A Survey of DICOM Viewer Software to Integrate Clinical Research and Medical Imaging

BeST-Graft viewer, a new system to improve the bone allograft-recipient matching process

INTRODUCTION

Tissue establishments are responsible for processing, testing, preserving, storing, and distributing allografts from donors to be transplanted into recipients. In some situations, a matching process is required to determine the allograft that best fits the recipient. Allograft morphology is a key consideration for the matching process. The manual procedures applied to obtain these parameters make the process error-prone.

MATERIAL AND METHODS

A new system to manage bone allograft-recipient matching for tissue establishments is proposed. The system requires bone allografts to be digitalized and the resulting images to be stored in a DICOM file. The system provides functionalities to: (i) manage DICOM files (registered in the PACs) from both allografts and recipients; (ii) reconstruct 3D models from DICOM images; (iii) explore 3D models using 2D, 3D, and multiplanar reconstructions; (iv) take allograft and recipient measurements; and (v) visualize and interact with recipient and allograft data simultaneously. The system has been installed in the Barcelona Tissue Bank (Banc de Sang i Teixits), which has digitalized the bone allografts to test the system.

RESULTS

A use case with a femur is presented to test all the viewer functionalities. In addition, the recipient-allograft workflow is evaluated to show the steps of the procedure where the viewer can be used.

CONCLUSIONS

The bone allograft-recipient matching procedure can be optimized using software tools with functionalities to visualize, interact, and take measurements.

The Application of Sodium Fluorescein in Resection of Medulloblastoma Under YELLOW 560 Filter: Feasibility and Preliminary Results of a Monocentric Cohort and Systematic Review

BACKGROUND

Maximizing surgical resection of medulloblastoma (MB) affects overall survival; nevertheless, surgical resection remains a because of the infiltrative behavior of this tumor. Several dyes have been tested for improving tumor visualization; however, few reports with different protocols of fluorophores use are available and the results are inconsistent. Hence, we report our experience with sodium fluorescein in MB surgery, aiming to assess the role of this technique on the extent of resection. Furthermore, we performed a literature review of this topic.

METHODS

Fluorescence characteristics, extent of resection, and clinical outcome were analyzed in 9 consecutively operated patients with MB. A comprehensive literature search and review for English-language articles concerning fluorescein application in MB was conducted.

RESULTS

In our cohort, no side effect related to fluorescein occurred; all tumors presented with an intense or moderate yellow-green enhancement, and fluorescein was judged fundamental in distinguishing tumors from viable tissue in 7 of 9 cases. Gross total resection or near-total resection (i.e., a residual tumor volume <1.5 cm3) was achieved in 8 patients. The review explored the different techniques and surgical interpretations as well as surgical radicality; we did not find a homogenous protocol for fluorescein injection in the published articles. Fluorescence appeared moderate or intense in almost all cases, with a high percentage of usefulness and consensual achievement of a high rate of gross total resection.

CONCLUSIONS

Based on these results, we can infer that fluorescein-guided surgical resection is a safe and valuable method for patients with MB.

Review of the Free Research Software for Computer-Assisted Interventions

Research software is continuously developed to facilitate progress and innovation in the medical field. Over time, numerous research software programs have been created, making it challenging to keep abreast of what is available. This work aims to evaluate the most frequently utilized software by the computer-assisted intervention (CAI) research community. The software assessments encompass a range of criteria, including load time, stress load, multi-tasking, extensibility and range of functionalities, user-friendliness, documentation, and technical support. A total of eight software programs were selected: 3D Slicer, Elastix, ITK-SNAP, MedInria, MeVisLab, MIPAV, and Seg3D. While none of the software was found to be perfect on all evaluation criteria, 3D Slicer and ITK-SNAP emerged with the highest rankings overall. These two software programs could frequently complement each other, as 3D Slicer has a broad and customizable range of features, while ITK-SNAP excels at performing fundamental tasks in an efficient manner. Nonetheless, each software had distinctive features that may better fit the requirements of certain research projects. This review provides valuable information to CAI researchers seeking the best-suited software to support their projects. The evaluation also offers insights for the software development teams, as it highlights areas where the software can be improved.

BlueLight: An Open Source DICOM Viewer Using Low-Cost Computation Algorithm Implemented with JavaScript Using Advanced Medical Imaging Visualization

Recently, WebGL has been widely used in numerous web-based medical image viewers to present advanced imaging visualization. However, in the scenario of medical imaging, there are many challenges of computation time and memory consumption that limit the use of advanced image renderings, such as volume rendering and multiplanar reformation/reconstruction, in low-cost mobile devices. In this study, we propose a client-side rendering low-cost computation algorithm for common two- and three-dimensional medical imaging visualization implemented by pure JavaScript. Particularly, we used the functions of cascading style sheet transform and combinate with Digital Imaging and Communications in Medicine (DICOM)-related imaging to replace the application programming interface with high computation to reduce the computation time and save memory consumption while launching medical imaging interpretation on web browsers. The results show the proposed algorithm significantly reduced the consumption of central and graphics processing units on various web browsers. The proposed algorithm was implemented in an open-source web-based DICOM viewer BlueLight; the results show that it has sufficient rendering performance to display 3D medical images with DICOM-compliant annotations and has the ability to connect to image archive via DICOMweb as well.Keywords: WebGL, DICOMweb, Multiplanar reconstruction, Volume rendering, DICOM, JavaScript, Zero-footprint.

Anthropometric study using three-dimensional pelvic CT scan in sex determination among adult Indonesian population

This study aims to determine pelvic anthropometry characteristics and logistic regression formula for adult sex identification obtained from adult three-dimensional pelvic computed tomography images. This study was an observational analytical study with retrospective regression and cross-sectional approach. The population was all patients at Radiology Installation of Dr. Soetomo General Academic Hospital as referral hospital in East Indonesian region, from September to December 2019 who underwent 3D pelvic CT examination. Then, age distribution and pelvic measurements data were obtained. In this case, statistical analysis was conducted for all the data obtained. A number of 204 samples were included in this study. All radiologic components were also significantly different between sexes (p < 0.05) except for transverse diameter of sacral segment (p = 0.180). Moreover, the conjugate pelvic inlet diameter (CPID), the left innominate height (LIH), and sub pubic angle (SPA) showed significant values for regression formula to determine an adult's sex using 3D pelvic CT. The calculation result > 0 is a prediction for female while < 0 is a prediction for male. From logistic regression model calculation, a high validity value (91.05%) was found with 100% sensitivity to identify male sex and 81.1% specificity to identify female sex. There were differences on radiometric variable characteristics in pelvic anthropometric study among adult Indonesians at Dr. Soetomo General Academic Hospital, Surabaya. The estimated values of pelvic measurements using 3D CT images could develop a pelvic model with a regression formula with high accuracy value using CPID, LIH, and SPA values.

Absorbed dose calculation for a realistic CT-derived mouse phantom irradiated with a standard Cs-137 cell irradiator using a Monte Carlo method

Computed tomography (CT) derived Monte Carlo (MC) phantoms allow dose determination within small animal models that is not feasible with in-vivo dosimetry. The aim of this study was to develop a CT-derived MC phantom generated from a mouse with a xenograft tumour that could then be used to calculate both the dose heterogeneity in the tumour volume and out of field scattered dose for pre-clinical small animal irradiation experiments. A BEAMnrc Monte-Carlo model has been built of our irradiation system that comprises a lead collimator with a 1 cm diameter aperture fitted to a Cs-137 gamma irradiator. The MC model of the irradiation system was validated by comparing the calculated dose results with dosimetric film measurement in a polymethyl methacrylate (PMMA) phantom using a 1D gamma-index analysis. Dose distributions in the MC mouse phantom were calculated and visualized on the CT-image data. Dose volume histograms (DVHs) were generated for the tumour and organs at risk (OARs). The effect of the xenographic tumour volume on the scattered out of field dose was also investigated. The defined gamma index analysis criteria were met, indicating that our MC simulation is a valid model for MC mouse phantom dose calculations. MC dose calculations showed a maximum out of field dose to the mouse of 7% of Dmax. Absorbed dose to the tumour varies in the range 60%-100% of Dmax. DVH analysis demonstrated that tumour received an inhomogeneous dose of 12 Gy-20 Gy (for 20 Gy prescribed dose) while out of field doses to all OARs were minimized (1.29 Gy-1.38 Gy). Variation of the xenographic tumour volume exhibited no significant effect on the out of field scattered dose to OARs. The CT derived MC mouse model presented here is a useful tool for tumour dose verifications as well as investigating the doses to normal tissue (in out of field) for preclinical radiobiological research.

Combination of Cerebral Computed Tomography and Simplified Cardiac Arrest Hospital Prognosis (sCAHP) Score for Predicting Neurological Recovery in Cardiac Arrest Survivors

Background

Cerebral computed tomography (CT) and various severity scoring systems have been developed for the early prediction of the neurological outcomes of cardiac arrest survivors. However, few studies have combined these approaches. Therefore, we evaluated the value of the combination of cerebral CT and severity score for neuroprognostication.

Methods

This single-center, retrospective observational study included consecutive patients surviving nontraumatic cardiac arrest (January 2016 and December 2020). Gray-to-white ratio (GWR), third and fourth ventricle characteristics, and medial temporal lobe atrophy scores were evaluated on noncontrast cerebral CT. Simplified cardiac arrest hospital prognosis (sCAHP) score was calculated for severity assessment. The associations between the CT characteristics, sCAHP score and neurological outcomes were analyzed.

Results

This study enrolled 559 patients. Of them, 194 (34.7%) were discharged with favorable neurological outcomes. Patients with favorable neurological outcome had a higher GWR (1.37 vs 1.25, p < 0.001), area of fourth ventricle (461 vs 413 mm 2 , p < 0.001), anteroposterior diameter of fourth ventricle (0.95 vs 0.86 cm , p < 0.001) and a lower sCAHP score (146 vs 190, p < 0.001) than those with poor recovery. Patients with higher sCAHP score had lower GWR (p trend < 0.001), area of fourth ventricle (p trend = 0.019) and anteroposterior diameter of fourth ventricle (p trend = 0.014). The predictive ability by using area under receiver operating characteristic curve (AUC) for the combination of sCAHP score and GWR was significantly higher than that calculated for sCAHP (0.86 vs 0.76, p < 0.001) or GWR (0.86 vs 0.81, p = 0.001) alone.

Conclusions

The combination of GWR and sCAHP score can be used to effectively predict the neurological outcomes of cardiac arrest survivors and thus ensure timely intervention for those at high risk of poor recovery.

Correlation Analysis between Fat Fraction and Bone Mineral Density Using the DIXON Method for Fat Dominant Tissue in Knee Joint MRI: A Preliminary Study

Purpose

This study aimed to investigate the correlation between the fat signal fraction (FF) of the fat-dominant bone tissue of the knee joint, measured using the MRI Dixon method (DIXON) technique, and bone mineral density (BMD).

Materials and Methods

Among the patients who underwent knee DIXON imaging at our institute, we retrospectively analyzed 93 patients who also underwent dual energy X-ray absorptiometry within 1 year. The FFs of the distal femur metaphyseal (Fm) and proximal tibia metaphyseal (Tm) were calculated from the DIXON images, and the correlation between FF and BMD was analyzed. Patients were grouped based on BMD of lumbar spine (L), femoral neck (FN), and common femur (FT) respectively, and the Kruskal-Wallis H test was performed for FF.

Results

We identified a significant negative correlation between TmFF and FN-BMD in the entire patient group (r = -0.26, p < 0.05). In female patients, TmFF showed a negative correlation with FN-BMD, FT-BMD, and L-BMD (r = -0.38, 0.28 and -0.27, p < 0.05). In male patients, FmFF was negatively correlated with only FN-BMD and FT-BMD (r = -0.58 and -0.42, p < 0.05). There was a significant difference in the TmFF between female patients grouped by BMD (p < 0.05). In male patients, there was a significant difference in FmFF (p < 0.05).

Conclusion

Overall, we found that FF and BMD around the knee joints showed a negative correlation. This suggests the potential of FF measurement using DIXON for BMD screening.

Towards an Established Intraoperative Oncological Favorable Tool: Results of Fluorescein-Guided Resection from a Monocentric, Prospective Series of 93 Primary Glioblastoma Patients

It is commonly reported that maximizing surgical resection of contrast-enhancing regions in patients with glioblastoma improves overall survival. Efforts to achieve an improved rate of resection have included several tools: among those, the recent widespread of fluorophores. Sodium fluorescein is an unspecific, vascular dye which tends to accumulate in areas with an altered blood-brain barrier. In this retrospective analysis of patients prospectively enrolled in the FLUOCERTUM study, we aimed to assess the role of fluorescein-guided surgery on surgical radicality, survival, and morbidity. A retrospective review based on 93 consecutively and prospectively enrolled IDH wild-type glioblastoma patients (2016-2022) was performed; fluorescence characteristics, rate of resection, clinical outcome, and survival were analyzed. No side effect related to fluorescein occurred; all of the tumors presented a strong yellow-green enhancement and fluorescein was judged fundamental in distinguishing tumors from viable tissue in all cases. Gross total resection was achieved in 77 cases out of 93 patients (82.8%). After a mean follow-up time of 17.4 months (3-78 months), the median progression-free survival was 12 months, with a PFS-6 and PFS-12 of 94.2% and 50%, respectively, whereas median overall survival was estimated to be 16 months; survival at 6, 12, and 24 months was 91.8%, 72.3%, and 30.1%, respectively. Based on these results, we can assert that the fluorescein-guided technique is a safe and valuable method for patients harboring a newly diagnosed, untreated glioblastoma.

Pretransplant Psoas Muscle Cross-Sectional Area and Postkidney Transplant Outcomes

BACKGROUND

Sarcopenia is associated with adverse outcomes in end-stage kidney disease. We evaluated if pretransplant sarcopenia affects posttransplant outcomes in kidney transplant (KT) recipients.

METHODS

In this single-center retrospective study of adult patients with end-stage kidney disease, we analyzed the association between pre-KT psoas muscle cross-sectional area and critical posttransplant outcomes of decline in estimated glomerular filtration rate (eGFR), graft loss, rehospitalization, and mortality using Cox proportional hazard model adjusted for age, sex, and race.

RESULTS

Pre-KT abdomen and pelvic computed tomography scans performed during evaluation for KT eligibility were available for 573 KT recipients. Of these, 465 KT recipients received kidney alone transplant, 71 received simultaneous liver kidney transplant (SLK), and 37 received simultaneous pancreas kidney transplant (SPK). Patients were 49 (SD, 13) years old, 16% Black, and 60% men. For kidney alone transplant recipients, a higher psoas muscle cross-sectional area was associated with a shorter length of hospitalization (β coefficient = -0.003; 95% CI, -0.005 to -0.0007). Conversely, pre-KT psoas muscle cross-sectional area did not predict decline in eGFR, graft loss, mortality, or early rehospitalization. For SLK recipients, psoas muscle cross-sectional area did not predict any of the priori outcomes. For SPK recipients, higher pretransplant psoas muscle cross-sectional area predicted a longer length of hospitalization (β coefficient = 0.03; 95% CI, 0.01-0.05). There was no association between psoas muscle cross-sectional area and other outcomes assessed.

CONCLUSIONS

Pretransplant psoas muscle cross-sectional areas are not predictive of post-transplant decline in eGFR, graft loss, rehospitalization or mortality in kidney alone, SPK, or SLK transplants.

French Imaging Database Against Coronavirus (FIDAC): A large COVID-19 multi-center chest CT database

Purpose

During the first wave of the COVID-19 pandemic, the French Society of Radiology and the French College of Radiology, in partnership with NEHS Digital, have set up a system to collect chest computed tomography (CT) examinations with clinical, virological and radiological metadata, from patients clinically suspected of COVID-19 pneumonia. This allowed the constitution of an anonymized multicenter database, named FIDAC (French Imaging Database Against Coronavirus). The aim of this report was to describe the content of this public database.

Materials and methods

Twenty-two French radiology centers participated to the data collection. The data collected were chest CT examinations in DICOM format associated with the following metadata: patient age and sex, originating facility identifier, originating facility region, time from symptom onset to CT examination, indication for CT examination, reverse transcription-polymerase chain reaction (RT-PCR) results and normalized CT report performed by a senior radiologist. All the data were anonymized and sent through a NEHS Digital system to a centralized data center.

Results

A total of 5944 patients were included from the 22 centers aggregated into 8 regions with a mean number of patients of 743 ± 603.3 [SD] per region (range: 102–1577 patients). Reasons for CT examination and normalized CT reports were provided for all patients. RT-PCR results were provided in 5574 patients (93.77%) with a positive result of RT-PCR in 44.6% of patients.

Conclusion

The FIDAC project allowed the creation of a large database of chest CT images and metadata available, under conditions, in open access through the CERF-SFR website.

IoT-Enabled Smart Cities: A Review of Concepts, Frameworks and Key Technologies

In recent years, smart cities have been significantly developed and have greatly expanded their potential. In fact, novel advancements to the Internet of things (IoT) have paved the way for new possibilities, representing a set of key enabling technologies for smart cities and allowing the production and automation of innovative services and advanced applications for the different city stakeholders. This paper presents a review of the research literature on IoT-enabled smart cities, with the aim of highlighting the main trends and open challenges of adopting IoT technologies for the development of sustainable and efficient smart cities. This work first provides a survey on the key technologies proposed in the literature for the implementation of IoT frameworks, and then a review of the main smart city approaches and frameworks, based on classification into eight domains, which extends the traditional six domain classification that is typically adopted in most of the related works.

Free DICOM-Viewers for Veterinary Medicine : Survey and Comparison of Functionality and User-Friendliness of Medical Imaging PACS-DICOM-Viewer Freeware for Specific Use in Veterinary Medicine Practices

There is increasing prevalence of digital diagnostic imaging in veterinary medicine with a progressive need to use medical imaging software. As Digital Imaging and Communications in Medicine (DICOM)-viewers for veterinary use do not require medical device approval in many countries, freeware viewers might be a practical alternative. The aim of this study was to identify and evaluate free DICOM-viewer software for veterinary purposes. The functionality and user-friendliness of various DICOM-viewers from the internet were analyzed and compared. Inclusion criteria for the evaluation were free availability, PACS (picture archiving and communication system)-connectivity, and stand-alone and client-based software. Based on this, eight viewers were found: Ginkgo CADx, Horos, K-PACS, MAYAM, MITO, OsiriX Lite, RadiAnt, Synedra personal. In these DICOM-viewers, 14 core tools were tested and rated on a score from 1 to 10 by multiple observers with different levels of training, using studies of four imaging modalities. Criteria were functionality and user-friendliness. For each viewer, the total number of a predefined set of 47 important tools was counted. The ranking based on functionality and user-friendliness of 14 core tools (mean score in brackets) was as follows: 1. Horos/OsiriX Lite (8.96), 2. RadiAnt (8.90), 3. K-PACS (8.02), 4. Synedra (7.43), 5. MAYAM (6.05), 6. Ginkgo CADx (5.53), 7. MITO (3.74). The DICOM-viewers offered between 20 and 44 tools of the predefined important tool set and are sufficient for most veterinary purposes. An increasing number of tools did not necessarily impair user-friendliness, if the user interface is well designed. Based on the results of this study, veterinarians will find suitable free DICOM-viewers for their individual needs. In combination with PACS-freeware, this allows veterinary practices to run a low-budget digital imaging environment.

Comprehensive Review of 3D Segmentation Software Tools for MRI Usable for Pelvic Surgery Planning

Patient-specific 3D modeling is the first step towards image-guided surgery, the actual revolution in surgical care. Pediatric and adolescent patients with rare tumors and malformations should highly benefit from these latest technological innovations, allowing personalized tailored surgery. This study focused on the pelvic region, located at the crossroads of the urinary, digestive, and genital channels with important vascular and nervous structures. The aim of this study was to evaluate the performances of different software tools to obtain patient-specific 3D models, through segmentation of magnetic resonance images (MRI), the reference for pediatric pelvis examination. Twelve software tools freely available on the Internet and two commercial software tools were evaluated using T2-w MRI and diffusion-weighted MRI images. The software tools were rated according to eight criteria, evaluated by three different users: automatization degree, segmentation time, usability, 3D visualization, presence of image registration tools, tractography tools, supported OS, and potential extension (i.e., plugins). A ranking of software tools for 3D modeling of MRI medical images, according to the set of predefined criteria, was given. This ranking allowed us to elaborate guidelines for the choice of software tools for pelvic surgical planning in pediatric patients. The best-ranked software tools were Myrian Studio, ITK-SNAP, and 3D Slicer, the latter being especially appropriate if nerve fibers should be included in the 3D patient model. To conclude, this study proposed a comprehensive review of software tools for 3D modeling of the pelvis according to a set of eight criteria and delivered specific conclusions for pediatric and adolescent patients that can be directly applied to clinical practice.

Effectiveness and Long-Acting of the Hyaluronic Acid Injected into the Nasolabial Fold Measured Through Magnetic Resonance Imaging

BACKGROUND

MRI analyzed quantitatively the HA injected into the NLF subcutaneous fat to correlate the gel diffusion and degradation with the morphological changes of the NLF appearance for twelve months. Measurements of the gel diffusion and degradation were taken by MRI as parameters to assess the clinical efficacy and long-acting of the HA in NLF rejuvenation.

METHOD

HA was applied into the superficial compartment of the subcutaneous fat of twenty NLFs. Each NLF received three injection points, from the nasal ala toward the oral commissure, 1.0-1.5 cm distant from each other, according to the NLF length. A bolus injection technique without retrograde backflow applied per injection point 0.15-0.20 ml of HA for moderate. NLF and 0.20-0.25 ml for severe NLF. Patients were evaluated through MRI and clinically twenty-four hours, one month and twelve months after the HA application.

RESULTS

MRI, in T2-weighted, displayed the gel as a dense, spindle-shaped nodule as pattern of the gel diffusion, measuring its largest longitudinal and transverse axes. Twenty-four hours after HA application the longitudinal axis measured 1.79 cm, after one month 2.33 cm and at month twelve 0.91 cm. The transverse axis measured 0.92 cm at 24 hours, 1.13 cm after one month and 0.47 cm at month twelve.

CONCLUSION

Despite reduction in size and denseness of the spindle-shaped nodule, the small amount of gel presenting into the subcutaneous fat after twelve months of the application evidenced the HA efficacy and long-acting in NLF rejuvenation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors - www.springer.com/00266 .

A Novel Virtual Reality Medical Image Display System for Group Discussions of Congenital Heart Disease: Development and Usability Testing

Background

The complex 3-dimensional (3D) nature of anatomical abnormalities in congenital heart disease (CHD) necessitates multidisciplinary group discussions centered around the review of medical images such as magnetic resonance imaging. Currently, group viewings of medical images are constrained to 2-dimensional (2D) cross-sectional displays of 3D scans. However, 2D display methods could introduce additional challenges since they require physicians to accurately reconstruct the images mentally into 3D anatomies for diagnosis, staging, and planning of surgery or other therapies. Virtual reality (VR) software may enhance diagnosis and care of CHD via 3D visualization of medical images. Yet, present-day VR developments for medicine lack the emphasis on multiuser collaborative environments, and the effect of displays and level of immersion for diagnosing CHDs have not been studied.

Objective

The objective of the study was to evaluate and compare the diagnostic accuracies and preferences of various display systems, including the conventional 2D display and a novel group VR software, in group discussions of CHD.

Methods

A total of 22 medical trainees consisting of 1 first-year, 10 second-year, 4 third-year, and 1 fourth-year residents and 6 medical students, who volunteered for the study, were formed into groups of 4 to 5 participants. Each group discussed three diagnostic cases of CHD with varying structural complexity using conventional 2D display and group VR software. A group VR software, Cardiac Review 3D, was developed by our team using the Unity engine. By using different display hardware, VR was classified into nonimmersive and full-immersive settings. The discussion time, diagnostic accuracy score, and peer assessment were collected to capture the group and individual diagnostic performances. The diagnostic accuracies for each participant were scored by two experienced cardiologists following a predetermined answer rubric. At the end of the study, all participants were provided a survey to rank their preferences of the display systems for performing group medical discussions.

Results

Diagnostic accuracies were highest when groups used the full-immersive VR compared with the conventional and nonimmersive VR (χ²₂=9.0, P=.01) displays. Differences between the display systems were more prominent with increasing case complexity (χ²₂=14.1, P<.001) where full-immersive VR had accuracy scores that were 54.49% and 146.82% higher than conventional and nonimmersive VR, respectively. The diagnostic accuracies provided by the two cardiologists for each participant did not statistically differ from each other (t=–1.01, P=.31). The full-immersive VR was ranked as the most preferred display for performing group CHD discussions by 68% of the participants.

Conclusions

The most preferred display system among medical trainees for visualizing medical images during group diagnostic discussions is full-immersive VR, with a trend toward improved diagnostic accuracy in complex anatomical abnormalities. Immersion is a crucial feature of displays of medical images for diagnostic accuracy in collaborative discussions.

The Time Has Come: a Paradigm Shift in Diagnostic Radiology Education via Simulation Training

Current radiology training for medical students and residents predominantly consists of reviewing teaching files, attending lectures, reading textbooks and online sources, as well as one-on-one teaching at the workstation. In the case of medical schools, radiology training is quite passive. In addition, the variety of important and high-yield cases that trainees are exposed to may be limited in scope. We utilized an open-source dcm4chee-based Picture Archiving and Communication System (PACS) named "Weasis" in order to simulate a radiologist's practice in the real world, using anonymized report-free complete cases that could easily be uploaded live during read-outs for training purposes. MySQL was used for database management and JBOSS as application server. In addition, we integrated Weasis into a web-based reporting system through Java programming language using the MyEclipse development environment. A freeware, platform-independent, image database was established to simulate a real-world PACS. The sever was implemented on a dedicated non-workstation PC connected to the hospital secure network. As the client access is through a webpage, the cases can be viewed from any computer connected to the hospital network. The reporting system allows for evaluation purposes and providing feedback to the trainees. Brief survey results are available. Implementation of such a low-cost, versatile, and customizable tool provides a new opportunity for training programs in offering medical students with an active and more realistic radiology experience, junior radiology residents with potentially better preparation for independent call, and senior resident and fellows with the ability to fine-tune high-level specialty-level knowledge.

Evaluation of Free, Open-source, Web-based DICOM Viewers for the Indian National Telemedicine Service (eSanjeevani)

The Digital Image and Communications in Medicine (DICOM) viewer is a very useful component in telemedicine applications. Owing to increased demand, adoption, and prospects of browser-based software in the recent past, web-based DICOM viewers have gained significant ground. There are myriad web-based DICOM viewers which are open source and are available free of cost as stand-alone applications. These freely available tools have rich functionality like the commercial ones. To find an optimal DICOM viewer for integration with a web-based telemedicine solution is quite a challenge, and no research has gone into assessing these freely available DICOM viewers. This research assessed a range of web-based, open-source, and freely available DICOM viewers from the perspective of their integration with the Indian National Telemedicine Solution (eSanjeevani). To introduce teleradiology module in eSanjeevani, a study is carried out to enable viewing of radiological images through DICOM viewer. eSanjeevani is being prepared for a national roll-out at 155,000 health and wellness centers across rural India by the Ministry of Health and Family Welfare (Government of India) under the Ayushman Bharat Scheme (the world's largest health insurance scheme). In total, 13 free, open-source, and web-based DICOM viewers were identified for evaluation; however, only six were shortlisted as assessed. This study can serve as a one-stop source for researchers looking for a suitable DICOM viewer for their healthcare IT applications.

Synchronization and Alignment of Follow-up Examinations: a Practical and Educational Approach Using the DICOM Reference Coordinate System

This work presents an approach for synchronization and alignment of Digital Imaging and Communications in Medicine (DICOM) series from different studies that allows, e.g., easier reading of follow-up examinations. The proposed concept developed within the DICOM's patient-based reference coordinate system allows to synchronize all image data of two different studies/examinations based on a single registration. The most suitable DICOM series for registration could be set as default per protocol. Necessary basics regarding the DICOM standard and the used mathematical transformations are presented in an educative way to allow straightforward implementation in Picture Archiving And Communications Systems (PACS) and other DICOM tools. The proposed method for alignment of DICOM images is potentially also useful for various scientific tasks and machine-learning applications.

How many streamlines are required for reliable probabilistic tractography? Solutions for microstructural measurements and neurosurgical planning

Diffusion MRI tractography is commonly used to delineate white matter tracts. These delineations can be used for planning neurosurgery or for identifying regions of interest from which microstructural measurements can be taken. Probabilistic tractography produces different delineations each time it is run, potentially leading to microstructural measurements or anatomical delineations that are not reproducible. Generating a sufficiently large number of streamlines is required to avoid this scenario, but what constitutes "sufficient" is difficult to assess and so streamline counts are typically chosen in an arbitrary or qualitative manner. This work explores several factors influencing tractography reliability and details two methods for estimating this reliability. The first method automatically estimates the number of streamlines required to achieve reliable microstructural measurements, whilst the second estimates the number of streamlines required to achieve a reliable binarised trackmap than can be used clinically. Using these methods, we calculated the number of streamlines required to achieve a range of quantitative reproducibility criteria for three anatomical tracts in 40 Human Connectome Project datasets. Actual reproducibility was checked by repeatedly generating the tractograms with the calculated numbers of streamlines. We found that the required number of streamlines varied strongly by anatomical tract, image resolution, number of diffusion directions, the degree of reliability desired, the microstructural measurement of interest, and/or the specifics on how the tractogram was converted to a binary volume. The proposed methods consistently predicted streamline counts that achieved the target reproducibility. Implementations are made available to enable the scientific community to more-easily achieve reproducible tractography.

Starviewer and its comparison with other open-source DICOM viewers using a novel hierarchical evaluation framework

METHODS

The aim of the paper is twofold. First, we present Starviewer, a DICOM viewer developed in C++ with a core component built on top of open-source libraries. The viewer supports extensions that implement functionalities and front-ends for specific use cases. Second, we propose an adaptable evaluation framework based on a set of criteria weighted according to user needs. The framework can consider different user profiles and allow criteria to be decomposed in subcriteria and grouped in more general categories making a multi-level hierarchical structure that can be analysed at different levels of detail to make scores interpretation more comprehensible.

RESULTS

Different examples to illustrate Starviewer functionalities and its extensions are presented. In addition, the proposed evaluation framework is used to compare Starviewer with four open-source viewers regarding their functionalities for daily clinical practice. In a range from 0 to 10, the final scores are: Horos (7.7), Starviewer (6.2), Weasis (6.0), Ginkgo CADx (4.1), and medInria (3.8).

CONCLUSIONS

Starviewer provides basic and advanced features for daily image diagnosis needs as well as a modular design that enables the development of custom extensions. The evaluation framework is useful to understand and prioritize new development goals, and can be easily adapted to express different needs by altering the weights. Moreover, it can be used as a complement to maturity models.

Quantitative Appraisal Through MRI of Breast Tissue Thickness and Implant Projection After Breast Augmentation with High- and Extra-High-Profile Round Implants

BACKGROUND

Changes in breast tissue thickness and in implant projection 5 years after augmentation with high- and extra-high-profile round implants were measured through MRI with a DICOM standard viewer.

METHODS

Twenty-four females with small-volume breast asymmetry without hypertrophy or ptosis underwent subfascial breast augmentation for cosmetic purposes, by using micro-textured soft cohesive silicone gel-filled round implants, from a single manufacturer. MRI measured the linear antero-posterior dimension of breast tissue thickness and projection of the implants. Statistical analysis of data was performed by Pearson correlation coefficient, line graph, and scatter diagram.

RESULTS

The "r" of Pearson for right and left breasts indicated a significant correlation between the breast tissue thickness before and 5 years after augmentation. Closeness of the lines displayed in the line graph indicated strong linear positive correlation between the breast tissue thicknesses. The "r" values for projection of right and left implants indicated a significant correlation between the projection standardized by the manufacturer and that encountered 5 years after augmentation with high- and extra-high-profile round implants. A scatter diagram of data indicated a strong positive correlation between implant projection standardized by the manufacturer and that encountered 5 years after augmentation, on both breasts.

CONCLUSION

Soft cohesive silicone gel-filled high- and extra-high-profile round implants supported breast tissue compressing without significant loss of the implant projection. Despite the consistency of the soft cohesive silicone gel, the implant softness and flexibility were preserved, resulting in low-pressure gradient over the mammary parenchyma without significant changes of the breast tissue thickness.

EBM LEVEL IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Good Practice-Compliant Clinical Trial Imaging Management System for Multicenter Clinical Trials: Development and Validation Study

Background

With the rapid increase in utilization of imaging endpoints in multicenter clinical trials, the amount of data and workflow complexity have also increased. A Clinical Trial Imaging Management System (CTIMS) is required to comprehensively support imaging processes in clinical trials. The US Food and Drug Administration (FDA) issued a guidance protocol in 2018 for appropriate use of medical imaging in accordance with many regulations including the Good Clinical Practice (GCP) guidelines. Existing research on CTIMS, however, has mainly focused on functions and structures of systems rather than regulation and compliance.

Objective

We aimed to develop a comprehensive CTIMS to meet the current regulatory guidelines and various required functions. We also aimed to perform computerized system validation focusing on the regulatory compliance of our CTIMS.

Methods

Key regulatory requirements of CTIMS were extracted thorough review of many related regulations and guidelines including International Conference on Harmonization-GCP E6, FDA 21 Code of Federal Regulations parts 11 and 820, Good Automated Manufacturing Practice, and Clinical Data Interchange Standards Consortium. The system architecture was designed in accordance with these regulations by a multidisciplinary team including radiologists, engineers, clinical trial specialists, and regulatory medicine professionals. Computerized system validation of the developed CTIMS was performed internally and externally.

Results

Our CTIMS (AiCRO) was developed based on a two-layer design composed of the server system and the client system, which is efficient at meeting the regulatory and functional requirements. The server system manages system security, data archive, backup, and audit trail. The client system provides various functions including deidentification, image transfer, image viewer, image quality control, and electronic record. Computerized system validation was performed internally using a V-model and externally by a global quality assurance company to demonstrate that AiCRO meets all regulatory and functional requirements.

Conclusions

We developed a Good Practice–compliant CTIMS—AiCRO system—to manage large amounts of image data and complexity of imaging management processes in clinical trials. Our CTIMS adopts and adheres to all regulatory and functional requirements and has been thoroughly validated.

Development of an informatics system for accelerating biomedical research

The Biomedical Research Informatics Computing System (BRICS) was developed to support multiple disease-focused research programs. Seven service modules are integrated together to provide a collaborative and extensible web-based environment. The modules-Data Dictionary, Account Management, Query Tool, Protocol and Form Research Management System, Meta Study, Data Repository and Globally Unique Identifier -facilitate the management of research protocols, to submit, process, curate, access and store clinical, imaging, and derived genomics data within the associated data repositories. Multiple instances of BRICS are deployed to support various biomedical research communities focused on accelerating discoveries for rare diseases, Traumatic Brain Injury, Parkinson's Disease, inherited eye diseases and symptom science research. No Personally Identifiable Information is stored within the data repositories. Digital Object Identifiers are associated with the research studies. Reusability of biomedical data is enhanced by Common Data Elements (CDEs) which enable systematic collection, analysis and sharing of data. The use of CDEs with a service-oriented informatics architecture enabled the development of disease-specific repositories that support hypothesis-based biomedical research.

An Evaluation of HTML5 and WebGL for Medical Imaging Applications

Despite the fact that a large number of web applications are used in the medical community, there are still certain technological challenges that need to be addressed, for example, browser plug-ins and efficient 3D visualization. These problems make it necessary for a specific browser plug-in to be preinstalled on the client side when launching applications. Otherwise, the applications fail to run due to the lack of the required software. This paper presents the latest techniques in hypertext markup language 5 (HTML5) and web graphics library (WebGL) for solving these problems and an evaluation of the suitability of the combination of HTML5 and WebGL for the development of web-based medical imaging applications. In this study, a comprehensive medical imaging application was developed using HTML5 and WebGL. This application connects to the medical image server, runs on a standard personal computer (PC), and is easily accessible via a standard web browser. The several functions required for radiological interpretation were implemented, for example, navigation, magnification, windowing, and fly-through. The HTML5-based medical imaging application was tested on major browsers and different operating systems over a local area network (LAN) and a wide area network (WAN). The experimental results revealed that this application successfully performed two-dimensional (2D) and three-dimensional (3D) functions on different PCs over the LAN and WAN. Moreover, it demonstrated an excellent performance for remote access users, especially over a short time period for 3D visualization and a real-time fly-through navigation. The results of the study demonstrate that HTML5 and WebGL combination is suitable for the development of medical imaging applications. Moreover, the advantages and limitations of these technologies are discussed in this paper.

Multipurpose computed tomography window for fusion display with functional imaging

Current positron emission tomography/computed tomography (PET/CT) and single photon emission CT (SPECT)/CT displays have major drawbacks, in that the CT only shows one tissue type at a time, which leads to a suboptimal fusion display. We developed a multipurpose CT level/window aiming at enhancing fusion display. A total of thirty CT examinations as part of fluorodeoxyglucose PET/CT examinations (15 were open source from the OsiriX website and 15 from our PET facility) and the open-source software MIPAV were used. During the development phase, a nuclear medicine physician manually modified the lookup table in a way that preserved the soft tissue contrast as well as enhanced the lung and bone tissue as much as possible. The developed multipurpose CT window was used in the subsequent validation phase and scored by two nuclear medicine physicians, who scored the image quality based on a 3-point score. Descriptive statistics was used to summarize the visual scores. The multipurpose CT window is a composite of several segments of linear CT levels/windows and contains an inverted linear level/window in the low range of Hounsfield unit designed to enhance lung/soft tissue contrast. In doing so, the multipurpose CT window preserves the high soft tissue contrast; the visualization of the lung parenchyma is satisfactory; the contrast for the bone tissue is improved but remains suboptimal when compared with conventional bone window. The multipurpose CT window was found to be “very useful” (median score 3; 95% confidence interval [CI] 2.0–3.0) for the purpose of fusion with functional imaging, with a prevalence asymmetry index 0.97 (95% CI 0.83–1.0). The multipurpose CT window was developed for image fusion and is not intended for diagnostic purposes. It shows favorable similarities to conventional CT windows with only minor artifacts and allows for enhanced visualization of fused PET/CT and SPECT/CT images. The multipurpose CT window is particularly valuable for case review/demonstrations on standard personal computers and handheld devices (smartphones, tablets).

An Enhanced Device-Transparent Real-Time Teleconsultation Environment for Radiologists

This paper describes a novel web-based platform promoting real-time advanced teleconsultation services on medical imaging. Principles of heterogeneous workflow management systems and state-of-the-art technologies such as the microservices architectural pattern, peer-to-peer networking, and the single-page application concept are combined to build a scalable and extensible platform to aid collaboration among geographically distributed healthcare professionals. The real-time communication capabilities are based on the webRTC protocol to enable direct communication among clients. This paper discusses the conceptual and technical details of the system, emphasizing on its innovative elements.

Is Preoperative Maintenance of the Curve of Spee Associated With an Increase of Facial Height in Class II Short Face Orthognathic Patients? A Never Answered Dogmatic Question

PURPOSE

To determine the association of maintaining the curve of Spee (COS) before surgery with post-treatment facial height in patients with Class II short face syndrome undergoing combined orthodontic and orthognathic treatment.

MATERIALS AND METHODS

In this retrospective cohort study, the clinical and radiologic data of all patients with Class II short face syndrome who underwent combined orthodontic and orthognathic treatment were reviewed. The primary outcome variables were 1) preoperative COS and 2) post-treatment facial height. Depth of the COS and skeletal and soft tissue relations were measured on digital lateral cephalometric radiographs. Descriptive and bivariate statistics were performed.

RESULTS

The sample was composed of 20 patients. Statistical analysis showed a significant increase of soft tissue facial height after treatment (P < .02). Preoperative depth of the COS was significantly associated with changes in sagittal skeletal relations (angle formed by the sella, nasion, and B point [SNB], correlation [cor] = -0.54, P < .02; angle formed by the A point, nasion, and B point [ANB], cor = 0.43, P < .06). These changes and changes in overjet were associated with the post-treatment increase of lower facial height (SNB, cor = 0.70, P < .001; ANB, cor = -0.69, P < .001; overjet, cor = -0.55, P < .049). The ratios of upper to lower soft tissue facial height and upper to lower lip height were improved to near normal values (1.0 and 0.5, respectively) for most patients.

CONCLUSION

In patients with Class II short face orthognathism, the present study found that maintaining the COS before surgery was associated with 1) an increase of soft tissue facial height and 2) an improvement of the ratio of upper to lower facial height and the ratio of upper to lower lip height to near normal values. Moreover, the depth of the COS was correlated with the post-treatment increase of facial height through changes in skeletal relations and was related to the degree of severity of the mandibular deficiency.

Fluorescein-Guided Surgery for Resection of High-Grade Gliomas: A Multicentric Prospective Phase II Study (FLUOGLIO)

Purpose: Sodium fluorescein is a dye that, intravenously injected, selectively accumulates in high-grade glioma (HGG) tissue through a damaged blood-brain barrier. In this article, the final results of a multicentric prospective phase II trial (FLUOGLIO) on fluorescein-guided HGG resection through a dedicated filter on the surgical microscope were reported.Methods: Patients with suspected HGGs considered suitable for removal were eligible to participate in this trial. Fluorescein was intravenously injected at a dose of 5 to 10 mg/kg. The primary endpoint was the percentage of patients with histologically confirmed HGGs, without contrast-enhancing tumor at the immediate postoperative MRI. Secondary endpoints were PFS, residual tumor on postoperative MRI, overall survival, neurologic deficits, and fluorescein-related toxicity. The sensitivity and specificity of fluorescein in identifying tumor tissue were estimated by fluorescent and nonfluorescent biopsies at the tumor margin. The study was registered on the European Regulatory Authorities website (EudraCT 2011-002527-18).Results: Fifty-seven patients aged 45 to 75 years were screened for participation, and 46 were considered for primary and secondary endpoints. Mean preoperative tumor volume was 28.75 cm³ (range, 1.3-87.8 cm³). Thirty-eight patients (82.6%) underwent a complete tumor removal. Median follow-up was 11 months. PFS-6 and PFS-12 were 56.6% and 15.2%. Median survival was 12 months. No adverse reaction related to SF administration was recorded. The sensitivity and specificity of fluorescein in identifying tumor tissue were respectively 80.8% and 79.1%.Conclusions: Fluorescein-guided technique with a dedicated filter on the surgical microscope is safe and enables a high percentage of contrast-enhancing tumor in patients with HGGs. Clin Cancer Res; 24(1); 52-61. ©2017 AACR.

PACS for Bhutan: a cost effective open source architecture for emerging countries

This paper reports the design and implementation of an innovative and cost-effective imaging management infrastructure suitable for radiology centres in emerging countries. It was implemented in the main referring hospital of Bhutan equipped with a CT, an MRI, digital radiology, and a suite of several ultrasound units. They lacked the necessary informatics infrastructure for image archiving and interpretation and needed a system for distribution of images to clinical wards. The solution developed for this project combines several open source software platforms in a robust and versatile archiving and communication system connected to analysis workstations equipped with a FDA-certified version of the highly popular Open-Source software. The whole system was implemented on standard off-the-shelf hardware. The system was installed in three days, and training of the radiologists as well as the technical and IT staff was provided onsite to ensure full ownership of the system by the local team. Radiologists were rapidly capable of reading and interpreting studies on the diagnostic workstations, which had a significant benefit on their workflow and ability to perform diagnostic tasks more efficiently. Furthermore, images were also made available to several clinical units on standard desktop computers through a web-based viewer.

MESSAGES/TEACHING POINTS

• Open source imaging informatics platforms can provide cost-effective alternatives for PACS • Robust and cost-effective open architecture can provide adequate solutions for emerging countries • Imaging informatics is often lacking in hospitals equipped with digital modalities.

Untwisting the Caenorhabditis elegans embryo

The nematode Caenorhabditis elegans possesses a simple embryonic nervous system with few enough neurons that the growth of each cell could be followed to provide a systems-level view of development. However, studies of single cell development have largely been conducted in fixed or pre-twitching live embryos, because of technical difficulties associated with embryo movement in late embryogenesis. We present open-source untwisting and annotation software (http://mipav.cit.nih.gov/plugin_jws/mipav_worm_plugin.php) that allows the investigation of neurodevelopmental events in late embryogenesis and apply it to track the 3D positions of seam cell nuclei, neurons, and neurites in multiple elongating embryos. We also provide a tutorial describing how to use the software (Supplementary file 1) and a detailed description of the untwisting algorithm (Appendix). The detailed positional information we obtained enabled us to develop a composite model showing movement of these cells and neurites in an 'average' worm embryo. The untwisting and cell tracking capabilities of our method provide a foundation on which to catalog C. elegans neurodevelopment, allowing interrogation of developmental events in previously inaccessible periods of embryogenesis.

DOI:http://dx.doi.org/10.7554/eLife.10070.001

Understanding how the brain and nervous system develops from a few cells into complex, interconnected networks is a key goal for neuroscientists. Although researchers have identified many of the genes involved in this process, how these work together to form an entire brain remains unknown.

A simple worm called Caenorhabiditis elegans is commonly used to study brain development because it has only about 300 neurons, simplifying the study of its nervous system. The worms are easy to grow in the laboratory and are transparent, allowing scientists to observe how living worms develop using a microscope. Researchers have learned a great deal about the initial growth of the nervous system in C. elegans embryos. However, it has been difficult to study the embryos once their muscles have formed because they constantly twist, fold, and move, making it hard to track the cells.

Now, Christensen, Bokinsky, Santella, Wu et al. have developed a computer program that allows scientists to virtually untwist the embryos and follow the development of the nervous system from its beginning to when the embryo hatches. First, images are taken of worm embryos that produce fluorescent proteins marking certain body parts. The program, with user input, labels the fluorescent cells in the images, which indicates how the embryo is bending and allows the program to straighten the worm. The program can also track how cells move around the embryo during development and show the positional relationships between different cells at different stages of development.

Christensen et al. have made the program freely available for other researchers to use. The next step is to increase automation, making the software faster and more straightforward for users. Ultimately, the software could help in the challenge to comprehensively examine the development of each neuron in the worm.

DOI:http://dx.doi.org/10.7554/eLife.10070.002