugin, some work may be required to
improve DICOM export compatibility. Secondly, the IFTM
plugin exports data without the patient demographics in
the metadata (DICOM header). This again is undesirable
for clinical applications, but with a bit of work it is possible
to alter the source code and preserve the metadata in the
DICOM export process. This is one of the clear benefits of
open source software and testament to ImageJ’s flexibility.
A third option is to use a plugin called ‘nucmed’12 which
exports data in Interfile format13. This plugin has proven to
be a very useful tool for research and development in our
department. It allows raw gamma camera data to be
exported to ImageJ, manipulated and then imported back
to a commercial DICOM workstation. Using this technique
we have been able to research the effect of count loss
and/or patient motion in tomographic projection data.
This plugin has also been useful for Monte Carlo
simulation experiments with SIMIND14, e.g. researching
the minimum detectable size of a parathyroid adenoma.
Non-image use of ImageJ
FIGURE 8. Example of a renogram output from the ImageJ program
t
30 | MARCH 2015 | SCOPE
ImageJ is primarily designed to be used with images.
However, ImageJ does offer some excellent tools to work
with numbers and arrays. One tool of note is the curve
fitting tool found under [Analyse > Tools > Curve
Fitting…] of the ImageJ toolbar. This is a built-in program
that optimises a mathematical fit to a set of data (X and Y)
using an iterative process. ImageJ has a wide range of
IMAGEJ FEATURE
standard built-in fitting functions, e.g. polynomials,
exponentials, Gaussians, gamma functions, etc., but the
user can also define a customised function. This program
is very powerful and easy to use. The user simply copies
and pastes the data into a clipboard-type dialog window
and clicks a button. ImageJ then does all the hard work in
typically less than one second. This technique is used
within our nuclear medicine department to quantify the
biological uptake and excretion of tracer through an organ
(specifically HIDA through the liver) using a biexponential model.
software at zero cost. The caveat to this is that the user
must invest the time required to write the program. The
number of users is growing, together with an increasingly
useful number of plugins, and there is a very useful user’s
forum for help with any problems. All readers of this article
should consider downloading ImageJ and having a play!
For more information on ImageJ there is an excellent
textbook called Digital Image Processing by Wilhelm Burger
and Mark J. Burge. There is a whole chapter dedicated to
ImageJ, which is the principle piece of software used for
the book. Further information is also available on the
ImageJ website: http://imagej.nih.gov/ij/index.html n
‘ Gregory
James
is a Clinical
Scientist based at
the Department
of Physics and
Nuclear
Medicine, City
Hospital,
Birmingham, UK
Similar software
There are other software packages similar to ImageJ, for
example MATLAB®, OsiriX, IDL, to name just a few.
Readers of this article may be more familiar with these
packages rather than ImageJ. All have advantages and
disadvantages. MATLAB® is very powerful but has a
steep learning curve and licences can require a significant
financial investment. OsiriX is excellent for viewing
DICOM images but has limitations with its built-in
programming language, making it difficult to write certain
customised programs. Like ImageJ OsiriX is free, but the
major limitation is that OsiriX only runs on Apple
computers. IDL is perhaps the least popular of the
packages mentioned, mostly because of its steep learning
curve and again it requires a significant financial
investment. Other packages will perform the same tasks
with greater efficiency.
ImageJ2
There has been a recent release of a more powerful version
of ImageJ called ImageJ2.15 It is a complete rewrite of
ImageJ with its focus more on scientific imaging. ImageJ2
includes the stable, current version of ImageJ with a
compatibility layer so that old-style macros and plugins
can run the same as they currently do in the original
ImageJ. The main advantage of ImageJ2 is its ability to
work with 3D regions of interest (or volumes of interest).
This will clearly be a major benefit within nuclear
medicine imaging or other areas.
REFERENCES
Hyperlinks checked on 12th February 2015
1 http://imagej.nih.gov/ij/
2 http://imagej.nih.gov/ij/features.html
3 http://imagej.nih.gov/ij/developer/macro/
functions.html
4 http://imagej.nih.gov/ij/docs/macro_reference_
guide.pdf
5 http://imagej.nih.gov/ij/plugins/index.html
6 http://imagej.nih.gov/ij/docs/guide/user-guide.pdf
7 http://imagej.nih.gov/ij/docs/examples/tem/
8 http://imagej.nih.gov/ij/docs/intro.html
9 http://www.mhra.gov.uk/Howweregulate/Devices/
10 http://www.iftm.de/telemedizin/dcmimex.htm
11 http://santec.tudor.lu/project/dicom
12 http://www.med.harvard.edu/JPNM/ij/plugins/
Interfile.html
13 http://www.nf.mpg.de/vinci3/doc/imageformats.html
14 http://www.msf.lu.se/forskning/the-simindmonte-carlo-program
15 http://fiji.sc/ImageJ2
t FIGURE 9.
Representative
output of the
Rutland-Patlak
analysis used
by the operator
The benefits of bespoke software
The benefits of in-house developed bespoke software are
endless. Above all, it promotes original and innovative
thinking. The IPEM recently held a ‘Bespoke Software’
meeting in Manchester in October 2014 that explored the
benefits and risks of bespoke software writing. It is not
farfetched to say that developments in modalities such as
MRI, nuclear medicine and radiotherapy would be
significantly hampered without the freedom to write
bespoke software. ImageJ offers the user this freedom.
ImageJ is built on a reputable platform (Java) and version
control is very straightforward.
Conclusion
ImageJ is a very versatile image analysis platform whilst
being intuitive and easy to use. For simple tasks such as
retrieving plot profile data, pixel value histograms or
simple image processing techniques, it is difficult to
imagine a better piece of software. ImageJ has the
functionality to replicate the look and feel of commercial
SCOPE | MARCH 2015 | 31
POLICY
UPDATE
Rosemary Cook CBE summarises
members’ involvement in influencing
policy across the UK on behalf of IPEM
Workforce intelligence
In September 2014, Andrew Tyler,
Secretary of the UK Liaison Group,
and Jemimah Eve, IPEM Workforce
Intelligence Unit Officer, presented
evidence at a workshop to discuss
inclusion on the 2014 National
Shortage Occupation List.
The Centre for Workforce
Intelligence (CfWI) was jointly
commissioned by the Department
of Health and Health Education
England to provide
recommendations to the Migration
Advisory Committee about which
health occupations should be
included the list. Following initial
research, the CfWI was proposing
that radiotherapy physicists and
possibly nuclear medicine
healthcare scientists be included.
IPEM provided evidence to support
this, drawing on the work of our
Workforce Intelligence Unit, and
also suggested adding both
radiotherapy and nuclear medicine
practitioners to the list.
Scottish consultation
Also in September 2014, Colin
Gibson, Vice President –
Professional, co-ordinated a
response from UKLG and other
members of IPEM to the Scottish
Government’s consultation on its
Healthcare Science National
Delivery Plan. The full response is
on the IPEM website.
Extended working hours
A Working Group chaired by Gill
Lawrence has published a Position
Statement on extended working
hours in radiotherapy services, and
the impact of this on staffing, as a
contribution to the national debate.
The full report and a summary
Position Statement are available on
the IPEM website.
32 | MARCH 2015 | SCOPE
IPEM was represented at the PSC annual lunch held at the House of Lords in November 2014
The President in action
n 11th September – attended the
Bioengineering14 conference to
present Lionel Tarassenko with his
HonFIPEM certificate and medal,
together with the Minister for Life
Sciences, George Freeman MP.
n 30th September – attended the
Health Care Science HEE Advisory
Group meeting to discuss
education and training policy
issues.
n 11th November – attended the
Parliamentary and Scientific
Committee’s 75th Anniversary
Reception.
Collaboration with HCPC
Andy Mosson, Registrar of the
Register of Clinical Technologists,
and IPEM CEO Rosemary Cook met
with the Health and Care
Professions Council at their
request, to help them put together
evidence for the House of
Commons Health Select
Committee. This was
commissioned following the
HCPC’s earlier appearance in front
of the committee to comment on
professional regulation. This was
an opportunity for IPEM to lobby for
statutory regulation for clinical
technologists.
New AQA qualifications
Colin Gibson lead the compilation
of a response to the AQA’s work
developing new science and level 3
technical qualifications in relation
to medical physics in October. The
response is posted on the IPEM
website.
Professional standards fees
The UK Liaison Group also
responded to the government’s
consultation in November on
proposals to allow the
Professional Standards Authority
to be funded by fees paid by the
nine healthcare professional
regulatory bodies it oversees,
instead of by the government.
PSC annual lunch
IPEM was represented at the
Parliamentary and Scientific
Committee’s (PSC) annual lunch
at the House of Lords in November
by Anna Barnes, Vice President –
External; Keratiloe Moyo, London
Regional Chair, and Jessica
Johnson, from the IPEM Trainees’
Network. The PSC is an all-party
parliamentary group which
includes members of the former
Associate Parliamentary
Engineering Group. This event was
a chance to raise IPEM’s profile
with the influential members who
make up this committee.
CLINICAL TECHNOLOGIST NEWS BY DAVID STANGE AND TREVOR WILLIAMS
‘ CLINICAL TECHNOLOGIST NEWS UPDATE
NEWS
UPDATE
Update on the scheme for clinical technologists
News at further attempts to enable technologists to obtain professional registration should be welcomed by all
in their current roles following on from the statement released below:
‘We hope to submit a proposal for accreditation of the Register for Clinical Technologists (previously the VRCT)
by the end of the year and to achieve accreditation during the first half of 2015’. Stephen Keevil – Scope
Editorial, December 2014
In anticipation of perhaps full registration all clinical technologists should be keeping CPD records, if not doing
so already. Forms and guidance for the uninitiated may be found on the IPEM website.
Dosimetric effects of swelling or shrinking tissue during
helical tomotherapy breast irradiation: a phantom study
RADIOTHERAPY PHYSICS
ll radiotherapy centres in the UK
have protocols to follow when
determining what action to take
regarding replanning or compensation if the
anatomy of the patient being treated alters
shape during treatment. Some treatment
sites are more straightforward in adapting
the original plan to match the change in
anatomy without the need for a rescan and
replan. Traditionally one such site has been
breasts. Often, a couple of weeks into
treatment the breast tissue may swell before
shrinking again during the remainder of the
radiotherapy course.
If the breast swells on treatment then the
obvious adaptation has been to increase the
field size to ensure the flash is adequate,
providing everything else is within
departmental tolerances, e.g. SSDs,
separation and dose reference point
distances. Equally, shrinkage compensation
may have been calculated by a reduction of
monitor units based on new measurements
taken in the treatment room.
However, with increasing use of VMAT,
tomotherapy and forward-planned
segmented treatments, is this simple
approach adequate?
An interesting paper from Rudolf
Klepper and team at Gesundheitsverbund
im Landkreis Konstanz, Germany, looks at
these issues with particular regard to
tomotherapy, but it is relevant to other IMRT
techniques used clinically. The study looked
at quantifying the under- or over-dosage of
breast tissue as well as a specific focus on
the surface dose received.
A
t
FIGURE 1. Simulation of the irradiation of the left breast. (Top left) Water-equivalent
cylinder phantom as the baseline medium for swelling, Gafchromic film in a 45° position; (top
right) dose plan cross-section with PTV (black outline) and the OAR lung (black central area).
The isodoses of the radiation plan are dark grey = 5 Gy ± 5% and white ≥ 2.5 Gy < 5 Gy. The
dose profiles are investigated along the arrow. (Bottom left) Cylinder phantom as above, with
a 15 mm Superflab layer as the baseline medium for shrinking, Gafchromic film in a 45°
position; (bottom right) dose plan cross-section with PTV (black outline) and the OAR lung
(black central area)
‰
SCOPE | MARCH 2015 | 33
CLINICAL TECHNOLOGIST NEWS BY DAVID STANGE AND TREVOR WILLIAMS
‰ To simulate the patient a homogenous
water-equivalent ‘cheese phantom’ was
used (figure 1).
The size of the phantom was
appropriate to the size of the thorax and
the thickness of a female breast. A
planning target volume (PTV) was
created and planned with tomotherapy
Hi-Art treatment planning system (TPS)
4.2.1 using the superposition/
convolution algorithm with polyenergetic
point kernels for dose calculations.
Gafchromic films were inserted for
dosimetry using specific procedures for
accurate surface dose measurements.
To simulate swelling of the breast,
successive 5 mm layers of Superflab
bolus material were positioned on the
phantom up to 15 mm. Similarly, to
simulate shrinkage, 15 mm of Superflab
was used as a baseline for treatment
planning before taking measurements
with just a 10 mm layer of Superflab
(representing 5 mm shrinkage), then a 5
mm layer (10 mm shrinkage) and finally
with no Superflab (15 mm shrinkage).
Dose distributions were assessed
using the integrated delivery quality
assurance (DQA) software built into the
TPS. Profiles along the 45 degree
direction were measured using the film
in the phantom.
It was found that swellings of 5 mm,
10 mm and 15 mm would produce an
average dose decrease to the PTV of 2 per
cent, 5 per cent and 7 per cent of the
prescribed dose, respectively. Just a 5 mm
increase can lead to areas of underdosage
of up to 23 per cent within the PTV
(figure 2). The magnitude of these
simulated swellings also led to reduced
values of up to 72 per cent, 55 per cent
and 50 per cent at the outer edge of the
actual target volume.
During breast tissue shrinkage, the
dose increased from 100 per cent to 106
per cent, while surface dose increased
from 29 per cent to 36 per cent,
potentially intensifying the occurance of
skin erythema.
In the author’s opinion a rescan and
replan should be considered for 5 mm
swelling based on ICRU recommendations.
With a 10 mm increase in swelling, a new
scan and plan is deemed essential.
Shrinkage of breast tissue may cause
only a moderate overdose to the PTV, but
the increase in skin dose may be a concern.
‘ MORE INFORMATION
Klepper R, Höfel S, Botha U, Köhler P,
Zwicker F. Dosimetric effects of swelling
or shrinking tissue during helical
tomotherapy breast irradiation: a phantom
study. J Appl Clin Med Phys 2014; 15(4).
http://www.jacmp.org/index.php/jacmp/a
rticle/view/4873,
doi:10.1120/jacmp.v15i4.4873
Both images © Rudolf Klepper, Sebastian
Höfel, Ulrike Botha, Peter Köhler and Felix
Zwicker
t
FIGURE 2. Dose-volume histograms for the PTV: (left) swelling of 0, 5, 10 and 15 mm; (right) shrinking of 0, 5, 10 and 15 mm. The profiles for
5 mm, 10 mm and 15 mm swelling or shrinking are coloured red, green and blue, respectively
‘ CLINICAL TECHNOLOGIST EDITOR COMMENTS:
Rudolf Klepper has reported that around 20 per cent of breast patients treated at his clinic need rescanning and replanning due to swelling or
shrinkage. It would be interesting to find out how many centres currently do something similar to the article. Please get in touch using the
ClinTech forum on the IPEM website or email me at [email protected]
34 | MARCH 2015 | SCOPE
MEETING REPORTS
KIRSTEN
HUGHES
Scope
Meeting
Reports
Editor
‘
ONLINE MEETING REPORTS
Reports of IPEM meetings are now online only, and together with online copies of the
travel bursary reports can be found at:
https://www.ipem.ac.uk/ConferencesEvents/Conferencereportsandabstracts.aspx
IPEM meeting reports added since the last issue of Scope went to press include:
Quality Assurance in Magnetic Resonance (14th November) by Daniel Butler.
MR SIG’s biannual QA meeting included an overview of some of the key updates to IPEM’s Report 80 (published in
1998), anticipated in early 2015, as well as the application of automated QA analysis methods to improve interobserver variability and to speed up test-times.
Developing Myocardial Perfusion Scintigraphy: Is Your Service Stressing or Resting? (7th October) by Andrew Harris.
This meeting provided an opportunity for centres to report on
developments and improvements to their services, with talks covering
implementation of resolution recovery software, the impact of
switching to the use of a different stress agent (regadenoson),
and the extension of staff roles (technologists, radiographers
and scientists) in the area of MPS.
Meeting reports posted online after the copy deadline for
this issue of Scope will also be available to be viewed.
BOSTON & TROY,
USA
8th–15th July 2014
‘
A
7TH WORLD CONGRESS OF BIOMECHANICS
COMBINED WITH A RESEARCH VISIT
GEORGE ADAMS (Cranfield Forensic Institute, Centre of Musculoskeletal
and Medicolegal Research, Cranfield University, Shrivenham, UK)
s a PhD student in my first year, this
trip was my first opportunity to
attend a conference on biomechanics
and to visit another university to discuss
research, which proved to be a valuable and
exciting experience. My trip to the USA was
divided into two sections, the first was
attending the World Congress of
Biomechanics (WCB; figure 1) where I
would be presenting a poster, and the
second was a trip to Rensselaer Polytechnic
Institute (RPI) in Troy, NY, to meet with
Deepak Vashishth and his research team at
the Center for Biotechnology and
Interdisciplinary Studies to discuss possible
future collaborations.
The 7th WCB was held in Boston, MA, at
the John B. Hynes Veterans Memorial
Convention Center. The WCB is held every
four years and is one of the largest, if not
the largest, congresses of its kind for
biomechanics. Attendees came from around
the globe, with a large proportion from
Europe. During the week over 1,400 posters
were displayed in daily poster sessions. In
addition to this, 80 podium sessions were
given per day (run in parallel) alongside
several plenary lectures. Peter Zioupos and
I were the only attendees from Cranfield
University, bringing two poster
presentations with us.
Tuesday 8th July
FIGURE 1. 7th World Congress of Biomechanics, held in Boston, MA
I decided to arrive on the Tuesday (the
second day of the conference) as the trip
was proving to be both long and expensive.
My initial booking would have allowed me
to arrive in time for morning coffee break;
however, due to recently increased security
for travelling to the USA regarding flat
batteries (which was first implemented the
day before my travel), I was delayed in
order to retrieve a charger from my suitcase
as my laptop battery was flat and in my
hand luggage. This delay caused me to
arrive several hours later than intended and ‰
SCOPE | MARCH 2015 | 35
MEETING REPORTS
‰ by the time I got to my hotel I had missed the
day’s presentations. However, that evening I
attended the European Society of
Biomechanics (ESB) social where I was able
to meet other ESB members and welcome in
new council members.
Wednesday 9th July
The first session of the day commenced at
8am when I attended a session put together
by Ralph Mueller (ETH Zürich, Switzerland)
and Peter Pivonka (University of Melbourne,
Australia) entitled ‘Multiscale techniques in
biomechanics and mechanobiology’, which
covered the first two time slots of the day.
During the session they discussed some of
the issues with the multiscale nature of
mechanobiology and how they can be
addressed.
In between these two sessions were the
plenary ESB award lectures, the first of which
was for the S.M. Perren Research Award and
FIGURE 2. George Adams, Zahra Asgharpour and Peter Zioupos (from left to right) in a break
was given by Fulvia Taddei (Rizzoli
between lectures
Orthopaedics Institute, Italy) on the ‘Safety
factor of the proximal femur during gait: a
population-based finite element study’. This
in vivo simulations. Another poster, entitled
presentation discussed possible issues with
in research. Another poster of interest was
‘Is computational bone assessment
the current/previous understanding of
by Simone Tassani (Institute for
proximal femur safety factors and provided a comparable with mechanical and micro-CT
Bioengineering of Catalonia, Spain) about
well-validated model, giving a more in-depth measures?’ presented by Dharshini
‘Micro-CT study of trabecular fracture’,
Sreenivasan (University of Auckland, New
look than I have seen previously in the
which identified the current issues of basing
literature. The second presentation was from Zealand), using FE simulations and
fracture prediction risk
the winner of the ESB Best Doctoral Thesis in mechanical testing, showed strong
on densitometry and used micro-CT to
correlations in prediction of cortical and
Biomechanics Award, Carlos Borau
identify fracture regions in cancellous
cancellous bone strength.
Zamora (University of Zaragoza, Spain),
bones as a predictive model. Further
In the evening there was the WCB
for his thesis entitled ‘Multiscale
development of this work could help
Banquet, hosted in the Veterans Memorial
computational modelling of single cell
improve clinical assessments.
Auditorium. This provided an opportunity to
migration in 3D’. His work was impressive
The afternoon sessions were started by X.
socialise and network in a broader sense but
and interesting but of little relevance to my
Edward Guo (Columbia University, NY,
still in an academic environment.
research interests.
USA) and Tony Keaveny (University of
During lunch I was introduced to Zahra
California at Berkeley, CA, USA), entitled
Asgharpour, a specialist in human modelling Thursday 10th July
‘Whole bone computations I’. This focussed,
who engages in finite element analysis (FEA) During the poster session I was introduced to as the title suggests, on finite element
modelling using commercial products such
modelling of whole bones. The emphasis of
Cathy Holt (Cardiff University), and we
as THUMS (Total Human Model for Safety)
discussed some of the issues that can be faced the session was on choices one needs to
for automotive applications (figure 2). She
make when designing a model as well as on
as an engineer dealing with the clinical and
was able to provide me with some valuable
model validation. The second afternoon
biological crossover that regularly occurs in
insights into FEA on bone and the problems I biomedical engineering. One poster that was session, ‘Whole bone computations II’, run
may face in my models, and I hope to discuss of particular interest to me was ‘Estimating
by Professor Guo, Bert van Rietbergen
modelling with her in more depth in the
(Eindhoven University of Technology, The
orthotropic elastic material properties using
future.
Netherlands) and Philippe Zysset
clinically available imaging parameters’,
Many of the posters presented focussed on presented by S. Majid Nazemi (University of (University of Bern, Switzerland), carried on
the modelling of both micro- and macrothe discussion. The session developed it
Saskatchewan, Canada), which looked at a
scales of bone. One poster, called ‘Failure
comparison between micro-CT scanning and further to discuss patient-specific
morphology in human trabecular bone: a
computations and its clinical relevance.
clinical CT scanning of cancellous bone. He
systematic classification’, was presented by
performed statistical analysis on the lower
Alexander Zwahlen (ETH Zürich,
resolution clinical scan data to obtain values
Friday 11th July
Switzerland). He combined mechanical
of bone mineral density (BMD) and bone
The morning of the last day of the
testing and micro-CT to observe different
volume/total volume (BV/TV) that agreed,
conference started with ‘Micromechanics of
failure morphologies, and by performing this to a very high correlation, with the micro-CT bone and biomaterials’ by Harry van Lenthe
alongside micro-finite element (FE)
data. This is very important as it enforces the (University of Leuven, Belgium), which was
simulations he was able to suggest criteria for clinical relevance of using micro-CT scanners followed by Alan Eberhardt (University of
36 | MARCH 2015 | SCOPE
MEETING REPORTS
FIGURE 3. The two posters presented by George Adams and Peter Zioupos of Cranfield
University
Alabama at Birmingham, AL, USA), Daniel
Cortes (University of Delaware, DE, USA)
and Professor van Lenthe with a session
entitled ‘Interface mechanics in orthopedics’.
These lectures focussed on the clinical
aspects of the field which rounded off my
time in Boston.
The rest of Friday I spent travelling to
Albany via the Greyhound coach service. It
was nice to see that the USA’s bus services
are just as delayed as ours. When I arrived at
Albany I was met by Stacyann Morgan, a
member of the RPI biomedical engineering
team, who I stayed with for the remainder of
my visit.
Cranfield posters
As previously mentioned, Peter and I
brought with us two posters (figure 3), one
of which I was the lead author of. The title
was ‘Bone surface distribution from a wide
porosity range in mammalian bone tissue’ in
which I used micro-CT to assess the
structure of bone in two ways. Firstly, it
investigated the relationship between the
porosity of bone and its active surface area,
an important relationship when considering
bone remodelling. Secondly, it assessed the
relationship between the material density of
bone and the apparent density, often referred
to as tissue mineral density (TMD) and bone
mineral density (BMD), respectively, which
showed that at the extremes of porosity bone
is significantly more mineralised. The lead
author of the other poster was Jade
Armstrong and was entitled ‘Assessment of
the physicochemical modifications caused
to bone by storage protocols’. In this work
popular storage protocols for bone were
used to assess the changes to the chemical,
mechanical and crystalline properties of
bone. This is of importance as different
laboratories around the world use various
different methods for storage that could be
responsible for many of the discrepancies
that occur between different research
groups.
Saturday 12th and Sunday
13th July
Over the weekend no lab research activities
had been planned for me so I took the
opportunity to experience some American
culture, something I hadn’t had time for in
Boston. On Saturday I visited a mall for the
first time and used the opportunity to fulfil
the mandatory gift-buying for family back
home. Whilst there I also got to experience
a Dave & Buster’s arcade which was great
fun. The weekend was rounded off on
Sunday watching Germany’s win in the
World Cup final.
Monday 14th July
Starting early on Monday I was given a
tour of the labs of RPI’s (Rensselaer
Polytechnic Institute) Biomedical
Engineering (BME) Department. I was also
introduced to the BME team. Shown in
figure 4, with their corresponding areas of
research, are Corinne Thomas (the study of
bone fragility accounting for the chemical
FIGURE 4. Rensselaer Polytechnic Institute’s
Biomedical Engineering team: (from left to
right) Corinne Thomas, Dr Timothy Cleland,
Catalina Bravo and Stacyann Morgan
modifications in bone that occur with age and
health), Dr Timothy Cleland (using a
proteomics approach to identify the
interaction between bone’s organic-mineral
interface), Catalina Bravo (determining the
contribution of cortical and cancellous bone
in vertebral fractures of healthy and diseased
mice) and Stacyann Morgan (the role of noncollagenous proteins in bone deformation
and fracture using genetically modified
mice). I was given an individual tour of each
of their labs and a brief introduction into
their research and goals. I also had lunch
with Dr Deepak Vashishth, in which we
discussed the various potential future
collaborative ideas.
Tuesday 15th July
I started Tuesday with a full campus tour and
an introduction to the resources available at
RPI. This was followed by further talks with
the research team. I really appreciated the
hospitability of the team at RPI and the visit
has given me the opportunity to expand my
research. I would like to give special thanks
to Stacy for housing me during my visit.
I would like to thank IPEM for the travel
bursary which made my trip possible. The
next World Congress of Biomechanics will be
held in four years’ time (2018) in Dublin; if it
is anything like Boston it should be a very
impressive and enjoyable event that I would
thoroughly recommend. n
‘ GEORGE ADAMS is a PhD Researcher at
Cranfield Institute, Cranfield University.
SCOPE | MARCH 2015 | 37
MEETING REPORTS
CHICAGO, USA
26th–30th August
2014
‘
IEEE ENGINEERING AND MEDICINE IN
BIOLOGY CONFERENCE
CLAIRE TARBERT (Medical Devices Unit, NHS Greater Glasgow and Clyde)
I
n August 2014, the 36th IEEE
Engineering in Medicine and Biology
Conference (EMBC) was held in
Chicago. I was fortunate enough to attend
the conference, along with two colleagues
from NHS Greater Glasgow and Clyde,
after we were invited to organise a session
on ‘Medical technology and next
generation mobile applications’.
EMBC is one of the world’s largest and
most comprehensive technical conferences
focussed on biomedical engineering
technologies. As such, it covered a very
wide scope. The overarching theme of the
conference was ‘Discovering, innovating
and engineering future biomedicine’. The
individual topics presented ranged from
cutting-edge biomedical technology R&D,
to the clinical application of new
technologies, and the future of
bioengineering education.
EMBC was, by some distance, the
largest conference I have attended, with
2,500 registered attendees from 65 different
countries presenting 2,800 peer-reviewed
papers. With such a busy programme
(there were typically around 20 parallel
oral sessions at any given time), it was
only possible to attend a small fraction of
the presentations. Those I did attend were
necessarily skewed towards my own
clinical and research interests, and in this
report I’ve sought to highlight a selection
that I found to be the most interesting.
Wednesday 27th August
A series of tutorials was held on Tuesday
26th August, but the conference itself
began on Wednesday morning. The
opening plenary lecture on ‘Systems
medicine and transformational
technologies and strategies: a revolution in
healthcare’ was delivered by Leroy Hood
(Institute for Systems Biology, Seattle, WA,
USA). This was a really interesting talk
that began by introducing the systems
biology approach as applied to the search
for protein biomarkers of disease. Dr Hood
went on to discuss the 100k Wellness
Project, which is in its early stages. This
study aims to recruit 100,000 subjects who
will have their genome sequenced and
their biometrics (clinical chemistry, heart
rate, respiration, blood pressure, quality of
sleep, gut microbiome) tracked over 20–30
38 | MARCH 2015 | SCOPE
years. It is anticipated that some subjects
will stay well, whilst others will transition
to disease as determined by their genome,
modulated by environmental factors.
An enormous amount of monitoring
data is anticipated and the authors aim to
mine that for metrics to define wellness.
In addition, they aim to provide
actionable information to participants to
prevent disease and to ultimately create
models of improving health for the
general public. This approach is dubbed
‘P4 medicine’ by the authors: predictive,
personalised, preventive and
participatory. The study is in the pilot
stages (see figure 1) with 100 participants
recruited, but aims to scale up to 1,000
subjects by the end of the year and
eventually to 100,000 subjects. The
technical challenges of collecting and
analysing such large and complex datasets
are clearly significant and require the
input of a multidisciplinary team of
physicists, engineers, chemists, biologists,
clinicians and more. A phased start has
been chosen in order to put in place the
frameworks necessary for such a largescale study.
One of the highlights of the day was a
keynote lecture by Stephen Oesterle
(Medtronic, Inc., Minneapolis, MN, USA),
deceptively titled ‘Converting low power
micro electronics, data and
communication technologies into medical
devices’. The talk began with a review of
some of Medtronic’s latest implantable
devices, for example a wireless cardiac
pacemaker that can be positioned directly
into the ventricle wall. However, Dr
Oesterle branched out from that topic to
discuss the global inequality in terms of
access to healthcare; whilst three billion
people have access to at least a
rudimentary health service, four billion
have essentially none. He proposed that
the current methods of western healthcare
delivery are inefficient and prohibitively
expensive. In order to reach the masses, he
suggested that we must leverage the
recent advances in wireless monitoring
and mobile communication, to distribute
diagnostic and therapeutic technologies to
people where they live, upload that data
to an off-site physician or to a cloud for
automatic analysis, and direct the patient
to a hospital as and when needed. He left
it as a (significant!) challenge to the
engineering community to design the
technology to make that a reality.
Thursday 28th August
On Thursday morning, our group
presented in the invited session ‘Medical
technology and next generation mobile
applications’. Analysis of mobile device
trends suggests that over 80 per cent of
healthcare professionals use smartphones
in their daily professional capacity. This
session was proposed as a means of
illustrating how powerful, cost-effective
solutions using smartphones and tablets
are improving detection and diagnosis of
common medical conditions.
Despite starting at 8am, the session
was well attended with between 50 and
60 people showing up. Alexander Weir
(NHS Greater Glasgow and Clyde,
Glasgow) began by presenting a suite of
cognitive assessment apps designed for
the assessment of dementia and delirium.
The Edinburgh Dementia App
implements two test paradigms that are
candidates for the discrimination between
Alzheimer’s disease and mild cognitive
impairment. Delirium is an acute, severe
deterioration in mental functioning with
severe consequences for patient outcome
and is known to be under-diagnosed. The
DelApp provides a suite of simple
cognitive tests, including a visual acuity
test and word building and counting
tasks as a means of measuring
inattention. Both apps were demonstrated
to have good test accuracy.
Jay Carlsson (University of NebraskaLincoln, Lincoln, NE, USA) presented a
behavioural monitoring system that
utilises communication between a smart
watch worn by the user and a wireless
sensor network positioned around the
home to provide localisation of the user’s
position via received signal strength
indication (RSSI). This system was a
prototype demonstrating that accurate
real-time localisation is achievable with a
low-cost system. The authors hope to
build on this system to create a home
monitoring system capable of performing
a wide array of behavioural classification,
ultimately as a means of reducing the cost
MEETING REPORTS
FIGURE 1. Schematic showing the data being monitored in the pilot study for the 100k
Wellness Project
FIGURE 2. A typical retinal image captured with
the Peek smartphone-based ophthalmoscope
of long-term care by delaying its onset
and improving its efficiency.
Mario Giardini (University of
Strathclyde, Glasgow) presented results
from the Peek smartphone-based
ophthalmoscope; an optical adapter and
smartphone application that can be used
as a low-cost alternative to a direct
ophthalmoscope. It provides highresolution views of the retina through a
dilated pupil (figure 2) and impressive
results were shown demonstrating
excellent agreement in glaucomatous disc
grading of optic nerve head images when
compared to commercial diabetic retinal
screening cameras.
An Android app designed to measure
the second heart sound split was
presented next by Shanti Thiyagaraja
(University of North Texas, Denton, TX,
USA). The device pairs a stethoscope
attached to an external microphone and a
Nexus 4. It implements continuous and
discrete wavelet transforms to interpret
the aortic and pulmonic components in
the second heart sound and uses that
information to classify them as normal
and abnormal. It is designed to allow
daily monitoring of heart sounds in any
environment that can easily be shared
with health professionals.
I presented the Stroke Vision app: an
Android-based screening tool for the
assessment of visual impairments in
for success’. Again, for a session starting
at 8am, it was well attended. Four papers
were presented, with each of the authors
stressing the high incidence of
preventable blindness that could be
reduced if screening technology was more
widely distributed. This would require a
low-cost ophthalmoscope as the fundus
cameras in common clinical use typically
cost in the order of £10,000. Each of the
four projects took a different approach, in
both the design of the optics and the
approach to commercialisation. However,
there were common themes: all were
interested in facilitating teleophthalmology whereby images are
acquired at a remote site and either
automatically analysed or uploaded to a
reading centre.
The first three devices targeted diabetic
retinopathy. Craig Robertson (Epipole,
Rosyth, UK) introduced Epipole: a handheld camera that requires minimal
training, can be used without dilation, is
equipped with a USB interface to connect
to a PC, uses cloud-based storage for the
large quantities of data expected from a
screening programme, and is designed
exclusively for the detection of diabetic
retinopathy. Paul Yates (Retivue,
Charlottesville, VA, USA) described a
retinal imager comprised of an optical
adapter that integrates with off-the-shelf
DSLRs. IDx, who were represented by ‰
stroke survivors. Visual defects associated
with stroke are under-diagnosed and can
act as a barrier to successful rehabilitation
outcomes. The Stroke Vision app includes
a series of assessments designed to
identify the most common visual
impairments associated with stroke,
together with educational material
targeting staff, patients and their carers. It
is intended to improve the screening of
visual stroke and thereby improve
rehabilitation outcomes.
Iain Livingstone (NHS Greater
Glasgow and Clyde, Glasgow) then
rounded off the session with an
interesting talk showing the potential for
mobile technology in infant acuity
testing. He presented a comparison
between a novel tablet-based assessment
and the current card-based standards.
The results suggest that the app provides
improved test-retest reliability at,
surprisingly, a significantly lower cost
than the card-based alternatives.
Overall, I thought this session
demonstrated the wide application which
mobile technology can have and how
mobiles and tablets are rapidly becoming
low-cost, generic medical devices.
Friday 29th August
I began Friday by attending a minisymposium on ‘Low cost fundus
cameras: state-of-the-art and key factors
SCOPE | MARCH 2015 | 39
MEETING REPORTS
‰ Eric Talmage (Iowa City, IA, USA), had
Saturday 30th August
also developed a non-mydriatic fundus
camera but their primary interest was in
software development and the production of
robust, reliable algorithms for detection of
pathology. Mario Giardini presented on the
Peek smartphone-based ophthalmoscope
that had been discussed on Thursday. This
time Dr Giardini focussed on the technical
details of the adapter and its intended use
for remote diagnostics, particularly in
developing countries. By using the native
camera on the phone, retinal images can be
tagged with GPS, allowing patients to be
tracked for follow up.
All authors stressed that the challenge of
designing and building ophthalmoscopes
with sufficient image quality for retinal
screening at a low cost has long since been
overcome. However, creating a sustainable
business model to sell low-cost medical
equipment is not simple. This session was a
fascinating insight into what can be achieved
with low-cost equipment, as well as some of
the challenges of lowering the cost of
healthcare in general.
Before lunch, John Gore (Vanderbilt
University, Nashville, TN, USA) delivered a
keynote lecture on ‘Current and future
trends in biomedical imaging’. This was a
comprehensive summary of the current
status of the major imaging modalities (CT,
PET, MRI, ultrasound), the physical and
technological factors that limit each, and the
potential for future advances. In particular,
he discussed the push towards quantitative
imaging and stressed the importance of
better understanding the cellular, molecular
and physiological properties of tissues
which give rise to the acquired signals.
Whilst this was largely a summary of the
current imaging landscape, it was
particularly interesting for someone like me
who does not specialise in one of the major
imaging modalities.
In the afternoon I attended a powerful
presentation by Chris Jerry (Emily Jerry
Foundation, Mentor, OH, USA) on ‘Patient
care and safety through the adoption of
technology’. He told the story of his 2-yearold daughter, and how a mistake by a
pharmacy technician in drawing up the
prescription for her last round of
chemotherapy led to her death. Since 2006
he has worked towards using technology to
improve patient safeguards, an example
being the promotion of RFID (radiofrequency identification) chips to track
medication as a means of preventing errors
in the administration of drugs. It was a good
reminder of the vital role physicists and
engineers can play in ensuring patient safety.
The highlight of the final morning for me
was a lecture by Maryellen L. Giger
(University of Chicago, IL, USA) on
‘Decoding breast cancer with imaging and
big data: imaging phenotypes in breast
cancer risk assessment, diagnosis,
prognosis, and response to therapy’. Dr
Giger began by discussing the limitations
placed by physics and safety considerations
on current imaging modalities, and how
utilising quantitative imaging techniques
will allow imaging to continue to evolve.
She stressed the increasing need for
objective quantitative analysis instead of
only qualitative viewing of images, and
used the example of breast cancer to
illustrate these points. In Dr Giger’s
research, the process begins by
quantitatively extracting lesion
characteristics from multimodality images.
In mammography, she uses these
segmentations along with classification
algorithms to provide decision support to
radiologists, with the computer acting as a
second reader. By data-mining large data
sets of this type, along with histopathology,
molecular tumour classifiers and genomic
information, they are able to define imagebased biomarkers for risk of cancer, for
screening, diagnosis and treatment
monitoring.
40 | MARCH 2015 | SCOPE
Chicago
Chicago is the largest city in the Midwest
with a population of around 9 million. It is
situated on the shores of Lake Michigan
and is known for its music, art and
architecture. There was a lot to explore
across the entire greater Chicago area, but
with only a day and a half of free time,
our group was really limited to the
downtown area.
On Tuesday afternoon a number of us
visited the Art Institute of Chicago (figure
3). The Art Institute’s collection is vast; it is
the second largest in the US, after the
Metropolitan Museum of Art in New York,
and covers everything from preRenaissance paintings through to
contemporary art. When we visited, an
exhibition of the surrealist painter René
Magritte’s work was on show. It featured
around 100 of his most famous pieces and
interestingly some of his early advertising
work. In his own words, Magritte sought to
‘make everyday objects shriek aloud’ and
based on this exhibition alone, with the help
of some very atmospheric lighting, he
certainly achieved that! I think my favourite
part of the museum, however, was the
incredible collection of Impressionist art.
Taking up almost an entire floor and
featuring some of the most well-known
pieces from the period (Seurat’s A Sunday
afternoon on the Island of La Grande Jatte,
Renoir’s Two Sisters), I think it was worth
the entry fee alone.
The Art Institute is located on the edge of
Grant Park, a large urban green space on the
shores of the lake. One corner of the park
was annexed in 2004, renamed Millennium
Park, and now houses large-scale interactive
public art installations such as Cloud Gate
(dubbed ‘The Bean’ by locals, figure 4) and
Crown Fountain (figure 5). It is obviously a
really popular place with visitors and locals,
with plenty of people enjoying the park
during the day and in the evening.
Millennium Park is also home to the Jay
Pritzker Pavilion, a really impressive
stainless steel bandshell, designed by Frank
Gehry. During our trip, the pavilion was
being used to host a series of free open-air
concerts as part of the Chicago Jazz Festival
and on Friday night a group of us were able
to catch some of the music.
Chicago is known for its varied and
innovative architecture and it was
immediately impressive on arrival
downtown. The city was founded in 1833,
but around 40 years later, much of what had
been built was destroyed in a fire. This was
seized upon by the architects of the time
and the devastated city was used as a blank
canvas to test out new designs. The timing
of the fire coincided with the development
of technology allowing for the construction
of steel-framed buildings, and in fact the
world’s first all steel-framed skyscraper was
built in Chicago. On Saturday afternoon, a
group of us took a Chicago Architecture
Foundation boat tour along the Chicago
River. It was a fascinating insight into the
architecture of the city, and an opportunity
to view some of the first prototype
skyscrapers of the 1890s, the art deco and
mid-century modern buildings, right
through to the postmodern buildings still
being built today, all from a different
perspective on the river (figures 6, 7 and 8).
I would like to thank IPEM for provision
of a travel bursary that, together with a
contribution from the Department of
Clinical Physics and Bioengineering (NHS
Greater Glasgow and Clyde),
made it possible for me to attend IEEE
EMBC 2014. n
‘ CLAIRE TARBERT (BSC HONS, MSC, PHD)
is a Senior Scientist in the Medical Devices Unit,
NHS Greater Glasgow and Clyde. She has a special interest in visual electrophysiology and the
application of mobile technology to healthcare,
and is an associate member of IPEM.
MEETING REPORTS
FIGURE 3. The Art Institute of Chicago
FIGURE 4. The Cloud Gate sculpture/The Bean
FIGURE 5. Crown Fountain
FIGURE 6. The Chicago skyline
FIGURE 7. Marina City (1964)
FIGURE 8. The Chicago Tribune Building (1923)
SCOPE | MARCH 2015 | 41
MEETING REPORTS
SECC, GLASGOW
31st August – 2nd
September 2014
‘
MEDICAL PHYSICS AND ENGINEERING
CONFERENCE AND RADIOTHERAPY MEETING
LAURA MORAN (Trainee Clinical Scientist of the North London Consortium,
based in Radiotherapy at Barts Health NHS Trust, London)
am very grateful to IPEM for awarding
me the IPEM bursary which enabled me
to attend their annual Medical Physics
and Engineering Conference (MPEC) in
Glasgow in September 2014 (figure 1). This
provided me with my first opportunity to
attend and present work at a large national
scientific conference and also an excuse to
visit Glasgow, Scotland’s largest city!
This year MPEC also incorporated the
Biennial Radiotherapy Meeting, which was
of particular interest to me as an STP trainee
specialising in radiotherapy. The conference
was held in the Scottish Exhibition and
Conference Centre (SECC) which is located
on the north bank of the River Clyde.
Unbeknown to me prior to my visit, Glasgow
is a city renowned for its architecture, having
been named UK City of Architecture and
Design in 1999. Adjacent to the SECC is the
impressive Clyde Auditorium, affectionately
called ‘The Armadillo’ (figure 2); it is a
modern example of just one of the many
beautiful buildings that can be found
throughout Glasgow (figure 3).
MPEC is IPEM’s annual conference and so
it was very well attended, with almost 300
representatives from many locations
throughout the UK, Europe, the USA and
even as far afield as Australia and New
Zealand. With 46 invited speakers, 80
proffered speakers and 36 posters there was
plenty to keep all the attendees entertained
and engaged over the three days!
Back in April I submitted an abstract to
MPEC on the work I had begun and planned
to carry out in the coming months for my
Masters project, which was concerned with
investigating the effects of thoracic motion
on volumetric modulated arc therapy
(VMAT) treatments. I was delighted when I
found out a few weeks later that I would be
presenting my work at the trainee session;
however, I will admit that the idea of
presenting my work at a national scientific
conference was very daunting! The months
leading up to the conference kept me very
busy with gathering all of my results and
writing my presentation.
MPEC commenced on Sunday 31st
August with a welcome breakfast and
opening ceremony followed by workshops in
the afternoon, which I was unfortunately
unable to attend. Thankfully, however, I was
I
42 | MARCH 2015 | SCOPE
able to attend the drinks reception that
evening at Merchant Square, which was a
great opportunity to catch up with familiar
faces and do some networking. The IPEM
trainee network had also organised a social
event on the Sunday evening after the drinks
reception which was a good way to meet
some other trainees from different parts of
the country.
Monday morning began bright and early
with the first talk scheduled for 8.30am. I
spent the morning at the trainee session
where I was very impressed by the high
standard of presentations. My time to speak
was upon me before I knew it and I was very
nervous making my way up to the podium.
Thankfully, once I started talking most of my
nerves went away. I was delighted when it
was all over and I was glad I had pushed
myself to do it! I would encourage other
trainees to present their work at the trainee
session at MPEC as it provides a friendly and
supportive audience which I felt was a great
introduction to presenting work at a large
scientific conference.
After my presentation I was able to relax
and enjoy the conference. With five sessions
running in parallel throughout Monday and
Tuesday, covering a range of topics such as
diagnostic imaging, radiotherapy physics,
big data, physiological measurement and
nuclear medicine, it was a challenge
choosing which talks to attend! The
following are presentations that I found
particularly interesting.
Woolmer lecture
Every year at MPEC there is a Woolmer
lecture dedicated to Professor Ronald
Woolmer, the first President of the Biological
Engineering Society (1959) and also the first
director of the Research Department of
Anaesthetics at the Royal College of
Surgeons (1957). This year’s Woolmer lecture
was entitled ‘A gateway to innovation’ and
was given by David Keating (NHS Greater
Glasgow & Clyde, Glasgow). In his lecture
Professor Keating outlined the historical role
that scientists and engineers in clinical
departments have had in developing
healthcare technology, highlighting in
particular Glasgow’s strong history of
innovation in this area. He discussed the
current landscape of clinical sciences and the
challenges that healthcare faces in the coming
years, such as changing patient
demographics, rising healthcare costs,
increased workloads and extended working
hours. A possible solution to these challenges
could be the greater adoption of new
technologies, procedures and diagnostics for
which scientists embedded in clinical
departments will play a crucial role.
Professor Keating concluded the lecture with
a fascinating introduction to some of his
research on the structural and functional
imaging of the retina using micromultifocal
electroretinography (ERG).
Debate
As a young physicist starting off my career in
radiotherapy I was particularly interested in
listening to the debate that ‘Treatment
planning is now a mostly technical task and
requires little physics input’, which I’m
happy to say did not disappoint! Carl
Rowbottom (The Christie NHS Foundation
Trust, Manchester) started off the debate for
the motion. He reframed the question that
planning is now a mostly automated task and
requires no physics input. He discussed how
humans are not suited to treatment planning
which is effectively a manufacturing process,
that manual treatment planning can be
stressful, leading to an increase in errors, and
the automation of the process would lead to
increases in productivity. Dr Rowbottom
continued to say that automated treatment
planning is already here, quoting several
recent studies that investigated the
generation of fully automated plans.
Next, Jason Cashmore (Queen Elizabeth
Hospital Birmingham) took to the stage
against the motion. He began by trying to
define exactly what is meant by treatment
planning: whether it is the physical creation
of a treatment plan for a patient or all the
steps in delivering the best plan for each
patient. He agreed that the majority of
planning tasks can be protocolised but who is
responsible for creating these protocols and
what happens when a patient doesn’t fit the
protocol? With the increasing use of various
different imaging techniques and modalities
such as PET, MRI, image fusion, deformable
registration and 4DCT, an in-depth physics
knowledge is required. Additionally, as
radiotherapy is a rapidly changing field and
MEETING REPORTS
Image © Justine Tyler
FIGURE 2. A side view of ‘The Armadillo’, Glasgow
FIGURE 1. My ‘skelfie’ from the IPEM stand
new technology will continue to be
introduced into departments such as VMAT
with couch rotation, MRI linacs, proton
therapy, cone-beam CT and MRI-based
planning, adaptive therapy and radiobiology,
if physics are not involved in planning then
how will they be able to make informed
judgements on these new techniques?
After some questions and answers the
debate seemed to conclude that physics
should definitely have some role in the
treatment planning process. However, the
question of whether this includes the
physical creation of treatment plans seems to
be undecided.
Skin margins in VMAT
Justine Tyler (Barts Health NHS Trust,
London) discussed the use of ‘Skin margins
for RapidArc optimisation: how much is
FIGURE 3. George Square and Glasgow City Chambers
enough?’. She explained in detail the
problem that can arise if the clinical target
volume (CTV) is contoured close to the skin;
the build-up region in the CTV can receive
high doses for inversely planned
IMRT/VMAT treatment plans. The use of
optimisation margins (OM) from the skin has
been shown to reduce these high dose areas.
Mrs Tyler described her work which
investigated the optimal OM to be used and
also how resilient these OM are to setup
uncertainties.
MRI-guided radiotherapy
Invited speaker David Thwaites (University
of Sydney, Australia) gave a fascinating talk
on the ‘Observations and rationale for MRlinac use: the Australian MR-linac project as
an example’. There are only three other
similar projects in the world that are clinical
or almost clinical with MRI-guided
radiotherapy. MR imaging offers the ultimate
in soft tissue position verification and realtime intrafraction monitoring. Professor
Thwaites outlined some of the different
techniques that are used in MR-guided
radiotherapy and some of the issues
involved in their implementation. These
include low-field MR imaging with cobalt-60
sources, split bore magnets orientated inline
or perpendicular to the linac and then the
complications of electron return from
interactions with the magnetic field. I found
the talk very interesting and thought that it
gave an insight into radiotherapy’s very
exciting future! n
‘ LAURA MORAN BSC MSC is a trainee clinical scientist with the North London Consortium,
specialising in Radiotherapy Physics at St
Bartholomew’s Hospital.
SCOPE | MARCH 2015 | 43
BOOK REVIEWS
Factory Physics
for Managers
INTRO
W
Factory Physics for
Managers may be a
surprise choice as a
book review for
IPEM, but as many
IPEM members
have managerial
responsibilities is it
prudent to ask
whether or not
their physics background can prove
beneficial in managerial aspects of their
jobs?
The book describes how scientific
processes can be applied in the
management of manufacturing-based
industry or supply chain. Whilst this
specific focus makes much of the text
irrelevant to those reading this review,
there is some content of which a physics
department – and the NHS in general –
could take note and parallels that can be
drawn from the examples are included.
The use of the term ‘physics’ in the
title sounds impressive; in fact, the
scientific analysis that is presented in the
book is straightforward, though it is
accurate and usually absolutely sensible.
Some concepts or analyses are
presented as equations, usually to allow
efficiency increases to be quantified as
percentages. In doing so, analysis such as
mean, standard deviation, variance and
coefficient of variation are introduced
and used throughout. Some of the
example analyses were logical and
useful, but the benefit was less clear in
other examples where it seemed that
variable were calculated because they
could be.
The scientific analysis in the text often
felt quite obvious. When introducing the
concept of ‘undercapacity scheduling’
e have a rather packed
and exciting mix of book
reviews in this first 2015
issue! There are six book
reviews which cover the
medical physics and popular science
genres. A list of the reviewed titles with
reviewers can be found in table 1.
There are a number of new medical
physics and popular science textbooks in
the ‘Just Published!’ section, one of which
is Bioengineering: A Conceptual Approach.
This book explores critical principles and
new concepts in bioengineering
integrating the biological, physical and
chemical laws and principles that provide a
foundation for the field.
The ‘New Reports and Newsletters’
section lists some useful items. An update
to the ‘Safer Radiotherapy’ report is also
provided. Links to the latest newsletters of
the AHCS, EFOMP and IOMP can be found
in this section.
Do you read any other medical physics
newsletters that may be useful to the
readership? If so, I would be very
interested to hear from you.
Urgent request! We would like to
increase our current numbers of book
reviewers to fulfil our quarterly target of
seven book reviews. Reviewing counts
towards your CPD (see ‘Self-directed
learning’, HCPC Guidance to Standards for
CPD – duties as a registrant). Moreover,
reviewing a book means you get to keep it.
As part of the reviewing process, we use an
online collaboration tool known as Wiggio,
offered free by Desire2Learn, in which
reviewers will find a list of the latest book
reviews and book request status. The tool
is also used to upload book reviews and for
all Scope activities.
If you would like to review a book (no
matter how old!) or have a comment on any
part of Scope then please email me.
(building down-time into a system in
expectation of failures), is it not obvious
that any service that is completely
reliant upon every component working
perfectly as planned at all times is
doomed to fail?
In general, the book encourages
individualised planning of a service and
not copying something that exists
elsewhere (but also champions Toyota
throughout). In doing this, the book
stresses how important it is that all
aspects of the process be considered and
modelled – as a physicist might
compare a model against empirical
measurement for verification. Once
again the approach is sensible.
No managerial text would be
complete without some discussion of
leadership. In this book it is fairly short,
and hiding in amongst the usual,
suggestions on the social aspects of
leadership is a good suggestion that by
thoroughly evaluating the expected
result of a change, and presenting
this evidence to colleagues, a leader
might have better success with
implementing changes.
If this book does indeed present a
framework for efficient service
management, perhaps physicists
already have a head start; the book
might not be necessary.
Mr Mark Worrall is a Clinical Scientist
in Diagnostic Radiology and Radiation
Protection (Radiation Physics) at
Ninewells Hospital, Dundee, UK
FACTORY PHYSICS FOR MANAGERS: HOW
LEADERS IMPROVE PERFORMANCE IN A
POST-LEAN SIX SIGMA WORLD
EDWARD S. POUND, JEFFREY H. BELL, MARK
L. SPEARMAN
Publisher: McGraw-Hill Professional
ISBN: 978-0071822503
Format: Hardback
Number of pages: 354
Price: £32.99
TABLE 1
Usman I. Lula is a a Principal Clinical
Scientist based in the Radiotherapy
Planning section (Radiotherapy Physics
QEMC) at the Queen Elizabeth Hospital,
University Hospitals Birmingham NHS
Foundation Trust, UK.
Email: [email protected]
44 | MARCH 2015 | SCOPE
Book title
Reviewer
n
n
n
n
n
n
Mark Worrall
David Hall
Julian Minns
Angela Newing
Julian Minns
Malcolm Sperrin
Factory Physics for Managers
Bird of Passage – Recollections of a Physicist
Heisenberg in the Atomic Age
The Physics of Radiation Therapy
Advanced Biomaterials and Biodevices
Radiation Biology of Medical Imaging
Reviews of textbooks published on
medical physics, along with recently
published books and new reports
Bird of Passage –
Recollections of a
Physicist
I nearly met Sir
Rudolf Ernst
Peierls – back in
1985 my college
needed a speaker
for our annual
physics dinner,
and the 78-yearold Peierls was
suggested. At the
same time, he was working on this
entertaining and informative memoir,
now republished through the
Princeton Legacy Library.
Born in Berlin in 1907, into a family
of Jewish merchants, as a young
theoretical physicist Peierls worked
with all the greats of the early days of
quantum mechanics. As well as
physics, we hear about Heisenberg’s
prowess at table tennis, Pauli’s sharp
wit, Bloch’s slow and deliberate
nature, Bohr’s odd turns of phrase,
Fermi’s use of early mechanical
calculators and Feynman’s skill at
fixing them, Dirac’s kindness, and
many others; one Christmas skiing trip
included three future Nobel laureates!
On a trip to Russia he met and
married a young physics graduate,
Eugenia (Genia) Nikolaevna
Kannegiser. She came back with him to
Zurich, but with political changes in
Europe the newly married couple
moved to England, living in
Cambridge, Manchester and then
Birmingham. Manchester in particular
was very rundown in 1933, the food
was awful, and the winter fogs would
last for two or three days, during
which you couldn’t see across the
road. However, they found the local
population to be warm and friendly –
something which hasn’t changed!
In 1940, the most important
calculation of Peierl’s life was to show,
with Otto Frisch, that a nuclear chain
reaction could be possible if sufficient
uranium-235 could be purified. As
enemy aliens Peierls and Frisch
weren’t initially allowed to be
involved in the ensuing discussions,
but common sense eventually
prevailed, and from 1943 Peierls led
the British delegation at Los Alamos,
developing the nuclear bomb. This
section of the book is particularly
fascinating.
After the war, he took up a
Professorship in Birmingham. In 1945,
a professorial salary could buy an 8bedroom house on an acre of land,
and successful PhD students could
get good academic jobs. A major
negative side of this period was that
women were still wives and
secretaries, rarely scientists, and
Peierls’ wife gave up physics without
comment from him. Peierls also
became active in the campaign
against the arms race and the spread
of nuclear weapons, through the
Pugwash conferences, a reminder of
Cold War days.
This is an excellent book with far
more in it than I can mention here,
which I wholeheartedly recommend.
Dr David Hall is Head of the Nuclear
Medicine Physics Section, Department
of Medical Physics and Bioengineering,
University Hospitals Bristol NHS
Foundation Trust, Bristol, UK
BIRD OF PASSAGE –
RECOLLECTIONS OF A PHYSICIST
SIR RUDOLF ERNST PEIERLS
Publisher: Princeton University Press
ISBN: 978-0-69160-220-2
Format: Softback
Number of pages: 350
Price (publisher’s website): £41.95
Heisenberg in
the Atomic Age
This book is
organised into
four parts: Part I
– Introduction,
Part II – Culture,
Part III – Politics
and Part IV –
Scientific reason
in the public
sphere,
containing a total of 15 chapters.
It is the most rigorously researched
book that I have reviewed and has
references quoted in the text,
numbered for each chapter, as well as
57 pages of bibliography!
The book is organised topically
rather than chronologically,
separating Heisenberg’s contribution
to the culture of nuclear science
research in pre- and post-war
Germany, his political stance changes
from the early part of his life to postwar modern Germany and his
scientific reasoning in the public
sphere throughout his professional
life.
Part I describes how he alone built
up long-lasting scientific institutes
defining science’s position as a public
good under public supervision. The
atmosphere in Germany before the
rise of the Third Reich was an
encouragement to play a major role in
the development of fission research
and production. Research of his
unified field theory, the so-called
‘world formula’, resulted in him
becoming a Nobel Laureate at the age
of 32, in 1933. It was more difficult
post war as there were still suspicions
of the influence of the Third Reich in
the place of science in the post-war
public arena.
Part II relates to his function as a
cultural figure and he based his early
model of the role of scientists in
society by attending and giving
public lectures to the educated middle
classes. He stressed that he provided
first and foremost a physicist, not a
philosopher. After Hiroshima, the
unmistakable power of science led
him to claim a larger responsibility for
scientists in public affairs. Practical
rebuilding after World War II
involved Heisenberg being
responsible for the Max Planck
Institute of Physics, the Max Planck
Society and becoming head of the
German Research Council. He was
very concerned that West German
nuclear technology might be diverted
for military uses. Post war it was
more difficult as there were still
suspicions about the influence of the
Third Reich in the role of science in
the post-war arena.
In 1946, after internment in Farm
Hall in England, he returned ‰
SCOPE | MARCH 2015 | 45
BOOK REVIEWS
renewing international ties, and in
1957 was instrumental in the
production of the ‘Gottingen
Manifesto’ following nuclearising the
West German military, confirming his
role as a public political spokesman.
Professor Julian Minns is a
Consultant Clinical Scientist and holds
an Honorary Chair in Medical Implant
Design, Product Design Research (PDR)
Centre at Cardiff Metropolitan
University, UK
HEISENBERG IN THE ATOMIC AGE:
SCIENCE AND THE PUBLIC SPHERE
CATHRYN CARSON
Publisher: Cambridge University Press
ISBN: 978-0-521-82170-4
Format: Hardback
Pages: 461
Price: £63 (US$99)
The Physics of
Radiation Therapy
The first edition
of Khan’s book
with this title
appeared in 1984,
with subsequent
editions 9, 10, 7
and now a further
4 years later. This
last is jointly
authored for the
first time and both authors are respected
senior figures in the American medical
physics world. I was looking forward to
seeing this most recent edition with
updates on the latest developments in
clinical and physical radiotherapy.
The basic physics has been similar in
all editions and Part 1 provides an
excellent grounding for physicists and
clinicians with clear text and diagrams.
This section fills 132 pages. Each chapter,
as with those throughout the book, ends
with ‘Key points’ and a list of references.
Some of the papers and books referred to
are surprisingly old, which seems
entirely reasonable for the basic physics
which has changed little, but I was
disappointed to find that most of the
references at the ends of all chapters
46 | MARCH 2015 | SCOPE
were also far from modern.
Part 2 shows the reader the data
required to begin external beam treatment
planning and how to measure dose,
isodose distributions and other
measurements needed to prepare for
patient treatment. It shows how to acquire
patient outlines and details of such things
as inhomogeneities. Photon and electron
therapy are covered in great detail, as is
low dose rate brachytherapy. Again I was
surprised by history. Radium, as the first
ever brachytherapy source, deserves a
mention, but it has not been in use in
hospitals for decades and hardly needs
the dozen pages of text and diagrams
devoted to radium dosimetry. Most of the
other isotopes used for implantation are
dealt with, including palladium-103 which
is much more recent. There are also
chapters on radiation protection and on
quality assurance. Part 2 has 280 pages.
Part 3 brings the reader up to date with
conformal therapy, IMRT, stereotactic
radiotherapy, high dose rate brachytherapy,
intraoperative work and so on, and
finishes with a very useful chapter on
proton beam therapy. Like the rest of the
book, this is well and clearly illustrated.
“
“
‰ to Germany to be a key figure in
I recommend this
volume particularly
to newcomers to
medical physics
In spite of my criticisms, I recommend
this volume particularly to newcomers to
medical physics. I could have done with
something like this many years ago when
I started out. An added advantage is
access to the complete contents online via
a sticker on the inside front cover with a
unique access code.
Professor Angela Newing is a retired
Director of Medical Physics for
Gloucestershire NHS, UK
THE PHYSICS OF RADIATION THERAPY
(FIFTH EDITION)
FAIZ M. KHAN, JOHN P. GIBBONS
Publisher: Wolters Kluwer
ISBN: 9-781451-182453
Format: Hardback
Pages: 572
Price: £157
Advanced
Biomaterials and
Biodevices
This second book in
the ‘Advanced
materials’ series is
in two parts: (1)
Cutting edge
biomaterials and (2)
Innovative
biodevices.
Most of the
chapters rely
heavily on the reader’s knowledge of
materials at a nanometre level, and
structures at the sub Angstrom level. The
authors are based throughout the globe;
six of the 15 chapters are produced from
research conducted in India, none from
the UK and only one from the USA.
In Part 1, the first chapter describes
the development and production of bulk
nanostructural metals described by the
Russian authors with 343 references
quoted. Drug loading and release using
stimuli-responsive materials are well
described in the next chapter, and drug
carriers using liposomes from the US
researchers in Chapter 3. Nano shells
and their application in targeted drug
delivery are discussed in Chapter 4.
I found the next two chapters in this
book the most interesting, dealing with
the use of Chitosan as an advanced
healthcare material. The range of
applications is very impressive, from its
use as a drug delivery agent, for wound
healing and tissue regeneration by
forming scaffolds of the material, and as
an antimicrobial carrier for wound
dressings. Most impressively, it has been
developed as a final coating for
ophthalmic lenses, allowing them to
move freely without adhering to the eye,
and having antimicrobial properties in
situ. The application of this antimicrobial
property is expanded in the next chapter
using low molecular weight Chitosan.
Part 2, dealing with innovative
biodevices, addresses the potential
applications of the newer materials
appearing in the market. This ranges
from label-free biochips and sensors
using microelectromechanical systems
(MEMS) technology to customised
Reviews of textbooks published on
medical physics, along with recently
published books and new reports
biochips providing real-time data.
A criticism one could level at the
production of a multi-author book
such as in this series is the variation in
the number and quality of the figures,
which when well produced can say a
thousand words. Examples of the
excellent use of diagrams are shown in
Chapters 9 and 11, the latter
describing molecular imprinting and
nanotechnology. For instance, in
describing ‘What is imprinting?’, a
simple schematic diagram clarifies for
the reader what is meant by the term.
The other diagrams in this chapter are
excellent but do require the reader to
have a fundamental knowledge of
chemistry.
Overall, this is a fascinating series
of diverse chapters, with a large range
of quality in the presentation and in
the diagrams, and the reader has to
have an extensive knowledge of
biochemistry and nanotechnology to
really appreciate the cutting-edge
technology presented in this book.
Professor Julian Minns is a Consultant
Clinical Scientist and holds an Honorary
Chair in Medical Implant Design,
Product Design Research (PDR) Centre
at Cardiff Metropolitan University, UK
ADVANCED BIOMATERIALS
AND BIODEVICES
ASHUTOSH TIWARI (series editor)
Publisher: John Wiley
ISBN: 9781118773635
Pages: 546
Price: £130
Radiation Biology
of Medical Imaging
This is a very
comprehensive
text that goes far
beyond the
content most
would expect
given the rather
specific title. The
introductory
chapters
concentrate on cell biology but as the
book progresses, there is an increasing
emphasis on radiation effects, and the
important aspects of dose limits,
regulation and environmental radiation
exposure are also covered.
There are some key aspects which
make the text particularly appealing to
the medical physics community.
Radiobiology of radiographic imaging
is a particularly interesting chapter,
with a second chapter on nuclear
medicine. Most readers would be
surprised to find additional chapters
on MRI and ultrasound but the
inclusion of these final chapters
emphasises the increasing awareness of
risk mitigation in non-ionising
radiation.
The material is particularly well
covered and has a lot to offer both the
novice to the field and also those who
have some degree of specialisation,
although a greater reference and
bibliography list would have been
beneficial. The book would be very
relevant to anyone working in fields
that are impacted by radiation
exposure, whether therapy or
diagnostic, and also to the radiation
protection community.
Having an origin in the USA, one
may expect the units to need
converting but it is very helpful that
the units used are those familiar to the
UK (where exposures are in mSv)
which further adds to the ease of
reading this book.
The layout is done in an intelligent
manner with a liberal sprinkling of
images, diagrams and tables, with
some of the images reproduced in
colour. The inclusion of colour certainly
helps with understanding and
interpreting the images and also reemphasises the overall quality.
Whilst other texts certainly exist in
this discipline, this volume presents
complex and useful information in a
manner that is particularly useful and
for me, this is one of the best that I
have come across. I can imagine that
the book has a place in both the
departmental library and also in the
personal collection of those in the field.
My only concern is that the quality will
be degraded if the book is not regularly
updated – this one is dated 2014.
I can imagine a companion text
looking more closely at the non-
ionising aspects of exposure and such a
text would be valuable if it matches the
quality of this one.
Professor Malcolm Sperrin is Director of
Medical Physics at Royal Berkshire NHS
Foundation Trust, Reading, UK
RADIATION BIOLOGY OF MEDICAL IMAGING
CHARLES KELSEY, PHILIP HEINTZ, GREGORY
CHAMBERS, DANIEL SANDOVAL, NATALIE
ADOLPHI, KIMBERLY PAFFETT
Publisher: Wiley Blackwell
ISBN: 978-0-470-55177-6
Format: Hardback
Pages: 315
Price: £60.25
Just Published!
Radiosensitizers and
Radiochemotherapy in the Treatment
of Cancer by Shirley Lehnert (Taylor &
Francis) catalogues and describes the
mechanism of action for entities
characterised as radiosensitisers. The book
addresses a range of topics from
molecular oxygen and high Z elements to
monoclonal antibodies and complex
phytochemicals.
Statistical Computing in Nuclear
Imaging by Arkadiusz Sitek (Taylor &
Francis) introduces aspects of Bayesian
computing in nuclear imaging. It provides
an introduction to Bayesian statistics and
concepts and is highly focussed on the
computational aspects of Bayesian data
analysis of photon-limited data acquired
in tomographic measurements.
Biomedical Signals and Sensors II
by Eugenijus Kaniusas (Springer) develops
a bridge between physiologic mechanisms
and diagnostic human engineering. This
second volume is devoted to the interface
between biosignals and biomedical
sensors. This book is intended to have the
presence to answer intriguing ‘Aha!’
questions.
Computational Hemodynamics – Theory,
Modelling and Applications by Jiyuan Tu,
Kiao Inthavong and Kelvin Kian Loong Wong
(Springer) discusses geometric and
mathematical models that can be used to
study fluid and structural mechanics in
the cardiovascular system. This book is
aimed at students and researchers ‰
SCOPE | MARCH 2015 | 47
Reviews of textbooks published on
medical physics, along with recently
published books and new reports
‰ wishing to engage in this emerging and
exciting field of computational
hemodynamics modelling.
Digital Signal Processing for Medical
Imaging Using Matlab by E. S. Gopi
(Springer) describes medical imaging
systems such as x-ray, computed
tomography and MRI from the point of
view of digital signal processing. It outlines
the physics behind medical imaging
required to understand the techniques
being described. Matlab programs and
illustrations are used whenever possible to
reinforce the concepts being discussed.
NEW REPORTS AND NEWSLETTERS
Physics and Engineering of Radiation
Detectors, 2nd Edition by Syed Naeem
Ahmed (Elsevier) covers the origins and
properties of different kinds of ionising
radiation, their detection and measurement
and the procedures used to protect people
and the environment from their potentially
harmful effects. There is also more material
related to measurements in particle
physics, together with a complete solutions
manual.
BOOK REVIEWS
Science and Technology in the Global
Cold War by Naomi Oreskes and John Krige
(MIT Press) considers whether the new
institutions and institutional arrangements
that emerged globally constrained
technoscientific inquiry or offered greater
opportunities for it. The contributors find
that whatever the particular science and
whatever the political system in which that
science was operating, the knowledge that
was produced bore some relation to the
goals of the nation-state.
critical principles and new concepts in
bioengineering, integrating the biological,
physical and chemical laws and
principles that provide a foundation for
the field. Both biological and engineering
perspectives are included, with key topics
such as the physical–chemical properties
of cells, tissues and organs; principles of
molecules; composition and interplay in
physiological scenarios; and the complex
physiological functions of heart, neuronal
cells, muscle cells and tissues.
Quality Management in the Imaging
Sciences by Jeffrey Papp (Mosby) provides a
thorough description of quality
management and explains why it is so
important to imaging technology. Step-bystep QM procedures include full-size
evaluation forms with instructions on how
to evaluate equipment and document
results. This book also helps you prepare
effectively for the ARRT advanced
certification exam in quality management.
Departure by A. G. Riddle (Riddle Inc.).
Harper Lane has problems. In a few
hours, she’ll have to make a decision that
will change her life forever. But when her
flight from New York to London crashlands in the English countryside, she
discovers that she’s made of tougher stuff
than she ever imagined. As Harper and
the survivors of Flight 305 struggle to stay
alive in the aftermath of the crash, they
soon realise that this world is very
different from the one they left. Their
lives are connected, and some believe
they’ve been brought here for a reason.
Bioengineering: A Conceptual Approach
by Mirjana Pavlovic (Springer) explores
n Potential Hazard Due to Induced Radioactivity Secondary to Radiotherapy.
Report of Task Group 136 of the American Association of Physicists in
Medicine (AAPM). Health Physics 2014; 107(5).
n ISO/TR 800001-2-6 ed1.0 (2014-11) – Application of Risk Management for
IT-networks Incorporating Medical Devices. Part 2-6: Application Guidance
– Guidance for Responsibility Agreements; 2014.
n AAPM and GEC-ESTRO Guidelines for Image-guided Robotic Brachytherapy.
Report of Task Group 192. Medical Physics 2014; 41(6).
https://www.aapm.org/pubs/reports/RPT_176.pdf
n NHS Scientist Training Programme. National School of Healthcare Science,
Trainee Handbook; 2014.
n Use of Water Equivalent Diameter for Calculating Patient Size and SizeSpecific Dose Estimates (SSDE) in CT. Report of AAPM Task Group 220;
September 2014.
https://www.aapm.org/pubs/reports/RPT_220.pdf
n Justification of Practices, Including Non-medical Human Imaging. IAEA
Safety Standard Series GSG-5, STI/PUB/1650; October 2014.
http://www-pub.iaea.org/MTCD/Publications/PDF/Pub1650web-23654722.pdf
n Strategies for the Management of Localized Prostate Cancer: A Guide for
Radiation Oncologists. IAEA Human Health Reports No. 11; September 2014.
http://www-pub.iaea.org/MTCD/Publications/PDF/Pub1646web-26036235.pdf
n Human Health IAEA Publication Catalogue, 2014–2015.
http://www-pub.iaea.org/books/SubjectBrochures/sb_hh.pdf
n Safety Standards IAEA; September 2014.
http://www-pub.iaea.org/books/SubjectBrochures/sb_ss.pdf
n Radiotherapy Errors and Near Misses:
Biennial Report. Public Health England, UK.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/f
ile/380981/Biennial_report_no_3_.pdf
https://www.gov.uk/government/uploads/system/uploads/attachment_
data/file/342253/HPA-CRCE-035_data_report_on_radiotherapy_
errors_and_near_misses.pdf
n Safer Radiotherapy: Summary of Error Data Quarterly Analysis. Issue 14;
October 2014.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/f
ile/368492/Safer_RT_No14_StdQ.pdf
n Radiological Impact of Routine Discharges from UK Civil Nuclear Licensed
Sites During 2000s. Radiation PHE-CRCE Report Series; November 2014.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/f
ile/380103/PHE-CRCE-015.pdf
n Radiation Protection in Nuclear Medicine. IPEM Report; 2014.
48 | MARCH 2015 | SCOPE
n AESP Curriculum – Medical Physics Expert, v1.0. MSC Curricula; October
2014.
n HSST Clinical Biomedical Engineering for 2014–15, v1.1. MSC Curricula;
October 2014.
n HSST Medical Physics for 2014–15, v1.1. MSC Curricula; October 2014.
n HSST Doctoral Programme Specification, v1.1. MSC Curricula; December
2014.
n IEC Newsletter No. 48 Q2-2014. Accident and Emergency Centre, IAEA;
September 2014.
http://www-pub.iaea.org/MTCD/Publications/PDF
/Newsletters/IEC_48.pdf
n Healthcare Science Newsletter. AHCS; October 2014.
http://www.ahcs.ac.uk/news/vox-the-ahcs-newsletter/
n Medical Physics Newsletter. EFOMP; Summer 2014.
http://www.efomp.org/index.php/efomp-publications/finish/3/459
n Medical Physics World Newsletter. IOMP; July 2014.
http://www.iomp.org/sites/default/files/empw-2014-01_0.pdf
n IPEM Scope; March 2014.
http://www.ipem.ac.uk/Portals/0/Documents/Publications/SCOPE/SCOPE
_MAR2014.pdf
n A Public Consultation Guide – Investing in Specialised Services, NHS
England, 2015.
https://www.engage.england.nhs.uk/consultation/investing-inspecialised-commissioning
n Medical Physics International, Nov 2014.
http://mpijournal.org/pdf/2014-02/MPI-2014-02.pdf
n MSC Accredited Expert Scientific Practice (AESP) Curriculum V1.0, Medical
Physics Expert, Oct 2014.
http://www.networks.nhs.uk/nhs-networks/msc-frameworkcurricula/documents/aesp-curriculum-medical-physics-expert-v1.0/view
DR JONATHAN WHYBROW OBITUARY
Dr Jonathan Whybrow
Remembering a true and highly intelligent scientist one year after he tragically passed away
Philip Niblett, Clinical Scientist and Head of Clinical Measurements
he 29th November 2014 was the first
anniversary of the death of Dr
Jonathan ‘Jon’ Whybrow who
continues to be greatly missed by his
colleagues in the Department of
Clinical Measurements and by others at the
Royal Devon and Exeter NHS Foundation Trust
where he was a respected healthcare scientist.
Jon joined Clinical Measurements as a
postgraduate trainee, having already enrolled on
the Clinical Scientist Training Programme,
completing his radiotherapy placement at
Cheltenham General Hospital and his medical
electronics and instrumentation placement at the
Royal United Hospital, Bath. In 2002 Jon applied
for a higher graded position than a trainee. His
potential was identified and Jon continued his
training, ultimately fulfilling the role that the
post required.
Jon had excellent credentials; an Honours
degree in Physics (Imperial College), a Master of
Science in Applied Radiation Physics with
Medical Physics (University of Birmingham) and
a Doctor of Philosophy in Medical Physics
(University of Exeter). He was awarded the
IPEM Diploma (September 2003), and
subsequently his Clinical Scientist registration
with the Health Professions Council.
Jon was a true scientist and an exceptionally
good ‘all round’ physiological measurement
scientist, a highly intelligent person with a
superb core grounding in many aspects of
physics, mathematics and computing, and the
rarer talent of understanding electronic design
fundamentals. A team player, he had a great
sense of fun and was interested in everybody
and everything. Despite his huge knowledge
base he would still seek advice and reassurance
that his work practices were at an optimal level.
His huge enthusiasm for training was
utilised in mentoring students and
enhancing the scientific team by
being influential in the
appointment of two trainee scientists.
Jon’s achievements during 11 years in
physiological measurements are extensive,
with modifications to several
physiological measurement
devices and the introduction of
computer applications designed
T
Dr Jonathan Whybrow
January 1974 – November 2013
using his high levels of competency with
various software programming tools. In his
quality assurance role, he developed the
‘Whybrometer’ and associated pressure testing
system specifically for the scientific evaluation
of air-filled microballoon catheters (developed
in Exeter for invasive physiological pressure
measurement).
Clinically Jon was responsible for the
development of the gastro-oesophageal
diagnostic service, consolidating the Bravo
radiotelemetry technique for recording
oesophageal pH and enhancing the manometry
service by introducing high-resolution
manometry and oesophageal impedance
measurements. He implemented the home sleep
study monitoring service and following his
request he became competent in modalities of
peripheral vascular ultrasound investigations,
sadly his last clinical specialism.
Jon’s professional desire was to ‘spread the
word’ and raise the profile of physiological
measurements. Being excited by the
opportunity to raise the profile nationally he
joined IPEM’s Physiological Measurement
Special Interest Group, a role that remained
unfulfilled.
Jon was my right-hand man in all scientific
developments and their medical applications,
and a potential scientific successor in the
department. I respected his knowledge and
input, and his contribution to scientific and
clinical publications and presentations
undoubtedly cemented his professional legacy.
We had many exciting discussions, sometimes
meeting in the restaurant and enjoying a full
cooked breakfast! There wasn’t time to achieve
all that we wanted to and even during his final
illness he reminded me of the numerous
uncompleted and potential projects. A colleague
recalled that Jon once remarked to the trainees,
‘don’t let those physiologists lead you up the
garden path’ – his way of reminding them to
remain true to their scientific principles!
It is so regrettable that Jon’s longstanding
medical condition unexpectedly took this very
talented clinical scientist from us far too early.
Jon left a wife Caitlin (also a clinical scientist)
and three young children: Elliot, Ethan and
Natasha.
SCOPE | MARCH 2015 | 49
Images © Shutterstock/khuruzero
HISTORICAL FEATURE: A HISTORY OF BIOMEDICAL ENGINEERING
PART 5: from the
BES to the IPEM
Stanley Salmons concludes his historical feature series: the discipline
gains recognition, journals are established, and BES merges with IPEM
T
semiconductor technology had made it possible to build
circuits that were not only small but could operate from
low voltages and without the need for heater circuits.
Initially such circuits were straightforward adaptations
of valve equivalents, using germanium p-n-p transistors
in the common-emitter configuration. Soon silicon
transistors appeared, with an n-p-n construction. Later,
with the introduction of silicon p-n-p transistors,
complementary pairs of transistors could be used in
configurations for which there were no earlier valve
equivalents (figure 1 is an example). The space race,
famously presaged by Russia’s Sputnik and President
J.F. Kennedy’s declaration of intent to go to the Moon,
stimulated the electronics industry to produce ever
more miniaturised components. These were pounced
upon by biomedical engineers. The first implantable
devices appeared: cardiac pacemakers and
radiotelemetry pills1 for medical use, and the first totally
implantable neuromuscular stimulator (figure 1), which
would open up a new chapter in muscle physiology and
clinical applications.2–6 The advent of implantable
devices focused attention on the need for biocompatible
materials and methods of encapsulation that would
prevent the ingress of water. At the opposite end of the
scale were developments in large apparatus: x-ray
machines, linear accelerators, gamma cameras,
radioisotope scanners, ultrasound equipment, and the
instrumented chambers needed to study human
physiology. Accompanying these studies was an
increasing adoption of digital methods of recording and
data logging.
The Society’s activities
Although the establishment of the International
Federation for Medical Electronics (IFME) had provided
the initial stimulus for the formation of a national
society, the Biological Engineering Society (BES) did not,
at first, affiliate itself. Once again, the Council had felt
that the title ‘Medical Electronics’ was too restrictive.
However, at the 5th International Conference on
Medical Electronics, held in Liège, Belgium, in July
1963, a proposition from the UK delegates was accepted,
and it was agreed that the name of the Federation
should be changed to the International Federation for
Medical Electronics and Biological Engineering
(IFMEBE). Affiliation of the BES followed. Subsequently,
at the 6th International Conference held in Tokyo in ‰
t
he new Biological Engineering Society
(BES) settled into a pattern of meetings
designed to familiarise members with each
other’s work whilst spanning the entire
discipline. The usual format was to have
communications in the morning and demonstrations in
the afternoon. These meetings were attractive not only
for the variety of subject matter but for the informal
mix of mature research on the one hand and
speculative research on the other. This encouraged
lively discussion and the exchange of ideas. The main
meetings were interspersed with more specialised
symposia hosted by members. The first of these, on
radio pills, was hosted by Heinz S. Wolff at the
Bioengineering Laboratory, MRC Hampstead, London,
on 28th October 1961. Subsequent meetings took place
at a variety of venues: hospital or university
departments; the Royal College of Art, Kensington;
research centres such as the Physiological Laboratory,
Cambridge, and the National College of Agricultural
Engineering, Silsoe; government research
establishments such as the RAF Institute of Aviation,
Farnborough, the Royal Naval Physiological
Laboratory, Portsmouth, the Water Pollution Research
Laboratory, Stevenage, and Rothamstead Experimental
Station; and industrial research establishments such as
the Vickers Group Research Establishment, Sunninghill,
and Shell Research, Sittingbourne.
This was a time of rapid progress in medicine and
engineering, including that made in replacement heart
valves, the artificial kidney, blood pumps,
measurement of blood flow, fracture fixation, highpressure oxygen therapy and gait recording. Britain
was making nuclear submarines and fast aircraft, and
there was a demand for more work in radiation physics
and radiation monitoring, and on the physiological
effects of sudden exposure to high barometric pressures
(as in escape from submarines) and low atmospheric
pressures (as in failure of pressurisation or the need to
eject at high altitudes). Although these developments
found a ready forum at the BES, there was always room
for more biological topics, such as the measurement of
the peak tension in the extensor muscle of the locust
during a jump, by R.H.J. Brown, Zoological Laboratory,
Cambridge (for interest, it was 1.5 kg).
There was therefore no lack of applications but
engineering, too, was developing rapidly. The spread of
The first
implantable
devices
appeared
SCOPE | MARCH 2015 | 51
HISTORICAL FEATURE: A HISTORY OF BIOMEDICAL ENGINEERING
t
Image © By kind permission of Professor N. de N. Donaldson
FIGURE 1. The first totally implantable neuromuscular stimulator2
FIGURE 2. P.E.K. Donaldson
t
52 | MARCH 2015 | SCOPE
‰ 1965, the General Assembly decided to drop
Electronics from the name altogether on the grounds
that it was included in Engineering, and the title
became, and remains, International Federation for
Medical and Biological Engineering (IFMBE).
By the end of 1965 the BES had over 240 members.
It had representatives on the Parliamentary Scientific
Committee, the Biological Council, and SAMB (the
United Kingdom Liaison Committee for Sciences
Allied to Medicine and Biology), which had been
formed that October to provide co-ordination between
relevant professional bodies. Following the December
1965 meeting on prostheses in Glasgow, the first
regional section, the Scottish Section, was formed.
Once affiliated to the IFMBE, the Society supported
each of the Federation’s international conferences with
papers and a British stand of scientific and commercial
exhibits. Over the period from 1971 to 1985 the
Federation grew from 15 member societies to 28.
Meanwhile BES meetings had also been expanded to
accommodate more special topic conferences: Blood
Flow Measurement; Education, Training and Careers
in Bio-Medical Engineering; and Biomaterials.
Publications generated by these conferences proved
popular. Other conferences were confined to three
topics related to local interests. There was a growing
demand for these more specialised meetings, which
led to a second Biomaterials conference (held jointly
with the Hospital Physicists Association), and
meetings on Technical Aspects of Renal Dialysis,
Foetal and Neonatal Physiological Measurements, and
Telemetry and Radio Tracking. The last attracted over
300 delegates and resulted in an 800-page book.7
The role of biomedical engineering in both research
and the provision of services now had national status.
In his introduction to a special issue of the Health and
Social Service Journal/Hospital International, 1975, the
then Minister of State (Health), Dr David Owen,
wrote: ‘The contents of this publication confirm that
biomedical engineering contributes to almost all
specialties and is in evidence at the bedside, in the
laboratories and in clinical departments and operating
theatres… I do not think the importance of biomedical
engineering can be overstressed…’
The Society’s 15th anniversary was celebrated with
a conference in Edinburgh in August 1975. His Royal
Highness Prince Philip, Duke of Edinburgh,
graciously consented to be its patron. He was
afterwards invited to be patron of the Society, an
invitation he declined, whilst adding that he would,
however, be delighted to become an Honorary
Member. The BES Council duly elected the Society’s
first Honorary Member.
The professional interests of Society members were
not being neglected. As early as 1965, discussions had
commenced with the Council of Engineering
Institutions (CEI) and after a number of rigorous
assessments the Society was admitted as an Affiliate,
enabling appropriately qualified members of
engineering professions to apply for registration as
Chartered Engineers through the BES. When the
government replaced the CEI with the Engineering
HISTORICAL FEATURE: A HISTORY OF BIOMEDICAL ENGINEERING
Council the Society’s affiliation was transferred. The
Society created an additional grade of Technical
Membership, through which members in that category
could register with the Engineering Council as
Technician Engineers. It also achieved alignment with
the IFMBE’s Clinical Engineering Division objectives of
examination and certification of members as Clinical
Engineers.
The IFMBE became a full member of the
International Council of Scientific Unions in 2002,
completing the goal of the founding members to
achieve recognition and respect for the discipline of
biomedical engineering.
“
“
His style was a delightful
combination of the kitchensink experiment and the
utmost rigour
Journals
In 1963 the IFMBE had founded a journal, Medical
Electronics and Biological Engineering, with Alfred
Nightingale as its first Editor, a tenure cut short by his
fatal accident. The Administrative Council then offered
the editorship to Peter E.K. Donaldson (figure 2). The
choice was a felicitous one; by now Donaldson’s 1958
book, Electronic Apparatus for Biological Research, was
frequently found on the shelves of physiologists and
engineers on both sides of the Atlantic,8 his name was
on the first list of members of the BES, and he had been
elected to Council at the first Annual General Meeting.
He went on to build the journal’s reputation over the
crucial first 5 years. Donaldson’s own research and that
of his colleagues in the MRC Neurological Prosthesis
Unit of the Institute of Psychiatry was to prove highly
influential in the development of microelectronic
implants, not least in tackling the problems of tissue
compatibility and water ingress mentioned earlier. His
style was a delightful combination of the kitchen-sink
experiment and the utmost intellectual rigour. This is
well illustrated by his discovery of the suitability of
silicone rubber as an implantable sealant:9
‘About that time the inside of my domestic coffee
percolator came to pieces. Looking along the workshop
shelf at home for some adhesive with which to carry
out a repair, I found the remains of a tube of Dow
Corning bathtub sealant, an acetic-acid-evolving
silicone rubber adhesive. I used this to mend the
percolator, and the mend lasted, withstanding a daily
boil of 5 min or so. At the time of writing, 8 years later,
that mend is still being boiled daily and is still good.
Evidently here was a promising material for an
implant sealant.’
Over the years this casual observation would be
subjected to detailed experimentation and analysis.10–13
The title of the Federation’s journal soon changed to
Medical and Biological Engineering and in January 1977,
with the minimum of fanfare, it was extended to
Medical and Biological Engineering and Computing. From
January 2006 the bimonthly publication was expanded
to 12 issues a year.
The BES had begun to issue a newsletter in January
1966, with A.S. Velate as its first Editor. But it also
wanted its own journal, and in 1966 launched the
monthly Bio-Medical Engineering. This succeeded in
providing articles that were accessible to the broad
interests of its readership, whilst leaving the
Federation’s journal to cover the more scholarly and
esoteric material. In January 1973 the journal took on a
new look, adopting the metric format and a brand new
cover design – and losing its hyphen. Following a
dispute over the ownership of the title, the publication
was reborn in 1979 as the Journal of Biomedical
Engineering. In January 1994, under the editorship of
V.C. Roberts, the name was changed yet again to
Medical Engineering & Physics. This was a controversial
decision, implying an emphasis on medicine as
opposed to biology, and producing a dip in readership
numbers for several years as well as a change in
content. The journal now accepted far more
specialised papers, overlapping to a much greater
extent with the Federation journal.
The merger
The BES had grown in the 30 years since its
foundation. It had a home in the Royal College of
Surgeons, which had hosted its initial stages of
formation. However, with the steady growth in
membership came an increasing administrative
burden, which had been managed over the years only
through the goodwill and hard work of its Honorary
Officers and members of Council. A critical point had
been reached: it was too large to manage informally,
yet too small to support paid staff. To solve the
problem, consultations began with societies having
allied interests. The Society had held many joint
meetings with the Hospital Physicists Association
(HPA) over the years, starting in 1966, and as early as
1973 discussions had taken place as to ways in which
the two organisations could benefit from closer cooperation and a possible merger. Some 20 years later
these discussions were revived with a greater sense of
purpose. There were more joint meetings with the
Institute of Physical Sciences in Medicine (IPSM), and
a 4th Annual Joint Conference in Keele in 1994. After a
5th and final Joint Conference in Sheffield in 1995, the
Institute of Physics and Engineering in Medicine and
Biology (IPEMB) was formed by the merger of the
HPA, BES, IPSM and Association of Medical
Technologists. Two years later, ‘Biology’ was dropped
from the title, which became the Institute of Physics
and Engineering in Medicine (IPEM).
The future?
By the end of the nineteenth century the era of the
polymath was over, and science and engineering had
become increasingly specialised. In the same way, it
has become harder for societies that once aspired to
encompass entire disciplines to do so. This trend has
already been observed in the BES in the popularity of
its special topic meetings. But each new imaging, ‰
‘ FEEDBACK
Scope welcomes
your feedback!
@IPEMScope
SCOPE | MARCH 2015 | 53
HISTORICAL FEATURE: A HISTORY OF BIOMEDICAL ENGINEERING
‰ measuring, or monitoring technique and each
‘ Stanley
Salmons
is Emeritus
Professor of
Applied Myology
at the University
of Liverpool.
Although still
scientifically
active, he is
carving out a
second career in
fiction writing. He
is a Fellow of
IPEM and an
Honorary Fellow
of the Anatomical
Society.
new treatment modality seems to generate the urge
to create yet more focused meetings, a more specific
forum and a new journal, threatening to remove
those interests from the relevant parent
organisation. This trend has the disadvantage of
restricting the breadth of vision and interaction
across subject boundaries that is afforded by
membership of a less specialised body. It is fortunate
that the IFMBE allows more than one society per
country to be a member, as this at least creates an
opportunity to assemble the fragmented groups
beneath a single umbrella.
The potential is undiminished for a convergence
between engineering and physics on the one hand
and biology and medicine on the other, but the
collaboration needs to be a two-way process.
Biologists and physicians know best what they need,
and engineers and physicists are best equipped to
provide it, but dialogue calls for a breadth of
understanding from both parties.
An almost exclusive emphasis on medical
applications has moved the IPEM further away from
the initial goal of encompassing biology. Yet the
problems facing the world are not merely those of
the health of its human population but the health of
the planet. Climate change, overfishing of the
oceans, deforestation, and the consequences of other
commercial activities are all reflected in the animals
that must share those resources. Engineering
techniques can help to study and to monitor these
effects, but once again specialisation tends to isolate
those whose interests should be overlapping. Over
50 years ago the Biological Engineering Society met
this need for a group of individuals who laid the
foundations of the discipline, and it promoted crossfertilisation through broadly based scientific
meetings. There is a need to find ways of preserving
this vision if biomedical engineering is to realise its
full potential in the future.
REFERENCES
1 Rowlands EN, Wolff HS. The radio pill – telemetering
from the digestive tract. Br Commun Electron 1960; 7:
598–601.
2 Salmons S. An implantable muscle stimulator. J Physiol
1967; 188: 13–14P.
3 Salmons S, Sréter FA. Significance of impulse activity in
the transformation of skeletal muscle type. Nature 1976;
263: 30–34.
4 Salmons S. Cardiac assistance from skeletal muscle: a
reappraisal. Eur J Cardio-Thorac Surg 2009; 35: 204–13.
5 Salmons S. Adaptive change in electrically stimulated
muscle: a framework for the design of clinical protocols
(Invited review). Muscle Nerve 2009; 40: 918–35.
6 Salmons S, Henriksson J. The adaptive response of
skeletal muscle to increased use. Muscle Nerve 1981; 4:
94–105.
7 Amlaner CJ, MacDonald DW (Ed.). A Handbook of
Biotelemetry and Radiotracking. Oxford: Pergamon
Press, 1980.
8 Donaldson PEK. Electronic Apparatus for Biological
Research. London: Butterworths Scientific Publications,
1958.
9 Donaldson PEK. In search of the reliable microelectronic
implant. Trends Neurosci 1978; 1: 49–50.
10 Donaldson PEK. Aspects of silicone rubber as an
encapsulant for neurological prostheses. Part 1:
osmosis. Med Biol Eng Comput 1991; 29: 34–9.
11 Donaldson PEK. Aspects of silicone rubber as
encapsulant for neurological prostheses. Part 3:
adhesion to mixed oxides. Med Biol Eng Comput 1995;
33: 725–7.
12 Donaldson PEK. Aspects of silicone rubber as
encapsulant for neurological prostheses. Part 4: twopart rubbers. Med Biol Eng Comput 1997; 35: 283–6.
13 Donaldson PEK, Aylett BJ. Aspects of silicone rubber as
encapsulant for neurological prostheses. Part 2:
adhesion to binary oxides. Med Biol Eng Comput 1995;
33: 285–92.
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