PACS experiences in Trieste.

The installation of a commercial PACS in the Hospitals of Trieste has been the start-point for a project of technology assessment, aimed at the evaluation of technical, clinical and economic aspects related to the introduction of this new and expensive technology in the health care system. During more than two years of use of this system in the clinical environment, several research activities have been carried out concerning the analysis of the organization of radiology departments in Italy, the analysis of work and data volumes, the evaluation of technical and clinical performances of PACS versus conventional film-based radiology, the integration between PACS and RIS, the experimentation of teleradiology applications. An overview of the most important activities and related results is given in this paper as well as some indications about future developments of the Trieste Project.

[Evaluation of the role of mammography and echography in breast diseases in a controlled caseload]. / Valutazione del ruolo della mammografia e dell'ecografia in senologia su casistica controllata.

Data concerning patients who underwent mammography and breast ultrasonography and then breast surgery were collected and analyzed with a computer archive system. In previous papers the authors reported both design and implementation of the computer archive and analyzed the results concerning uncontrolled collected data; in the present paper data concerning controlled cases are evaluated, distinguishing between symptomatic and asymptomatic cases. Asymptomatic patients represented 92% of the whole evaluated population. However only one third of the patients who underwent surgery for breast cancer was included in this group. Breast cancer was discovered in 65% of the patients who underwent diagnostic procedures and then surgery because of a palpable nodule. This percentage was lower (52%) in asymptomatic patients. Mammographic accuracy was about 90% in symptomatic patients and 81% in asymptomatic patients. Breast ultrasonography was performed as a subsequent step and always detected the lesion when palpable. Its sensitivity was 86% in asymptomatic patients. In patients who underwent surgery the false positive rate for cancer was higher with ultrasonography (59%) than with mammography (45%). Focal dysplasis were responsible for the majority of false positive diagnoses with both procedures. However, the false positive rate is low referring to the whole investigated population and is reshuffled by guided bioptic procedures. Ultrasonography was a useful tool when mammography had limitations: in fact ultrasonography detected a focal lesion in all patients with a surgically proven cancer and a previous negative mammography. The sets of data available from the continuous updating of the computer archive immediately clarified the differences between symptomatic and asymptomatic patients and stressed the diagnostic capabilities of the different procedures.

[Modular project of the Picture Archiving and Communication System (PACS). Preliminary clinical experience. II]. / Sistema PACS a progetto modulare. Esperienza clinica preliminare. II Parte.

In the previous paper in this volume the PAC System installed in the Radiology Department of the University of Trieste has been described and its advantages and limitations have been analyzed, mainly from an operational point of view. This paper deals with the clinical evaluation of the system in ordinary operative conditions. A series of cases with specific characteristics was monitored in order to reveal different performances in both diagnostic process and conclusions using the PACS viewing console (DW) vs. conventional CRT film images on alternators. In a first test, 100 routine (not pre-selected) brain CT cases were independently analyzed by 4 radiologists, each of them giving 2 interpretations of the same case, one based on film and the other on PACS. The data were analyzed by conventional statistical methods, showing a substantial agreement of the results obtained with the 2 modalities. A second test concerned the evaluation of 100 lumbar intervertebral disks by CT, with the same procedure as above. Four radiologists were again asked to decide on film and PACS images about normality, protusion, or herniation of the disks. The results demonstrate the possibility of adequately reporting on the PACS monitor and stress the need of an adequate training period and the efficacy of the image processing capabilities of the system.

[Modular project of the Picture Archiving and Communication System (PACS). Preliminary operational experience. I]. / Sistema PACS a progetto modulare. Esperienza operativa preliminare. I Parte.

Since september 1988 a PAC System (Comm View by AT & T and Philips) has been operating in the Radiology Department of the University Hospital, Trieste. A research project is presently in progress aiming at providing factual evidence for the evaluation of this kind of systems as far as operational, technical, clinical and economic aspects are concerned. The general approach to this research consists in implementing and monitoring a PACS in a stepwise way, starting with a small system connected to some digital modalities only, in order to test the feasibility and effectiveness of the system within a Radiology Department, and to test the possibility of matching the PACS to the Radiological System. The present paper describes in detail the present configuration of this entry-level system and its technical features. The planned development (october 1989) is also depicted. Further developments devise at managing in an integrated way all the radiological images of the four hospitals of Trieste. At present, the PACS is currently used to manage and store on optical disks all the images acquired from the connected modalities plus the related reports, and to perform the reporting sessions for CT examinations (brain and abdomen). The present research effort is devoted to two main areas: clinical evaluation and operational analysis. The object of the operational analysis was the assessment of the impact of PACS on the operations of a Radiology Department. The general approach followed for this research consists in analysing the procedures as they are performed in the conventional way (manual operations), and comparing them to the way they are, or could be, performed using a PACS System (automatic operations). This stage of the project is divided into three phases, concerning respectively the analysis of the organization and operations before PACS, the analysis of the impact of PACS in its initial configuration and the forecast of the influence of PACS in its future setting. A first evaluation concerned the activities carried out from the moment the images are generated to the moment they are ready to be achieved. They include image acquisition, reporting, delivering and returning of images from the departments. The time required to carry out each of the activities involved was recorded, both in the manual and in the automatic version; furthermore, a more detailed analysis was performed on the reporting procedure. The conclusions reached through this analysis are that this kind of operation is mostly affected by the way the Radiology Department is managed, rather than by the tools employed.(ABSTRACT TRUNCATED AT 400 WORDS)

[Tha data management of a breast radiology section via a computerized archive]. / Gestione mediante archivio informatico dei dati di una sezione radiologica di senologia.

In the Institute of Radiology of the University of Trieste, from January to December 1988, 7123 patients underwent breast diagnostic procedures following a screening program for breast cancer or in order to evaluate specific symptoms. The data relative to this series of cases were collected and processed using the system described in a colleague's paper. Several sets of data became available concerning the percentage distribution of the techniques employed, their main indications, the distribution of pathological features in relation to different indications, the diagnostic value of combining different techniques, and the suggestions based on the findings collected. Both mammography and US proved to be able to solve the great majority of diagnostic problems, sometimes also as a tool to guide bioptic procedures. Other techniques (galactography, pneumocystography, CT) were devoted to specific diagnostic problems. The results are interesting in view of their clinical, epidemiological and management implications.

[The definition and realization of a computerized archive for radiological data of scientific interest]. / Definizione e realizzazione di un archivio informatico per dati radiologici di interesse scientifico.

The general requirements are analyzed of a system designed to acquire and manage radiological data of scientific interest. These requirements consist in: easy implementation, to develop the system in the same environment where it is going to be used; easy use, to avoid excessive needs and resources for the system to be managed in practice; reduced implementation cost, in terms of resources required for its implementation; user-oriented approach, in the sense of meeting the radiologists' requirements, and flexibility, for the system to be an effective tool for the widest range of possible applications. Two actual applications of this general approach are then discussed, one relative to breast investigations data, and the other to digital procedures (US, CT, DSA, MR) data. For each application the software tools employed are analyzed, together with the archive structures and the used codes, the collecting data procedures and the programs. For the breast investigations archive the possibility of obtaining standard periodic reports is pointed out. These reports summarize the global department activity in this area during selected periods (six months-one year). They allow interesting clinical conclusions to be drawn. As for the digital procedures archive, the possibility is stressed of searching different combinations of scientific data out of tens of thousands of cases in just a few minutes.

Trieste PACS project: a functional assessment.

A picture archiving and communication (PAC) system (CommView by AT&T and Philips) has recently been installed in the Radiology Department of the University of Trieste, Italy, and is currently under experimental evaluation. The current status of the system and the planned developments are reported. A major project at present is the evaluation of the impact of the PAC system on the radiology system on a functional basis, by applying in the medical field a modelling methodology developed to analyse manufacturing systems. Other research in progress is devoted to technical, clinical and ergonomic aspects, on the basis of a comprehensive assessment project.

[An information system for the management support of a radiology institute. Critical analysis and experience]. / Un sistema informatico di supporto per la gestione di un Istituto di Radiologia. Analisi ed esperienza critica.

The Radiology Information System (RIS) for the management of the Radiology Department at the Trieste University Hospital is here presented. It consists of 3 subsystems: the first one is devoted to the management of the patients archive and to the examination scheduling function, the second deals with the statistical and administrative reporting task, and the third manages the archives of scientific data. Each subsystem is analysed in details, in terms of functions, hardware, software, archives, and personnel. The actual implementations of such systems are considered, with respect to the main functions of the Radiology Department, on the basis of the authors' actual experience. An attempt is made to set aside features related to the local situation, thus providing useful data for different realities. Specific quantitative measures are presented, whenever appropriate, to provide a solid ground to explain and motivate the most relevant aspects relative to the management of the Radiology Department in general and of the RIS in particular. Workloads and/or execution times of the main functions were collected and the RIS has turned out to yield significant benefits (e.g., easier and more confident access to the information). On the other hand, the costs are not negligible and must be carefully planned during the projecting phase. Some expected future developments of the RIS are outlined: in the short run the network conversion is devised, and a functional integration among the subsystems; in the medium run an autonomous system is planned, and in the long run a connection is considered with a Picture Archiving and Communication System (PACS) and with the Hospital Information System (HIS).

[The quality of urography with iopamidol and various diuretic agents]. / Qualità dell'urografia con ipoamidolo e diversi agenti diuretici.

The results obtained in four successive trials based on the analysis of urography performed on patients with normal kidney function are reported. The scores obtained with a non-ionic contrast (iopamidol) were compared with those produced after injecting the same contrast medium with the addition of various diuretics (furosemide, various quantities of 5% glucose solution, 20% mannitol). The results obtained by injecting the diuretic together with the iopamidol were usually unsatisfactory. Injection of diuretic 15 ms after the iopamidol gave better results in the lower urinary tract, particularly the bladder. The best results were obtained by injecting 250 ml, 20% mannitol, after 15 ms. However this technique is not applicable to patients requiring a voiding cystourethrogram due to the inadequate opacification of the urethra it provides.

[Quality control in urography with iopamidol and iohexol. A parallel comparison]. / Controllo di qualità in urografia con iopamidolo e ioexolo. Confronto parallelo.

Iohexol has a slightly higher osmolarity in comparison with iopamidol; therefore it might induce a more pronounced diuretic effect and then a better distension of the excretory pathway. A trial was carried out in two groups of 50 patients with normal renal function who underwent urography, namely with 50 ml (15 gI) of iopamidol and of iohexol. No significant differences in the evaluated parameters (nephrography, calyces, pelvis, ureters and bladder) have been found. Both contrast media allowed to perform good quality urographies.