September 2011 - Institute of Physics and Engineering in Medicine

DOSIMETRYSOLUTIONS

SCOPE | CONTENTSTHIS ISSUE50COVER FEATUREPIERRE PELLETANThe establishment ofmedical physics,1823–1843, and authorof the first medicalphysics textbook08 METHODS TO DETECT A FEVERA description of new standards for instrumentation used for human bodytemperature measurement13 E-ENCYCLOPEDIA OF MEDICAL PHYSICS EMITEL – A USER GUIDEA brief user guide for the international project, written on behalf of theEMITEL Consortium0814 CLINICAL ENGINEERING: A RECENT PATH TO CEng REGISTRATIONContinuing the theme from previous issues, another path to registrationfollowing a slightly alternative career start16 VIDEO GAME TRAININGA novel video game-based neuromuscular stimulation system for muscletraining motivates a patient and shows significant muscle improvementTUTORIAL22 RISK MANAGEMENT AND REHABILITATION ENGINEERINGMichael Dolan and Jennifer Walsh142832TRAVEL AWARD28 IPEM/AAPM USA/CANADA TRAVEL AWARD, APRIL 2011Young LeeMEETING REPORTS32 SOUTH WEST ANNUAL SCIENTIFIC MEETINGGregory Stephens36 ANNUAL SCIENTIFIC MEETING OF THE IPEM SOUTH EAST GROUPMatthew Bolt, Thomas Hague, Pedrum Kamali and Emma Whitehead39 OUTCOME MEASURES IN ASSISTIVE TECHNOLOGYKit Tzu Tang40 RADIATION PROTECTION ADVISERS (RPA) UPDATE MEETING 2011Chris WoodREGULARS03 PRESIDENT’S LETTER Unique selling points05 EDITORIAL Autumn flavour06 NEWS A selection of radiotherapy-related stories42 INTERNATIONAL NEWS Meetings occurring throughout the rest of the year44 MEMBERS’ NEWS New members admitted to IPEM46 BOOK REVIEWS An incredible six reviews in this issue!04 | SEPTEMBER 2011 | SCOPE

METHODSTO DETECTA FEVEREFJ Ring (University of Glamorgan)describes new standards forinstrumentation used for themeasuring of human bodytemperatureThe clinical thermometeris the single most usedpiece of low-costinstrumentation inmedicine worldwide. Atleast, that statement wastrue until the last few decades. Themeasurement of human bodytemperature still plays a prominentpart in medicine, although thetechnology has now diversified.The pioneer of clinicalthermometry was Dr CarlWunderlich (figure 1). In his 1868thesis he set out the basic principlesfor the knowledge of temperature inthe study and treatment of fever.Many of Wunderlich’s statementson the rationale for studyingtemperature in relation to diseaseremain undisputed. A very briefsummary of some of his statementsis: ‘A knowledge of the course oftemperature in diseases is highlyimportant to the medical practitioner,and indeed, indispensable08 | SEPTEMBER 2011 | SCOPE

FEATURE | SCOPEn because temperature can beneither feigned or falsified,n because certain degrees indicatethat there is fever,n because the height of thetemperature often decides both thedegree and danger of the attack,n because thermometricinvestigations indicate mostrapidly and most safely, anydeviations from the regular courseof the disease, and discovers bothrelapses and ameliorations beforeFIGURE 1.Dr CarlWunderlich.▼we should otherwise recognisethem,n because thermometry is able to beused to regulate the results of ourtherapeutical efforts,n lastly it furnishes a certain proofof the reality of death, when thisis otherwise uncertain.’Wunderlich’s data from a verylarge cohort of patients establishedthat axillary (under the armpit)temperatures were normally 37ºC(98.4ºF), with a range of 36.2ºC to37.5ºC. 1 One significant result fromhis studies of human bodytemperature was the introduction ofthe clinical thermometer thatoptimised accuracy over a limitedtemperature range, with aconstricted capillary to holdmaximum temperature recordedduring use.In recent years other devices havereplaced the mercury-in-glassclinical thermometer, i.e. themaximum thermometer that hasbeen used worldwide since itsinception by Wunderlich.Thermocouples, thermistors andinfrared radiometers for tympanicand forehead measurement are nowincreasingly being used. Somecommercial systems have usedalgorithms for an estimate of coretemperature, although the accuracyof these devices is often challenged. 2Rectal temperature, commonly usedin small infants, is probably thenearest estimate of body coretemperature, although internal use ofthermocouples at the distaloesophagus is still regarded as thegold standard. However, coretemperature of the human body isnot constant, being affected by anatural circadian rhythm.Rectal temperature is higher thanperipheral surface measurements,but any changes induced by physicalactivity or of circadian origin areslow, and can lag behind the moresurface-located measurements ofskin temperature. Interest intympanic membrane temperature isbased on the fact that there is ashared blood supply to the brain.However, the complexities ofmeasurement in the ear are such thatunskilled users of tympanicthermometers can relatively easilymiss febrile individuals. For exampleit has been reported that three orfour out of every 10 fevers inchildren can be missed with thistechnique, depending on the skill ofthe operator. 3 While different scaleshave been introduced, we in Europenow standardise on degrees Celsius.This in itself has a curious history,since Celsius himself first proposed ascale with 100 at freezing point, andzero for boiling. It was Carl Linnaeus,the Danish botanist, who a few yearslater proposed the inverse, i.e. zerofor freezing point, which has sincebecome the normal scale.CLINICAL THERMOMETRY:NEW STANDARDRecently an important new standardhas been written pertaining to clinicalthermometry, ISO/FDIS 80601-2-56Medical electrical equipment – Part 2-56:Particular requirements for basic safetyand essential performance of clinicalthermometers for body temperaturemeasurement.This has now been accepted by allthe participating National Standardagencies.This standard brings togetherwithin one document the variousregional clinical thermometerstandards, including the EuropeanEN series, the Japanese JIS standardand the US ASTM standard. Itdescribes the general and technicalrequirements for electrical, includingcontact (probe) and non-contact(tympanic (ear)), clinicalthermometers (liquid-in-glassthermometers and other nonelectricalthermometers are excludedfrom the standard). This standardwas developed by a committeecomprising representatives fromdifferent National MeasurementInstitutes, including the BritishStandards Institute, manufacturers ofclinical thermometers and otherinterested parties. It includesdefinitions and operationalrequirements for the minimumoutput range of the thermometer; themaximum allowed laboratoryaccuracy over this minimum outputrange; evaluation and calibrationrequirements and equipment,including tolerances for thecalibration equipment, andrequirements for assessing the clinicalaccuracy of devices. It also providesinformation about the essentialinclusions in the documentationaccompanying the thermometer, andfull operating instructions. Forexample, the descriptors required forthe rated output temperature range ofthe thermometer and the laboratoryaccuracy over the range are given. It▼SCOPE | SEPTEMBER 2011 | 09

SCOPE | FEATURE▼also should include the results of theclinical accuracy validation, theminimum insertion time when takinginternal measurements andinstructions for use of a probe cover,etc. It also specifies that, in relevantcases, the manufacturer provides thecorrection method used to convert themeasured temperature to the readinggiven by the thermometer. This israrely shown by manufacturers, whoseem to regard this as their own tradesecret!In summary, the standardharmonises the various regionalstandards, and provides clearrequirements for manufacturers ofelectrical clinical thermometers withregards to performance specifications,laboratory calibration and testing ofthe thermometers, laboratory accuracyand clinical evaluation. It alsospecifies the information that shouldbe marked on the thermometer andshould also be included in theaccompanying documents andinstructions for use.The clinical thermometers referredto in the document are described indifferent categories, as follows.“Thereadingsmade byparentsdiffered bya clinicallysignificantamountfrom thereferencestandardusinghospitalequipment”A direct mode clinical thermometeris a clinical thermometer whoseoutput temperature is intended torepresent the true temperature ofthe measuring site or object which isthermally coupled to the sensor.This means that the actualtemperature detected by the sensoris displayed as the outputtemperature; i.e., the temperaturethat is measured is indicated withno corrections.The operation of a zero-heat flowclinical thermometer, also called anequilibrium clinical thermometer,relies on a thermal equilibriumbetween the sensor and themeasuring site, i.e. there isnegligible heat flow between themeasuring site and the sensor. Thesensor and the measuring site aretherefore in thermal equilibrium orhave nearly the same temperature.Some examples of an equilibriumclinical thermometer include asublingual ‘pencil’ clinicalthermometer and a pulmonaryartery clinical thermometer. It isimportant to recognise that anequilibrium clinical thermometercan take a significant period of timeto reach thermal equilibrium anddisplay its output temperature. Forexample, it takes approximately 5minutes for a ‘pencil’ sublingualclinical thermometer, and about 10minutes for an axilla clinicalthermometer, to achieve thermalequilibrium.ADJUSTED MODETHERMOMETERSThe output temperature indicated bya clinical thermometer is notnecessarily the same as thetemperature of the sensor that isthermally coupled to the measuringsite. In the direct mode the outputtemperature indicated by a clinicalthermometer is the same as thetemperature of the sensor that isthermally coupled to the measuringsite, but direct mode thermometersmay be inconvenient. For example,the time response for an accuratemeasurement might be too slow, or itmight be impossible to place thesensor close to the desired body site.Some clinical thermometers willgive the output temperature as the10 | SEPTEMBER 2011 | SCOPE

FEATURE | SCOPEresult of a signal adjustment orconversion and so the mode ofoperation is called the ‘adjustedmode’. An example of this will bewhere an infrared probe can beplaced in an ear canal but the digitaldisplay (output temperature)indicates an estimated sublingualtemperature of the patient. In thiscase, the temperature is corrected toallow for the difference betweensublingual and tympanictemperatures, based on clinical dataand physiological and anatomicalproperties of the two sites. Suchadjusted mode clinical thermometerscompensate for limitations of directmode clinical thermometers by usingsignal processing algorithms toestimate temperature from measuredvalues, though there is often acorresponding reduction in clinicalaccuracy.TEMPERATUREMEASUREMENT SITESDifferent patient sites can be used fortemperature measurement both fordiagnosis and regular or continuousmonitoring. These will range fromthe detection of fever and lifethreateningsituations (e.g.malignant hyperthermia or sepsis) tothe determination of ovulation,monitoring a physiological responseto medications and procedures, theeffects of exercise and physical work,etc. Temperature can be measuredfrom internal organs or from the skinsurface. Either location can providevaluable information about bloodperfusion and transcutaneoustemperatures, such as those of theunderlying arteries and veins.In the detection of fever, bodytemperatures have been historicallymeasured by contact clinicalthermometers in the sublingual,rectal or axilla measuring sites.However, most externally accessiblemeasuring sites have not representedthe body core temperature with aspecific quantitative relationship.Thus, during surgical proceduresand intensive care, temperatures areoften measured by invasive probesplaced at recognised coretemperature measuring sites, e.g.pulmonary artery, distal oesophagusand urinary bladder. The concept ofcore temperature is oftenoversimplified, there is no singleunique core temperature, andvariations can be found acrossinternal organs of the body.FIGURE 2.Correctlyacquiredthermogram ofthe face. Thesubject on theleft is normal,while that onthe right has afever – the innercanthi of theeyes are ›38°C,while theforehead iscooler. Thissubject wouldbe missed in ascreeningsystem basedon foreheadtemperature,which is morethan 1°C coolerthan thescreeningthreshold.▼TRAININGAs well as the requirement for aninternationally agreed standard forclinical thermometers, there is alsothe requirement for adequate trainingfor nursing staff and professionals toensure instruments are used correctly.This is particularly true for some ofthe newer thermometers currently inuse, such as tympanic (ear)thermometers. The National PhysicalLaboratory in the UK has developed atraining course to address this need(within the project ‘NPL TrainingFramework For Measurement InMedical Health & Optical RadiationTechnologies’, in conjunction with theSouth East England DevelopmentAgency).Robinson et al. 4 reported a studyin which parents and then nursesmeasured the temperature of 60children with a tympanicthermometer designed for home use.The readings made by parentsdiffered by a clinically significantamount from the reference standardusing hospital equipment, with afailure to detect fever in some 25 percent of cases.THERMAL IMAGINGIn recent years, since the SARSoutbreak in south-east Asia, moreattention has been given to thepotential of temperaturemeasurement as a method ofscreening for fever in travellingpassengers. The first organised guideof good practice in this field waspublished by SPRING, the standardsagency of Singapore. The mostefficient way to screen for fever isconsidered to be the use of aninfrared thermography camera toimage the face. Interest in the methodincreased with the appearance ofH5N1 avian influenza, and after theWorld Health Organization’sannouncement of H1N1 swineinfluenza reaching pandemicproportions in June 2009. In recentyears there has been an increase insales of thermal imagers for theapplication of fever screening. 5The International StandardsOrganization has produced aguidance document on the use ofthermography in fever screening. Aninternational committee has beenworking for some 3 years, under ISOTC121/SC3-IEC SC62D, resulting inthe standard Particular requirementsfor the basic safety and essentialperformance of screening thermographsfor human febrile temperature screening.This was followed by a technicalreport on the deployment of thesedevices, ISO/TR 13154:2009 ISO/TR80600, Medical electrical equipment –Deployment, implementation andoperational guidelines for identifyingfebrile humans using a screeningthermograph.These documents provide a bestpractice guide to the important targettemperature assessment, using theinner canthus of the eye, whichrequires a close-up sharply focussedand well-calibrated thermal camera.It also shows that the incorrect use ofa thermal imaging camera mountedat an angle, or attempting to image amoving crowd, is bad and inaccuratepractice. Even so, there have beenmany reported uses of thermalimagers incorrectly used in a numberof international airports.In summary, a thermal imagingcamera with defined sensitivity andaccuracy should be mounted on aparallax-free system to obtain athermal image of the face, optimisedfor viewing the areas around theeyes, so that the temperature of theinner canthi can be measured with atleast 9–16 pixels per eye region. Thisrequires the subject to look directly at▼SCOPE | SEPTEMBER 2011 | 11

SCOPE | FEATUREthe lens of the camera for severalseconds (figure 2). Spectacles,sunglasses, face masks and largehead coverings must be removed toobtain a reliable temperaturemeasurement. Positive, hightemperaturerecordings will alert thescreening operator with a visible andaudible alarm. If a febrile individualis detected this will then lead to amore exhaustive evaluation of thatindividual by a clinical practitionerto ascertain their febrile condition.There are a number of practicalissues arising from the standard thatmust be worked out in field trials,and the design of an optimal mountand alignment system is stillrequired. Most infrared cameramanufacturers sell thermal imagingsystems for industry where portabletripod mounts are adequate. Theseare unsuitable in an airportinstallation for use on humansubjects of different heights and ages.More clinical data is required toestablish limits of normality for innercanthi maximal temperatures inhealth and in fever, and theirrelationship to the conventionalclinical thermometry methods thatwill be used to verify any personswho register the high temperaturealarm during screening. One suchstudy is in progress at the PaediatricClinic in the Military Institute ofMedicine in Warsaw, since childrenremain at higher risk of suchinfection. 6 Although infrared“If afebrileindividualis detectedthis willthen leadto a moreexhaustiveevaluationof thatindividual”thermography has been in use in anumber of medical researchinstitutes worldwide, few studieshave focussed on fever detection,and the relationship betweenthermal data from the face withother methods of clinicalthermometry. The Warsaw data(in progress) indicates that infebrile children, there is ahigh correlation betweeninner canthitemperatures andaxillarythermometry.Finally, for themeasurementswith a thermal imaging system to bewidely accepted, and to achieveinter-centre agreement ontemperatures, it is essential that theimagers be regularly calibratedtraceably to national standards ofradiance temperature. 7,8There is one remaining issueconcerning the use and selection ofthermal imagers and a moreuniform methodology to determineand present their specification. Inthe current situation this can lead toconfusing and conflictinginformation on differentmanufacturer’s data sheets. Thisimportant issue is now beingaddressed by the sub-committee ofIEC TC/SC/WG5 (June 2009) thatshould during 2011 bringrecommendations on how thermalimager specifications can be unified.SUMMARYAll three of the abovenew documents shouldhave a significant positiveimpact on the use of thermometersand thermal imaging in medicine.While the fever screening standard isprimarily intended for that specificpurpose, it provides some clearguidelines for how a thermalimaging system should be correctlyused in clinical medicine. The newSpecification Standard for ThermalImaging will provide an essentialplatform for the properimplementation of the two feverscreening standards.These documents not only dictatestandards in manufacture andspecification for performance but arespecific in the description ofcalibration procedures that lead totraceability to both national andinternational standards fortemperature. nREFERENCES1 Wunderlich CA. On the Temperature in Diseases, a Manualof Medical Thermometry. Translation from German by W.Bathurst Woodman. London: The New Sydenham Society,1871.2 Crawford DVC, Hicks B, Thompson MJ. Whichthermometer? Factors influencing the best choice forintermittent clinical temperature assessment. J Med EngTechnol 2006; 30: 199–211.3 Dodd SR, Lancaster GA, Craig JV, Smyth RL, WilliamsonPR. In a systematic review, infrared ear thermometry forfever diagnosis in children finds poor sensitivity. J ClinEpidemiol 2006; 59: 354–57.4 Robinson JL, Jou H, Spady D. Accuracy of parents inmeasuring body temperature with a tympanicthermometer. BMC Fam Pract 2005; 6:http://biomedcentral.com/1471-2296/6/35 Ring EFJ, Jung A, Zuber J. New opportunities for infraredthermography in medicine. Acta Bio-Opt Inform Med 2009;15: 28–30.6 Ring EFJ, Jung A, Zuber J, Rutkowski P, Kalicki B, BajwaU. Detecting fever in Polish children by infraredthermography. Proceedings of the 9th InternationalConference on Quantitative Infrared Thermography.Krakow, 2nd–5th July 2008: 125–8.7 Machin G, Simpson RC, Broussely M. Calibration andvalidation of thermal imagers. Proceedings of the 9thInternational Conference on Quantitative InfraredThermography. Krakow, 2nd–5th July 2008: 133–47.8 Simpson R et al. In field-of-view thermal image calibrationsystem for medical thermography applications. Int JThermophys 2008; 29: 1123–30.12 | SEPTEMBER 2011 | SCOPE

FEATURE | SCOPEe-Encyclopaedia of Medical PhysicsEMITEL – a brief user guideASlavik Tabakov and Cornelius Lewis (on behalf of the EMITEL Consortium)bout a year ago theinternational projectEMITEL launchedthe e-Encyclopaediaof Medical PhysicsEMITEL(www.emitel2.eu). The projectattracted more than 300 specialistsfrom 36 countries as contributorsand developed an expandabledatabase of specific medical physicsterms which were translated into 29languages. To build theencyclopaedia each term from thisdictionary was covered by anexplanatory article (entry) inEnglish. Many articles are supportedwith images and diagrams. The e-Encyclopaedia includes c. 3,400entries. Currently EMITEL has6,000+ users per month. To answerquestions about the most effectiveuse of EMITEL we present a briefuser guide.To use the dictionary, selectDictionary, choose the input andoutput languages, write the termyou want to see at the window andthen click Search. A list with terms isdisplayed, where the terms arefound either as a single word or incombination with other words (thee-dictionary assumes that the user’sInternet browser already supportsthe languages). Terms without anexisting translation are in English.To use the encyclopaedia articletitles only (quick search in English),select Encyclopaedia plus Title. Writethe term you want to see in thewindow and then click Search. A listwith terms is displayed – againsteach one is a blue hyperlink relatedto the area of the term. Click thehyperlink to read the article. Thissearch covers only the titles of thearticles. Some articles have twoentries (related to two categories,e.g. magnetic resonance andultrasound). To minimise problemswith spelling the search may usepart of the word only.The website was built with twosearch engines – one searching intothe lists of terms (in all languages)and another one (in English only)searching inside the text of the▼ FIGURE 1.An example ofthe ‘searchinside’ feature ofthe EMITEL e-Encyclopaedia (inall areas):here the searchfor the term‘phase’ hasresulted in a listof articles, where‘phase’ ismentioned in thetext, includingone with asynonym of‘phase wrap’ –‘aliasing’.articles (figure 1). The latter allowssignificant increase of the potentialof the e-Encyclopaedia, includingsearching for related terms,acronyms and synonyms (theauthors made all efforts to includethese in the text). To use thispowerful facility the user has toselect Encyclopaedia plus Search in fulltext, specify the category/area of thesearch (e.g. radiotherapy) andproceed as above. In the case of UKor American/English differences(e.g. colour > color; optimise >optimize) try both spellings orsearch only part of the term (e.g.colo, optim). At the end, mostentries include references andrelated articles. To see the latter,copy and paste the related articletitle into the search window.To use both the encyclopaediaand dictionary, select Combined andproceed as above (this search islimited only to the title of the article,not inside its text). The text andimages of the articles allowcopy/paste in another file (n.b.formula-related text is presented asan image).CONTENT MANAGEMENTRecently a content managementsystem was added to the EMITELwebsite (by our partner AM Studio).This allows not only online editing ofthe materials, but also adding newterms/entries, diagrams/images,including new languages, etc. TheEMITEL Network has editorialcontrol over the online material andwill be happy to receive suggestionsfor expanding the entries, newmaterials/images or new terms withexplanatory articles. Our aim is tojointly develop EMITEL as anexpandable free online reference formedical physics. nSCOPE | SEPTEMBER 2011 | 13

SCOPE | FEATURECLINICALENGINEERINGA RECENT PATH TO CEng REGISTRATIONDavid Long (Nuffield Orthopaedic Centre NHS Trust,Oxford) continues the CEng theme from previous issues ofScope with his path to registrationEngineering is, I believe,in my genes. At ayoung age I wasbuilding machines outof Lego and throughmany moments ofelation and frustration learnt a lotabout the laws of physics. Soon Iwas building radio-controlled cars.Having obtained my driving licenceI turned my hand to larger projectsand before long I was busyrestoring a 1973 MG Midget whilstat the same time keeping it as mydaily driver – very challenging! Myfather has always been verypractical and I think some of hisskills and enthusiasm have rubbedoff on me.AFTER SCHOOLFollowing GCSEs I studied for aBTEC Ordinary National Diplomain engineering. I proceeded touniversity to undertake a BEng(Hons) in Manufacturing SystemsEngineering with a year out inindustry. During my sandwich yearI spent 9 months on a placement inEngland and 3 months in Germany,both companies specialising in theautomated assembly of electronicdevices. Whilst at college anduniversity I worked part-time at aspecialist car garage. The proprietorwas a professional engineer andencouraged me to develop mythinking and to apply a logicalapproach to solving problems. Hewas keen for me to work alongsidethe mechanics and this encouragedme to apply and develop myengineering knowledge and skills.FIRST STEPS TO HEALTHCAREHaving finished university I wasentirely unclear which way to turnbut quite liked the idea of doingsomething completely different fora while. I came across an advert forcare work at a local day centre foradults with learning difficultiesand challenging behaviour.The people whointerviewed mewere curious asto why I shouldwant such a jobgiven my recentgraduation, andmy parentswere, to put itmildly,concerned. ButI got the job and spent 18months in a predictably rewardingenvironment doing a range of workfrom assisting people with personalcare through to taking groups outon social trips. There were fourpeople at the day centre who usedwheelchairs. Three of these had“I wasbuildingmachinesout ofLego andlearnt a lotabout thelaws ofphysics”very curious looking seats thatseemed to be shaped to theindividual (two ‘Derby’ mouldsand one ‘matrix’, as I was later tolearn). I really enjoyed workingwith the people at the day centreand now saw an opportunity to linkthis with my training inengineering, but this was not tohappen quite yet.HONING MY SPECIALISMMy next opportunity was a fixedtermcontract with CoRE (Centre ofRehabilitation Engineering), abranch of Medical Engineering andPhysics at King’s College Hospitalin London. I became a researchassistant on the EMPAT project(Effective Methods for theProvision of Assistive Technology)14 | SEPTEMBER 2011 | SCOPE

FEATURE | SCOPEworking under Dr Alan Turner-Smith. My job was to visit as manywheelchair services as possible andinterview their staff about their jobsfrom a variety of angles. I visitedover 70 services in the space of 15months and this exposed me towhat was to come. In the office nextdoor worked a gentleman by thename of Paul Richardson who wasthe head of the RehabilitationEngineering Division for King’s.Paul was instrumental in gettingmy career truly started in offeringme the position of rehabilitationengineer at the special seatingservice in Stanmore, Middlesex,where I started in the summer of1998. Initially, my role was to repairseating systems on issue from theservice. This quickly turned into aclinical role and by the followingyear I was part of the clinicalassessment team which was headedby Dr Linda Marks, a consultantphysician in rehabilitationmedicine. Linda welcomed inputfrom anyone during clinics, but onehad to provide a clear rationale forone’s argument. It was a superblearning environment.HIGHER EDUCATIONIn 2000, my line manager left and Itook over managing therehabilitation engineering sectionTOP LEFT.Mobility systemfor a child with abrain injury.▼TOP RIGHT.Assessing rangeof hip joint motionin a child withcerebral palsy.▼BOTTOMRIGHT. Vacuumconsolidationcasting forbespokecontouredwheelchairseating.▼LEFT. A logicalapproach tosolving problemswas the start of acareer.▼of the service. This prompted areview of my position and thewheels were put in motion to assistme in moving towards becoming aclinical scientist and towardsbecoming chartered. In 2001 Istarted the MSc in ClinicalEngineering at Cardiff Universitywhich I completed in 2004.Alongside my academic studies Ideveloped professionalcompetencies that would later fulfilthe requirements of both corporatemembership of IPEM and CEngregistration.STATE REGISTRATION ANDCHARTERSHIPIn 2004, I moved to work at theOxford Centre for Enablement,based at the Nuffield OrthopaedicCentre NHS Trust in Oxford, underthe leadership of Dr David Porter,Consultant Clinical Scientist. Myrole was still to be based largelyaround specialist wheelchairseating. In 2005 I finally becameregistered as a clinical scientistwhich provided me with a greatsense of achievement. Followingthis I started to prepare myapplication for corporatemembership of IPEM and CEngregistration. I wanted to becomechartered as to me it signified someform of maturation as an engineer. Ialso believed it would be a positiveattribute for future careerdevelopment. I had my viva in 2008and as with any interview therewere some aspects I knew I couldhave presented better, but overall itwas a good experience, theexaminers being very facilitatoryand encouraging.I am pleased to have beenawarded CEng and wouldrecommend other engineers toapply. It adds to our professionalstanding as engineers in our ownright and in the healthcare settinggenerally. As an engineer, I believe Ihave an important role to play inthis context, bringing both clinicaland engineering experience not onlyto clinical service provision, but alsoto the training of new clinicalscientists and to the otherdisciplines that attend the coursesrun in my department on which Iteach, including physiotherapists,occupational therapists and nurses.I have chosen the images you seein the photographs as they illustratethe variety of my work. I relish achallenge and gain a great sense ofsatisfaction from solving problemsfor which commercially producedequipment is not available. To mymind, this is a fundamental reasonfor professional engineers to engagewith healthcare. nSCOPE | SEPTEMBER 2011 | 15

VIDEO GAME TRAININGA NEUROMUSCULAR STIMULATION SYSTEMDG Sayenko, K Masani, MF Robinson, M Milosevic and MR Popovic (TorontoRehabilitation Institute, Canada)Spinal cord injury (SCI) isa complex andfrequently devastatingcondition for bothpatients and theirfamilies. It also has anenormous cost on the healthcaresystem. 1 SCI can affect the physical,psychological and emotional aspectsof occupational performance, andactivities of daily living. 2 Reduction orloss of skeletal muscle function hasbeen described as one of the mostsignificant problems impacting thehealth and quality of life of personswith SCI. It has been demonstratedthat secondary health conditions, suchas pressure sores, low impactfractures and deep venousthrombosis, are at least partiallyrelated to musculoskeletal atrophyand disuse in these individuals. 3 Thus,one of the major components ofphysical therapy in this population ismuscle strengthening.Neuromuscular electricalstimulation (NMES) uses trains ofFIGURE 1.Schematicdiagram of themaincomponents andsequence ofaction of thetraining system:(a) joystick, (b)neuromuscularelectricalstimulator(Compex Motion,Compex SA,Switzerland) and(c) foot platform.▼short electric pulses to generate musclecontraction. 3,4 By stimulating a specificset of muscles and employing specificstimulation sequences, NMES cangenerate functional movements inindividuals with paralysis, such asindividuals with SCI. It is wellestablished that NMES training cancounteract musculoskeletal atrophy. Ithas been shown that, as withneurologically intact muscle, repetitivemuscular overload elicits the greatestimprovements in paralysed musclestrength and endurance. 5 Acomparatively novel therapeuticapproach implements coupled NMESand goal-oriented exercises to elicitand facilitate spinal cord repair viaadaptive plasticity of spinal cordcircuits. 6 It has been hypothesised thatthis approach can elicit regenerativecellular events that could contribute toimproved outcomes. Moreover, it hasbeen shown that some elements ofspinal circuitry associated with motorcontrol clearly remain after SCI andcan be improved by task-specific andgoal-oriented training, 7 which suggeststhe existence of spinal networks andraises the possibility of greaterfunctional outcomes as well asclinical/physiological improvementsafter training. As such, NMES could beused to promote neuroplasticity andassist neurological patients improvetheir voluntary function. However, aswith any training protocol, a criticalissue with this rehabilitative approachlies in maintaining the participants’interest in performing repetitivetraining tasks and in ensuring theircontinued motivation to complete thetraining. 5 Novel approaches forphysical rehabilitation are needed topromote interactive and entertainingexercise. These approaches shouldoffer the chance for the intensiverepetition of meaningful task-relatedactivities necessary for effectiverehabilitation in a manner that can bemore interesting and conducive to selfdirectionthan either conventional orleading-edge therapies. In other words,there is a need to develop a method16 | SEPTEMBER 2011 | SCOPE

FEATURE | SCOPEwhich would allow clients to have funwhilst stretching their physical andfunctional capabilities.Recent advances in technologyhave resulted in the availability ofvideo games that have the capabilityto be used in rehabilitation. 2,8 It hasbeen suggested that since interactivecomputer gaming plays an importantrole in the lives of many people, videogame applications may be also used toenhance motivation duringrehabilitation. The use of rewardingactivities and entertainingenvironments during game-basedrehabilitation can substantiallyimprove people’s motivation toadhere to their treatment regimensand result in better functional andpsychological outcomes. Moreover, avideo game-based approach can beimplemented when the course ofconventional therapy is completed,thus encouraging patients to furtherimprove their functions afterdischarge from rehabilitation. To date,the implementation of the videogame-based approach has beenlimited because of the lack or absenceof motor control in individuals withneuromuscular impairments. Bycoupling NMES with a video game weintend to combine and augment theadvantages of both rehabilitationtechniques.Consequently, by combining twokey technologies, namely NMES andvideo gaming, we believe that we canprovide a training method that willpromote muscle strengthening andmotivate individuals withneuromuscular disorders to adhere totheir treatment regimens. The aim ofthe present study was to determinethe feasibility and efficacy of a videogame-based NMES training systemwith respect to physiological andpsychological outcomes in individualswith complete SCI.FIGURE 2.An overall viewof the footplatform with theinvertedpendulum lockedin place at theend of the mainshaft, and aparticipant on apadded benchusing thesystem: (a) footplatform, (b)invertedpendulum, (c)NMES electrodesand (d) joystick.▼circulation and bone demineralisation,and to improve his muscle mass inorder to be able to participate inrehabilitation programmes that useNMES. The participant gave writteninformed consent to the experimentalprocedure, which was approved bythe local institutional ethics committeein accordance with the declaration ofHelsinki on the use of human subjectsin experiments.Experimental setupThe participant was actively involvedin the training procedure by operatingthe video game via NMES-inducedankle joint motions (figure 1). Theparticipant adjusted the level ofelectrical stimulation delivered to hisplantarflexors or dorsiflexors usingthe joystick, which was connected tothe programmable four-channelneuromuscular electrical stimulator.The applied electrical stimulationevoked corresponding musclecontractions that controlled the videogame through the resulting changes inankle joint angular displacement(figure 1). The training systemconsisted of a dynamic ankle jointtraining device, a tilt sensor, anelectrical stimulator, a joystick and avideo game-based visual feedbacktraining software program (figure 2).Dynamic ankle joint training deviceDuring the training, the participantwas seated on a padded bench with abackrest support. The position of thehip and knee joints were set to 90º offlexion, and the feet were firmlystrapped to the foot platform (figure2(a)). The platform was attached to themain shaft of the training device,which was inserted in the sidebearings allowing for smooth rotation.The axis of rotation of the main shaftwas aligned with that of the anklejoints. The main shaft was composedof two sections, one of whichsupported the foot plate and the otherheld the inverted pendulum (figure2(b)). The inverted pendulum was 1 min length and was held in the uprightposition by the notch in the mainshaft. The system allowed theparticipant to perform plantarflexionsand dorsiflexions using NMES. Thecontractions were performed againstexterior resistance (invertedMETHODSParticipantThe male participant was 57 years oldand sustained chronic SCI (T3–T4) 4years prior to taking part in this study.The participant’s lesion completenesswas classified as AIS A (AmericanSpinal Injury Association ImpairmentScale classification A). At the time ofinitial assessment, the participantdemonstrated complete motor andsensory loss below the T4 level. Hispersonal treatment goals were toprevent secondary health conditionsassociated with impaired blood▼SCOPE | SEPTEMBER 2011 | 17

SCOPE | FEATURE▼pendulum with a weight on it), andthe angle of the ankle joints was usedas the control input to the video game.To prevent excessive joint movementsduring the training exercise, the rangeof angular displacements of the footplatform was mechanically restrictedfor safety consideration within therange of 30º plantarflexion and 20ºdorsiflexion. The stoppers werecovered by softer materials to absorbpotential mechanical shocks when theplatform stopped moving. Thereaction torque sensor (TS11-200,Durham Instruments, Germany) wasmounted to the main shaft to measurethe torque produced during thetraining exercise.Tilt of the foot platform in thefrontal plane was registered by anaccelerometer-inclinometer (KXM52-1050, Kionix Inc., USA), which wassecurely attached to the rotatingplatform between the left and the rightfoot. The tilt was used as the real-timecontrol input to the video game. Realtimedata acquisition, processing,visualisation and storage wereperformed using the LabVIEW 8.5software package (NationalInstruments, USA).Neuromuscular electrical stimulationA programmable four-channelneuromuscular electrical stimulator(Compex Motion, Compex SA,Switzerland) was used to delivertranscutaneous electrical stimulationto the ankle joint muscles. Two pairs ofself-adhesive gel electrodes(ValuTrode, Denmark) were placedover the motor points on proximal(active electrode) and distal (referenceelectrode) ends of the triceps suraeand tibialis anterior muscles of eachleg, i.e. the surface of plantarflexorsand dorsiflexors, respectively. The 9 ×5 cm electrodes were placed on theplantarflexors and 5 × 5 cm electrodeswere placed on the dorsiflexors (figure2(c)). NMES applied to plantarflexorsgenerated an ankle torque that causeda forward rotation of the ankle joints,whereas NMES applied to dorsiflexorsresulted in a backward rotation of theankle joints.The stimulation current had arectangular, biphasic, monopolar pulsewaveform with a pulse duration of 300µs, and the stimulation was deliveredwith a frequency of 40 Hz. Themaximal amplitude (intensity) of thestimulation was set to 80 per cent ofthe intensity required to producemaximal torque. The range of theFIGURE 3.Interface ofgame-basedexercise: (a)‘snake’, (b)targets, (c) scoreand (d)adjustableparameterswhich include:speed of snake,number oftargets,adjustment ofneutral positionof ankle jointsand range ofmotion (i.e. peakplantarflexionand dorsiflexion).▼NMES intensity was determined priorto the training exercise and was basedon the muscles’ motor threshold(lower limit) and 80 per cent of theintensity required for maximumtorque elicitation (upper limit). Forthe individual in this study, thestimulation ranged from 30 to 80 mAand from 20 to 60 mA forplantarflexors and dorsiflexors,respectively.JoystickThe stimulation intensity wascontrolled by the participant inresponse to the video game scenariousing an analogue joystick controller(figure 2(d)). A forward inclination ofthe joystick, which was connected tothe electrical stimulator through ananalogue input port, resulted instimulation of plantarflexors, whereasa backward inclination resulted instimulation of dorsiflexors. Theintensity of the stimulation increasedlinearly with joystick motion.Game-based exerciseThe goal of the game was to navigatea moving ‘snake’ (figure 3(a)) aroundthe screen in an attempt to hitrandomly appearing targets (figure3(b)). The turning radius of the‘snake’ was controlled by the positionof the ankle joints detected by the tiltsensor. Although only one type ofankle joint motion was used (i.e.plantarflexion and dorsiflexion in thefrontal plane), the video game utilisedthree types of motion: with the jointsin neutral position, the ‘snake’ movedin a straight line; in order to produceclockwise or counterclockwise turnsof the ‘snake’, the participant had toelicit plantarflexions (forwardinclination of the joystick) ordorsiflexions (backward inclination ofthe joystick), respectively.Visual feedback was provided by alarge monitor placed at eye levelabout 1.5 m in front of the participant.To motivate the participant toimprove his performance, a scorerepresenting the number of collectedtargets was displayed (figure 3(c)).With an increased number of collectedtargets, the ‘snake’ increased itslength. The trial was restarted everytime the snake crossed the borders ofthe screen (‘out of bounds’). The gameparameters were adjustable (figure3(d)); namely, the speed of the snakeand the number of targets, as well asthe neutral position in the ankle jointsand the sensitivity of the tilt sensor tothe angular displacement of the footplatform. In addition, the amount ofadditional weights added to thependulum varied the resistive force(torque) during movements of theankle joint. For the purpose of thisstudy, the parameters were set by theresearcher.The training was performed threedays per week for a total of 48sessions. Each session lasted up to 60minutes with a total time of the NMESof at least 45 minutes. The study wasperformed at the TorontoRehabilitation Institute. A researcherassisted with the initial setup (i.e.electrode placement and gameparameters) prior to each trainingsession. During the training, theparticipant was focussed on the gamemost of the time, and did not interferewith the researcher.Outcome measurementsThe following parameters wererecorded throughout the trainingperiod: (a) the NMES intensity, (b) theoverall torque representing resultanttorque exerted by the stimulatedmuscles and passive torque producedby the training device, and (c) theangular displacement of the footplatform (corresponding to ankle jointposition). In addition to theaforementioned recordings, an openquestioninterview was carried out toassess motivational aspects of thetraining and to capture theparticipant’s opinion on how thetraining system could be improved.RESULTSFigure 4 shows an example of onecycle of the exercise fromplantarflexion to dorsiflexion and backto plantarflexion. Two kinds of muscleactivities were utilised. First, isotonicconcentric contractions occurredduring rotation of the foot platformfrom plantarflexion to dorsiflexion andvice versa. The peak torque valueswere exerted when the pendulum wasmoved away from its outermostposition towards the upright position.As the angle in the ankle jointsapproached the neutral position, themagnitude of the torque decreased dueto the fact that the inverted pendulumapproached the upright position. Afterthe pendulum reached the verticalpoint, it continued to move under itsown weight until the foot platformreached the opposite outermostposition (i.e. dorsiflexion orplantarflexion). Second, while the foot18 | SEPTEMBER 2011 | SCOPE

FEATURE | SCOPESCOPE | SEPTEMBER 2011 | 19

SCOPE | FEATURE▼platform was kept in its outermostposition, the participant continued toapply stimulation, which resulted inisometric contractions until arotation in the opposite direction wasrequired by the game.The training resulted in asignificant improvement of thestrength and endurance of theparalysed lower leg muscles.During the first training session,the peak torque values reached 11.0 ±1.7 Nm and −5.1 ± 0.8 Nm duringplantarflexion and dorsiflexion,respectively, whereas during the 48thsession, the torque values increasedto 27.0 ± 4.0 Nm and −16.0 ± 2.0 Nmduring plantarflexion anddorsiflexion, respectively (figure5(a)).The range of motion of the anklejoints also increased from 17.7 ± 2.1ºand −2.9 ± 0.8º (first session) to 28.7 ±3.4º and −17.9 ± 1.5º (48th session)“Theparticipantreportedthat heenjoyedcontrollingthe videogamebasedtraining”during plantarflexion anddorsiflexion, respectively (figure 5(b)).The game score representing theoverall number of collected targetsduring the first session reached 12points. However, the score increasedthroughout the training period,reaching 421 points by the 48thsession.During the interview, theparticipant reported that he enjoyedcontrolling the video game-basedtraining. He stated that the videogame was challenging to play, butcould be easily adjusted to meet theneeds of the participant. Theparticipant also reported that theinstruction to maximise his scoreduring each trial motivated him toplay and to keep his attention on thegame throughout the whole session.The participant was encouraged toparticipate in this training programmeon a regular basis.DISCUSSIONWe developed a new training systemthat integrates NMES and visualfeedback. We demonstrated that theprotocol used in this study yieldedsignificant training effects on thestrength and endurance of theparalysed lower leg muscles, as seenthrough increased torque values andtraining session duration, andimproved the range of motion of theankle joints. As opposed to existingtraining programmes, our approachincorporated non-isometric concentriccontractions against different levels ofresistance, included an entertainingcomponent and required minimalsupervision by staff.Often, the existing protocols oflower leg muscles’ NMES-training inpopulations with SCI includestimulation during isometriccontractions, i.e. with a constantmuscle length and fixed ankle joints.20 | SEPTEMBER 2011 | SCOPE

FEATURE | SCOPESuch conditions introduce a higher riskof bone fracture, decreased bloodcirculation and decreased ankle jointmobility. 9,10 We therefore suggested asystem that includes dynamicplantarflexion and dorsiflexionmovements against exterior resistance,and thus decreasing the probability ofthe aforementioned risks. Themotivation to obtain a higher scoreguided the participant through theprotocol, thus providing an overloadfor the muscles during the training. Webelieve that the muscle overloadinduced by the current protocolresulted in an increment of the musclestrength, and, thus, almost tripledtorque by the end of the training periodin comparison with the initial values.Another key observation resultingfrom this study was that the interactivegaming NMES intervention canmotivate a person with chronic SCI toperform muscle-training exercises. Ourparticipant indicated that he enjoyedthe video game-based tool, and that hewould like to continue the treatment.We believe that the proposed videogame-based NMES trainingprogrammes will be effective inmotivating participants to train morefrequently and adhere to otherwisetedious training protocols. Moreover, avideo game-based approach can beimplemented when the course ofconventional therapy is completed,thus encouraging patients to furtherimprove their functions after dischargefrom inpatient care.Additionally, the feasibility of oursystem was demonstrated in anindividual with motor and sensorycomplete paraplegia. It has been notedearlier that a regular trainingprogramme might not be available ormight be too difficult to participate in,either physically and/orpsychologically. 11 Our systemparameters could have been changedpermitting the participant tosuccessfully train even withprogressively increasing fatigue. Webelieve that characteristics of thesystem would allow individuals witheven less preserved motor function (i.e.with weaker muscles, a higher degreeof muscle atrophy, and/or withnarrower ROM in the ankle joints) toparticipate in this training programme.Finally, the system setup andapplied protocol required minimalsupervision from medical or researchstaff: once the game parameters, rangeof motion and the level of resistancewere set, the participant was able toperform the training without anyfurther assistance.As an extension of the present study,we designed a portable foot platformwhich does not require the participantto transfer from their wheelchair, andcan be easily used in both clinicalsettings and during home-basedtraining programmes. Further researchalong with a randomised control studywill be performed in the future toinvestigate and compare themotivation level and to what extentmuscle function might be enhancedusing our system and otherrehabilitation approaches.CONCLUSIONThe proposed system that integratesNMES and video gaming successfullymotivated the participant and resultedin significant training effects on thestrength and endurance of theparalysed lower leg muscles as well asimproved the range of motion of theankle joints. This research programmerepresents an extension of our previouswork in the field of improvement andrestoration of neuromuscular functionsusing NMES-based technologies. Thisapproach can be implemented in thefuture in a clinical setting starting at avery early post-injury stage byproviding a regular physical exerciseprogramme in the hospital that canthen easily be transitioned to a homebasedtraining programme. Finally, theproposed approach has the potential tobe implemented in other neurological,orthopaedic and geriatric populations.It can help the targeted patientpopulation achieve higher levels ofindependence in activities of dailyliving by improving their function andconfidence, and decreasing the severityand likelihood of secondary healthconditions. In the future, we propose tocollaborate with game developers todesign different types of rehaborientedvideo game-based exerciseswith the goal of making them asenjoyable and appealing as possible.We believe that in this day and age, it istime to create the whole niche forrehabilitation games which can be usedby millions of needed users. nACKNOWLEDGEMENTThe primary author (DS) is supported bythe fellowship programmes of theCanadian Paraplegic Association ofOntario. We thank Mr Egor Sanin for histechnical contributions. This project wassupported by the Toronto RehabilitationInstitute, which receives funding under theProvincial Rehabilitation ResearchProgram from the Ministry of Health andLong-Term Care in Ontario.FIGURE 4[LEFT] Exampleof one cycle ofthe exerciserecorded duringthe secondminute of thefirst trainingsession:transition fromplantarflexion todorsiflexion andback toplantarflexion.(a) NMESintensity; (b)torque (boldblue line) andangulardisplacement(bold greenline). Periods ofisotonicconcentriccontractions areshown by greycolour. Scale forthe torque isshown on theleft; scale for theangulardisplacement isshown on theright.▼FIGURE 5[RIGHT] Peak(a) torque and(b) angulardisplacement ofthe footplatform duringthe first and48th trainingsessions.Positive valuesrepresentparametersduringplantarflexion;negative valuesrepresentparametersduringdorsiflexion.Asterisksindicatestatisticallysignificantdifferences incomparison withthe first trainingsession (* P‹0.05).▼REFERENCES1 Spinal cord injury facts andfigures at a glance. J Spinal CordMed 2010; 33(4): 439–40.2 Kizony R, Raz L, Katz N,Weingarden H, Weiss PL. Videocapturevirtual reality system forpatients with paraplegic spinalcord injury. J Rehabil Res Dev2005; 42(5): 595–608.3 Ragnarsson KT. Functionalelectrical stimulation after spinalcord injury: current use,therapeutic effects and futuredirections. Spinal Cord 2008; 46(4):255–74.4 Popovic MR, Keller T. Modulartranscutaneous functionalelectrical stimulation system.Med Eng Phys 2005; 27(1): 81–92.5 Shields RK, Dudley-Javoroski S.Musculoskeletal adaptations inchronic spinal cord injury: effectsof long-term soleus electricalstimulation training. NeurorehabilNeural Repair 2007; 21(2): 169–79.6 Nandoe Tewarie RD, Hurtado A,Bartels RH, Grotenhuis JA,Oudega M. A clinical perspectiveof spinal cord injury.NeuroRehabilitation 2010; 27(2):129–39.7 Edgerton VR, Roy RR. Robotictraining and spinal cord plasticity.Brain Res Bull 2009; 78(1): 4–12.8 Sayenko DG et al. Positive effect ofbalance training with visualfeedback on standing balanceabilities in people with incompletespinal cord injury. Spinal Cord2010; 48(12): 886–93.9 Crameri RM, Cooper P, SinclairPJ, Bryant G, Weston A. Effect ofload during electrical stimulationtraining in spinal cord injury.Muscle Nerve 2004; 29(1): 104–11.10 Petrofsky JS, Stacy R, Laymon M.The relationship between exercisework intervals and duration ofexercise on lower extremitytraining induced by electricalstimulation in humans with spinalcord injuries. Eur J Appl Physiol2000; 82(5–6): 504–9.11 O'Connor TJ et al. Evaluation of amanual wheelchair interface tocomputer games. NeurorehabilNeural Repair 2000; 14(1): 21–31.SCOPE | SEPTEMBER 2011 | 21

SCOPE | TUTORIALRISK MANAGEMENT AND REHABILITATION ENGINEERING:COMMON ISSUES IN AN UNCOMMON AREA OF WORKMichael Dolan and Jennifer Walsh (NHS Lothian) describe the application of riskmanagement in rehabilitation engineering illustrated with case studiesONE OF THE MANY DAILY ISSUES facedby members of IPEM is that of riskmanagement. Risk management canrange from an, apparently, quickdecision to a lengthy process involvingassessment of all possible risks andtheir probability of occurrence. In theend, the benefit of the procedure orequipment needs to outweigh the risksinvolved. It is the application of riskmanagement in the area ofrehabilitation engineering (RE) that isdealt with in this tutorial.RE has been defined as the ‘clinicalapplication of engineering principles andtechnology in the provision of services,research, and development to meet theneeds of individuals with disabilities. Itinvolves the reduction of environmentalbarriers, and/or the restoration orimprovement of the physical, mental andsocial function of a person with adisability’; 1 for example, wheelchairs andspecialised seating systems orenvironmental controls. A key function ofany RE service is the ‘analysis of risksassociated with the use, provision, ordevelopment of technology’. 1In the field of RE, patients are issuedwith equipment on a long-term loan thatthey will use on a daily basis. Suchequipment can permit an increasedquality of life by allowing the person tomobilise or perform a function that theywere previously unable to doindependently without this equipment.This daily, unsupervised interaction withthe provided device makes themanagement of the associated risk ofparamount importance. This is not newin the RE field, but as medical devices,such as infusion pumps and ventilators,have become more portable andsophisticated, making it possible to treatand monitor chronic conditions outsideof the hospital, it is now an increasinglywidespread consideration for otherareas of healthcare science.Wheelchairs and seating account forthe largest quantity of RE equipmentsupplied on long-term loan to patientsby the NHS. The importance ofmanaging risk for users of NHSwheelchairs has recently beenhighlighted in the Clinical Standards forNHS Scotland Wheelchair and SeatingServices. 2 Indeed, the Standard forequipment provision and managementstates that ‘wheelchairs, seating andassociated equipment are medicaldevices and should be safe and fit forpurpose and provided in a timely mannerin accordance with risk managementprinciples’. Clinical scientists and otherhealthcare science professionals areoften responsible for risk management inthis area.Risk management attempts to reduceidentified risks proactively to anacceptable level by creating a culturefounded upon assessment andprevention, rather than reaction andremedy. Risk management is not solelyapplied to the use of technology but haswider application to the patient safety andquality assurance in the provision ofhealthcare generally and can beconsidered to be part of clinicalgovernance. 3 Risk management can beseen as the balance between benefits andharms, which may be judged both at thelevel of the individual and at the level ofsociety; for example, the balance betweencosts of an intervention and the potentialfor cost savings to society as a whole.RISK MANAGEMENT ANDMEDICAL DEVICESThe application of risk management tomedical devices is set out in ISO14971:2009. 4 The concept of risk has twocomponents:n the probability of the occurrence ofharm, andn the consequences of harm; that is,how severe it might be.Medical devices are defined as ‘anyinstrument, apparatus, implement,machine, appliance, implant, in vitroreagent or calibrator, software, materialor other similar or related article,intended by the manufacturer to be used,alone or in combination, for humanbeings for one or more of the specificpurpose(s) of:n diagnosis, prevention, monitoring,“In thefield of RE,patientsare issuedwithequipmenton a longtermloanthat theywill use ona dailybasis”treatment or alleviation of disease,n diagnosis, monitoring, treatment,alleviation of or compensation for aninjury,n investigation, replacement,modification, or support of theanatomy or of a physiologicalprocess,n supporting or sustaining life,n control of conception,n disinfection of medical devices,n providing information for medicalpurposes by means of in vitroexamination of specimens derivedfrom the human body, and whichdoes not achieve its primary intendedaction in or on the human body bypharmacological, immunological ormetabolic means, but which may beassisted in its function by suchmeans.’In the field of RE, examples of medicaldevices include:n aids for daily living (e.g. commodes,bath aids),n environmental controls (e.g. personalalarm systems, remote control ofdoors),n mobility aids (e.g. wheelchairs,walking frames, prostheses),n moving and handling systems (e.g.hoists, stair lifts),n posture management (e.g.wheelchair seating systems),n pressure management (pressureredistribution/relief), andn speech and hearing aids.Manufacturers of these low-risk ‘class I’devices must fulfil the Medical DeviceDirective’s 93/42/EEC (MDD) EssentialRequirements set out in Annex I. Theseinclude conforming to the safetyprinciples:n eliminate or reduce risks as far aspossible (inherently safe design andconstruction),n where appropriate take adequateprotection measures includingalarms if necessary, in relation torisks that cannot be eliminated, andn inform users of the residual risksdue to any shortcomings of theprotection measures adopted.▼22 | SEPTEMBER 2011 | SCOPE

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SCOPE | TUTORIAL▼FIGURE 1. Schematic representation of the riskmanagement process (adapted from ISO 14971:2009).TABLE 1SectionABCDEFGHeading/contentTitle of deviceName and profession of assessorDate completedFile nameUnique identifierName of patient/recipient bodyGeneral description of disability / problemSummary of proposed solutionSources of hazard[contains 37 questions based on Annex Cof ISO 14791:2009 requiring yes/no responses]Action taken to address any hazards identifiedaboveOther hazards with action takenWhat standards apply in the design of thisdevice?Risk assessment summary:In your opinion are residual risksbalanced by the therapeutic/ rehabilitativebenefits?Does the user have an opinion orunderstand the benefits vs. residual risk?TABLE 1. Summary of the primary risk assessment form.The terms ‘risk analysis’, ‘riskevaluation’, ‘risk assessment’ and ‘riskmanagement’ are often usedinterchangeably, but they are distinctlydifferent and must be understood. Theyare defined in ISO 14971:2009 as follows: 4Risk analysis: systematic use ofavailable information to identify hazardsand to estimate the risk.Risk evaluation: process of comparingthe estimated risk against given riskcriteria to determine the acceptability ofthe risk.Risk assessment: overall processcomprising a risk analysis and a riskevaluation.Risk management: systematicapplication of management policies,procedures and practices to the tasks ofanalysing, evaluating, controlling andmonitoring risk.The relationship between theseelements is illustrated in the schematic ofthe risk management process (figure 1).The ISO 14791:2009 standardspecifies a procedure by which amanufacturer can identify the hazardsassociated with medical devices,estimate and evaluate the risks, controlthese risks and monitor the effectivenessof the control. Importantly, though, thestandard does not apply to clinicaljudgements relating to the use of amedical device. It might be thought thatany risk associated with a medical devicewould be acceptable if the patient’sprognosis were improved. Nevertheless,this cannot be used as a rationale for theacceptance of unnecessary risk. Any riskshould be reduced to the lowest levelpracticable, bearing in mind the benefitsof accepting the risk and the practicabilityof further reduction.In the real world, and particularly inthe RE field where equipment is usedunsupervised in the community for longperiods, it is not possible to eliminate allrisks. The emphasis, therefore, needs tobe on minimising and managing risks.MODIFYING MEDICAL DEVICESIt is often overlooked that themodification of CE-marked medicaldevices and the in-house manufacturingand off-label use of devices to meetparticular needs are subject to therequirements of the MDD. Technicallymodification counts under the terms ofthe MDD as re-manufacture, meaningliability, should ‘modified’ devices fail,rest with the modifier. Modifying existingdevices or using them for purposes notintended by their manufacturer (whichalso counts as modification of a device)may have serious safety implications.Most prescriptions of RE equipmentcan be met by commercially availableequipment, though devices fromdifferent manufacturers are oftencombined. However, in cases wherethere is no commercially availableequipment to meet the needs of thepatient it might be possible to design andprovide bespoke equipment. This designmight involve the combination and/ormodification of existing devices or themanufacture of a completely new device.The modification or manufacturing maybe done internally by an RE service orexternally by a commercial contractor.Modifying a CE-marked medicaldevice can be deemed to be subject tothe same regulations as manufacturinga new device and may therefore besubject to the requirements of theMedical Devices Regulations (MDR). Inthese circumstances it is necessary to:n keep a full record of the design,n carry out and document a riskassessment,n consider the ethical and legalimplications,n implement suitable precautions tominimise the risk, andn review the risk assessment atsuitable periods. 6This tutorial does not attempt tocover the use of third party spares,which can also be deemed to be amodification.RISK ASSESSMENT IN ACLINICAL SETTINGThe application of the conceptsdescribed above to a clinical setting willdepend on a number of factors includingthe organisation and scope of theservices offered. The practicalinterpretation described here is basedon the system used at the SoutheastMobility and Rehabilitation Technology(SMART) Centre, Edinburgh. It was firstintroduced in 1998 and has been revisedas required to keep current with updatedstandards and best practice.The system requires the responsibleclinical scientist to determine the level ofrisk during the design phase of a newdevice (which includes the modificationof devices). Three levels of risk are used:n significant risk,n low risk, andn no risk.The level that applies is, in each case,at the professional judgement of theclinical scientist who is responsible forthe design. ‘No risk’ would apply incases whereby a CE-marked medicaldevice is being used as themanufacturer intended.24 | SEPTEMBER 20 11 | SCOPE

TUTORIAL | SCOPEExperience has shown that the vastmajority of designs in this area can betreated as ‘low risk’. In low risk cases aprimary risk assessment is conducted.This covers devices that are regularlyprescribed by the service. If a particularmodel of assistive technology isprovided to different patients but hasthe same intended use then a singleassessment can be conducted.Table 1 summarises the content ofthe primary risk assessment form thatis used. The responsible clinicalscientist completes the form anddetails the problems, the proposedsolution and identifies any possiblesources of hazards using the promptsbased on Annex C of ISO 14791. Theymust then address the identifiedhazards, reduce them as much asreasonably practicable and evaluate ifthe overall residual risk is acceptable.The completed form and associateddocuments, such as engineeringdrawings, are linked to the patient’srecords (which together constitute therisk management report). Any issuesarising after production or once in useare recorded and linked for futurereference and any subsequent use ofthe device. The six steps illustrated infigure 1 are thereby covered. Thedetailed nature of this process ensuresthat all relevant standards are beingmet and a safe and effective device isprovided.For devices with levels of ‘significantrisk’, a more extensive full riskassessment is conducted thatincorporates a semi-quantitativeestimation of risk. This involves thecalculation of the risk factor (orcriticality) for each identified risk,before and after each risk reductionmethod is carried out using thequalitative measures of ‘likelihood’ (orprobability) and ‘severity’ (table 2). Thisencompasses the two components ofrisk described at the start of the sectionon risk management and medicaldevices above. Other methods of riskestimation are detailed in Annex D ofISO 14971:2009.CASE STUDIES BASED ON REALCLINICAL EXAMPLESThese case studies are based on realclinical examples that were riskassessed by clinical scientists workingat the SMART Centre, Edinburgh. TheSMART Centre provides a wide range ofRE services for the south-east ofScotland, covering Lothian, Fife and theBorders NHS Boards. These includemobility and postural services“Thedetailednature ofthisprocessensuresthat allrelevantstandardsare beingmet”(wheelchairs and special seating),prosthetics, bioengineering services(electronic assistive technology andspecial needs design equipment), aDisabled Living Centre and GaitAnalysis Service.Case 1: mounting a ventilator on apowered wheelchairThis case study considers themechanical mounting of a ventilatoron a powered wheelchair. For somepatients who have a tracheotomy and apowered wheelchair, mounting aventilator to the back of a wheelchairwill provide them with a considerableamount of freedom. The developmentof small-sized, self-containedventilators has reduced the level ofrestrictions on these patients. Thisindependence can be optimised whenTABLE 2LikelihoodTABLE 2. Risk factor matrix.Risk factor = likelihood x severity5 Certain 5 10 15 20 254 Very likely 4 8 12 16 203 Likely 3 6 9 12 152 Unlikely 2 4 6 8 101 Very unlikely 1 2 3 4 5Severity1Insignificantinjury / illness(no treatment)2Minorinjury /illness(first aid athome)the patient has a powered wheelchair.In the past, larger ventilators thatcould only be used for short periods oftime on battery power could besupplied by the powered wheelchair’sbatteries, but, as in this case, this isnow rarely necessary due toimprovements in ventilator andbattery technology. Wheelchairs andventilators are, of course, medicaldevices and will be risk managed bytheir respective manufacturers.However, rarely will themanufacturers have considered theinteraction of these two devices, letalone provide a mounting kit.The housing used to hold theventilator in place must be robust andprovide protection to the ventilator incase of a collision with another object(figure 2). The ventilator must be3Significantinjury / illness(hospital /doctor)4Major injury /disabilityFIGURE 2. Drawing of ventilator housing (restraining straps not shown).▼5DeathSCOPE | SEPTEMBER 2011 | 25

SCOPE | TUTORIAL▼TABLE 3Source of hazardInteracts with otherequipmentRequires adjustment by theuser / clientMay involve more than onecarer / operatorIs mobile or portableSpecific hazards and action taken to addressMounted on powered wheelchair. The danger is that it becomes loose.This is addressed through the design of mounting – the carrier fits ontolateral trunk support receiver runners. The air taken in by the ventilator isdrawn in from underneath. The hole in the carrier shell allows for thisintake. The carrier has clear space underneath.The user’s carers are required to fit the ventilator into the carrier correctlyand secure it using adjustable straps which hook onto D rings designed forone of the ventilator’s carry strap to be attached to. Carers will be shownhow to fit and secure. If the ventilator was put in back-to-front there isanother hole that has been cut out to allow for the connection of mainsand auxiliary power cables that will allow for air intake.Due to the ventilator being on the back of the wheelchair there is a chancethat, if the wheelchair is reversed into an object, the ventilator could becrushed. The carrier has a PVC shell around it to protect it and this isadditionally supported by steel tubing underneath.TABLE 3. Hazards associated with a ventilator mounted on a powered wheelchair.TABLE 4Source of hazardInteracts with otherequipmentRequires adjustment by theuser / clientFreely standingIs mobile or portableSpecific hazards and action taken to addressThe device supports the hair dryer by means of a cradle. The hair dryer islowered into place. Does not obstruct airflow, does not interfere withleads.The user is trained in one-hand adjustment of tilt and height. By design thecradle cannot fall down the support poles. The device is semi-portable assupport poles can be disassembled from the chassis by unscrewing across-knob – instruction is given on issue.TABLE 4. Hazards associated with a hair dryer holder for unilateral upper limb amputees.TABLE 5HazardInjury to skin and softtissue of residual limbSerious injury resultingfrom the failure to controla weight during a liftThe device freely stands and is wheeled to allow repositioning. Is forindoor use only – instruction to the user will be given.Source of hazardPatient’s method ofsocket suspensionLoading of soft tissuesvia socket duringweightlifting manoeuvresMechanical failure of thedeviceBeforeAfterL S R L S R3 2 6 2 2 43 2 6 2 2 43 4 12 1 4 4TABLE 5. Hazards and risk factors associated with upper limb prosthesis attachmentfor bench press exercise. L = likelihood, S = severity, R = risk factor (L x S).removed from the wheelchairwhen the patient transfers out ofthe wheelchair – this will also haveassociated risks. The design of themounting device must ensure thatthe air inlet pipe is not blockedeven if the ventilator is positionedback-to-front. A primary riskassessment was conducted,identifying a number of sources ofhazard. The four main sources arelisted in table 3, along withdescriptions of the actions takento reduce the identified hazards.This design has been usedsuccessfully for a variety ofpatients.Case 2: hair dryer holder forunilateral upper limb amputeesAn example of a device speciallydesigned due to there being nocommercially available product isa hair dryer holder for unilateralupper limb amputees. Thesepatients are unable to hold a hairdryer and also style their hair. Thedesign of the device must be ableto hold the hair dryer securely andallow for it to be tilted, thusenabling the patient to style theirhair as needed. A primary riskassessment was conducted. Inaddition to the hazards associatedwith a hair dryer’s normal use,such as it being a heat source, fourother main possible sources ofhazard were identified. These arelisted in table 4, along withdescriptions of the actions takento reduce the identified hazards.This device was designed for asingle patient and has since beenissued to other patientspresenting with the same needs.Case 3: upper limb prosthesisattachment for bench pressexerciseMany patients wish to participatein recreational activities despitetheir impairment. An example of abespoke device to enable someonewith an upper limb amputation tolift weights is described here. Dueto the inherent risks associatedwith weightlifting, the potential forharm was deemed to besignificant and therefore a full riskassessment was undertaken. Thedesign comprises a stainless steelyoke, central shaft and twogussets to increase weldedconnection and buckling strength(figure 3).26 | SEPTEMBER 2011 | SCOPE

The risk assessment included adetailed examination of thecompressive, bucking and off-axisloads that would be applied to thedevice when in use. The mainpotential hazards and sources aresummarised in table 5. The highestrisk factor was 12 due to thelikelihood of a significant injury inthe case of the mechanical failureof the device. Risk reduction wasclearly necessary. It wasdetermined that in terms of thedesign, 0 the risk 1 could not 3 be 2reduced without compromising itspurpose. Therefore, in order tominimise the residual risk, detailed1 2 0 3written instructions and guidancewere issued to the patient coveringthe requirements to:n check 2 the 3skin and 1soft tissues 0of their residual limb,n visually check the condition ofthe 3 socket 0and the 2device prior 1to each use,n check that the socketcontinues to fit the residuallimb properly,n not exceed the press load limitof 60 kg, andn use with the U-shaped barholder oriented verticallyupwards.0After the 1application 4 of 2these3risk control activities, the highestrisk factors were reduced to 4. This1 2 0 4 3REFERENCES0 2 1 3 44 0 2 3 14 2 1 0 30 1 4 2 30 2 1 3 44 London: 0 BSI, 22009.3 1was considered to be anacceptable level of risk in thiscase.SUMMARYThis tutorial has illustrated theapplication of risk managementin the rehabilitation engineeringfield. This is an area wheremedical devices are frequentlymodified, issued to patients andsubsequently usedunsupervised in the community.It is often not appreciated bynon-healthcare scientists thatthe off-label use or thecombination of devices fromdifferent manufacturers istantamount to the manufactureof a new device and is thereforesubject to the requirements ofthe MDR.A number of case studiesbased on the system used by theSMART Centre in Edinburghwere presented and described indetail. Nevertheless, it should beappreciated that no oneapproach is applicable to eachand every situation. Existingmodels and techniques used inrehabilitation engineering needto be adopted and adapted tosuit the prevailingcircumstances and intendedapplication. n1 IPEM. Policy Statement: Rehabilitation EngineeringServices. York: IPEM, 1999.2301232 3 1 0FURTHER READING3 0 2 12 Scottish Government. NHS Scotland Wheelchair andSeating Services – Clinical Standards. Edinburgh, 2011.3 NHS Quality Improvement Scotland. Clinical1Governance2 0and Risk4Management3– NationalStandards. Glasgow, 2005.4 ISO. BS EN ISO 14971:2009 Medical Devices –Application of Risk Management to Medical Devices.5 ISO. BS EN ISO 13485:2003 Medical Devices – Quality4Management2 1Systems 0– Requirements3for RegulatoryPurposes. London: BSI, 2003.6 MHRA. Medical Device Alert Action Update,MDA/2010/001. London: MHRA, 2010.“Theoff-label Recenuse iurgia or the finiscombination est curaeof sapines devices etfrom promisadifferent fortis estemanufactur perfectosers centum istantamount qui deciditto est thevetusmanufactur novis ete of scrire a newdevice estes”1 Fortis et alter Homerus JFIGURE Curare, 3. Upper ut critici limb prosthesis este leviterattachment.curare videtur este videtur,quo promissa alter inter vilisACKNOWLEDGEMENTperfectos, October 1824.The authors would like to thank theircolleagues, 2 Fortis in et particular alter Homerus Rob Farley, JSusan Curare, Hillman ut and videtur, James Hollington, quowho have contributed to the developmentpromissa alter inter vilisof the system described and who haveprovided perfectos, background October material 1824. on thecase studies.3 Fortis et alter Homerus JCurare, ut critici este levitercurare videtur este videtur,quo promissa alter inter vilisperfectos, October 1824.4 Fortis et alter Homerus JCurare, ut perfectos, OctoberBlache L, Robbins P, Brown S, 1824. Jones P, Liu T, LeFever J.Risk Management and its5ApplicationFortis et alterto MedicalHomerusDeviceJManagement. York: IPEM, 2008.Curare, ut videtur, quopromissa alter inter vilisIPEM. Report 74: Application of perfectos, Medical Device October Directive 1824.Guidance Notes. York: IPEM, 1997.6 Fortis et alter Homerus JMHRA. Managing Medical Devices Curare, Guidance ut videtur, for quoHealthcare and Social Services promissa Organisations, alter inter MHRA vilisDB2006(05). London: MHRA, perfectos, 2006. October 1824.7 Fortis et alter Homerus JMedicines and Healthcare products Curare, Regulatory ut videtur, Agency quo(MHRA), http://www.mhra.gov.uk/index.htmpromissa alter inter vilisperfectos, October 1824.Southeast Mobility and Rehabilitation Technology (SMART)Centre, NHS Lothian, http://www.smart.scot.nhs.uk8 Fortis et alter Homerus JCurare, ut critici este leviterMedical Devices Regulations 2002.curareStatutoryvideturInstrumenteste2002, No. 618,perfectos, October 1824.http://www.opsi.gov.uk/SI/si2002/20020618.htm9 Fortis et alter Homerus JCurare, ut perfectos, October1824.SCOPE | SEPTEMBER SCOPE | JUNE 2011 07 | XX 27

SCOPE | TRAVEL AWARD▼variables are introduced and work isneeded to strengthen this area ofstudy.For three days, I was ‘wined anddined’ (well, no wine but hey! Seefigure 2) for lunch by the various postdocsand residents in the department.We chatted about their individualresearch interests as well as the stateof US radiation physics, managementof home/work life and medicalphysics accreditation. It wasfascinating to hear how different it isto get ‘accredited’ in medical physicsin the US, a more exam-orientedprocess compared to the UK.UNIVERSITY OF FLORIDAPROTON THERAPY INSTITUTE,JACKSONVILLEAfter being in New York City wherethe maximum temperature never wentabove 12°C, sunny 30°C Jacksonvillewas a bit of a shock! The hottemperature was soon forgotten as Ihopped from one air-conditionedbuilding to another.There is a huge amount of interestin proton therapy, especially by thepaediatric community as the steepdose gradient created by the treatmentshould result in a large reduction inorgans-at-risk and normal tissue dose.Special paediatric cases from the UKget referred for proton therapy andthe Proton Therapy Institute hashosted some of these patients. Thecentre, which opened in 2006 (figure3), is well-equipped to deal withpatients from far away with roomywaiting and children’s play areas, andall the staff including clinicaloncologists, information technologystaff as well as secretarial andfundraisers share a floor.The physics team led by DrZuofeng Li is made up of ninephysicists and around 20 associatephysicists, dosimetrists and engineers.The iba proton therapy machine withthree gantries has a 24-hourengineering service (figure 4). One ofthe gantries is dedicated to treatingprostate cancer patients and another isdedicated to paediatrics, wheregeneral anaesthetic staff are availablefor the whole day. The centre also hastwo Varian linacs and PET/CTscanner, CT simulator and a 0.23T MRscanner. Most proton treatments inFlorida use the double-scatteringtechnique and the shapes of beams areformed using individual brassapertures and the dose is conformedat the distal target end using a Lucite30 | SEPTEMBER 2011 | SCOPE

TRAVEL AWARD | SCOPEcompensator. The end of thecompensator is positioned as close tothe patient as possible and the setup ischecked using images acquired usinga pair of kV x-ray sources anddetectors. It was good to observe theoperation of the machine andplanning of the treatments so that Ican evaluate the pros and cons of thesystem compared to linacs.The current rationale behindpaediatric proton treatment, asdiscussed with Dr Danni Indeligato, apaediatric consultant, is to achieve thesame survival rate as achieved withthe equivalent photon treatments andto study the long-term benefits tohaving proton therapy. Thereforeequivalent dose prescriptions are usedfor protons as in the photonradiotherapy. The main selectioncriterion for paediatric proton therapycases here is that the patients areexpected to have a good long-termsurvival (>40 per cent). There is a lotof effort to conduct long-term followupfor these patients, but as manypatients are not from the area, chasingand co-ordinating data collection arecomplicated.One of my projects is to improvethe current craniospinal axisradiotherapy. The proton therapy forthis site is very different to photontherapy. Though the doseprescriptions are similar, the spinetarget for proton therapy is anterior tothat of the vertebrae, whereas inphotons it is usually anterior to thespinal canal. This is in order to avoiddefective bone growth that can resultif the steep dose gradient in protontherapy lies in the middle of thevertebrae. The dose to the anteriorpart of the patient is much lower thanwhat is seen in photon treatments.PRINCESS MARGARETHOSPITAL (PMH), TORONTOFlying back up north meant that onceagain I had to brace myself for thecold. I flew from Jacksonville toBuffalo (a US city about 2 hours’ drivefrom Toronto) and spent a lovelyweekend with my parents who live inNiagara Falls, Canada. Then I headedup to Toronto on Sunday for my visitto the well-renowned PMH.My visit started with the head andneck rounds at 8am on Monday. Therounds are a forum for differentclinical oncologists to discuss theirdifficult or unusual cases with theteam (organised into cancer sitegroups), which consist of oncologists,radiotherapists and physicists. PMHradiotherapy department is one ofthe largest departments in the worldand treats more than 9,000 patientsper year. It has 16 Varian and Elektalinacs and over 60 Pinnacle treatmentplanning system terminals as well asits own multiple CT, MR and PET-CTscanners. In such a large department,the weekly rounds serve multiplepurposes of keeping team membersinformed, promoting discussions onissues that arise and keeping theteam together.The division of cancer sites intoteams seems to promotespecialisation. During the week, Iwas fortunate enough to spend timewith all four of the physics teamleaders, Drs Stephen Breen, TomPurdie, Tim Craig and DanielLétourneau, and I also had a chanceto speak to some of the oncologists.The oncologists and physicistsoccupy offices that are located in thesame area, which appear to promotespontaneous discussions that mayhelp in development and researchespecially in setup imaging. Some ofthe other imaging studies that arecurrently underway are: using PET-CT during and post lung treatmentsto observe tumour progression forthe purposes of adaptive planningand imaging tumour perfusion usinga 320-slice volumetric CT to see thechanges during and post treatment.Many of the planning andchecking procedures are heavilyscripted (programmed to runautomatically), which can helpdecrease human error that may occurthroughout the process. Thedepartment is ‘paperless’ with theuse of MOSAIQ (record and verifysystem, RMP Publishing). Thisallows easy access to all the recordsthroughout the department and it ispossible for oncologists to approveplans and physicists to check parts ofthe plan off-site. Thereare shared scriptsthroughout theteams butthey aremanagedseparatelyby theteamleaders.One of themostfascinatingautomationprocesses IFIGURE 2.Lunch with DrJoseph Deasy’sgroup in an Italianrestaurant in NewYork.▼FIGURE 3.Enjoying a nicecup of coffee withDr StellaFlampouri in frontof the entrance tothe University ofFlorida ProtonTherapy Institute.▼FIGURE 4.Gettingacquainted with aproton therapygantry.▼observed was the ‘fully-scripted’breast plan, which results in minimalinteraction between the planner andthe planning system (Purdie TG etal., Int J Radiat Oncol 2011; 13 Jan[Epub]).Most of the physicists areinvolved in managing machines andchecking plans, but the qualitycontrol and pre-treatmentverification measurements are doneby associate physicists. This frees upthe physicists’ time to concentrate ondevelopment and research as well aspresenting their work at nationaland international conferences. Manyof the physicists are also involved inco-ordinating meetings and courseson IMRT, image-guidedradiotherapy and quality control.Considering the size of thisdepartment (located in a multistoreybuilding just like MSK), it hadthe feeling of a small departmentand there was good communicationbetween the teams. Patients’treatments were run smoothly andthe control areas were clutter-freedue to the ‘paperless’ system.Frequent quality meetings attendedby all members of oncology staff todiscuss and analyse errors and nearmisses also seem to keep everyonewell-informed and promotedreporting of problems.I felt a little sad when my tripcame to an end as I had been madeso welcome at the three centres, butat the same time I felt glad to bereunited with my family. This triphas given me the opportunity toexperience and get a feel for thedifferent approaches to both clinicalpractices and research in the US andCanada. I had a wonderful time andfeel a sense of renewed excitementfor the work I do. I have come backwith some interesting project ideasas well as how I want to continuemy current work. I recommendanyone who has the time andinterest to apply for this award as itis a fantastic opportunity to learnand grow.ACKNOWLEDGEMENTSFirstly, I would like to thank the IPEM andAAPM for the giving me this opportunity tovisit some of the most excitingradiotherapy departments in NorthAmerica. I would also like to thank my hostcentres, with special thanks to Drs HowardAmols, Stella Flampouri and StephenBreen who organised my visits. Finally, Iwould like to thank the Royal Marsden NHSFoundation Trust, especially myDepartment of Radiotherapy Physics, forallowing me the time to visit these centres.SCOPE | SEPTEMBER 2011 | 31

SCOPE | MEETING REPORTSSOUTH WEST ANNUAL MEDICAL PHYSICS ANDCLINICAL ENGINEERING SCIENTIFIC MEETINGGREGORY STEPHENS Plymouth Hospitals NHS TrustPENINSULA RADIOLOGY ACADEMY, PLYMOUTH 13th–14th May 2011OUR SOUTH WEST REGIONAL SCIENTIFIC MEETING isheld annually; the host is chosen on a rotational basis fromacross the region. This year’s meeting was held atPlymouth Hospitals NHS Trust on the 13th and 14th May2011 in the Radiology Academy. This 2-day event providedan opportunity for regional medical physics and clinicalengineering departments, manufacturers and suppliers andother delegates to meet, present novel work and discussissues relevant or unique to the region, and consisted of ablend of entertainment, management service meetings anda scientific meeting (figure 1).The purpose of the meeting is ‘to celebrate success andshare ideas and best practice in pursuit of excellent medicalphysics and clinical engineering services for the purpose ofimproving the understanding, detection and treatment ofdisease and the management of patients’.The meeting kicked off with a Head of Departments’meeting. Thereafter, two different visits were on offer: a tripto Plymouth dockyard or to the Sharpham winery. The visitto the winery was thoroughly enjoyed by all, and led to aconsiderable quantity of wine and cheese being consumed.The trip to Plymouth dockyard showed a fascinating sideto Plymouth, not usually seen by members of the public(the historical dockyard is still a naval base and, therefore,usually inaccessible to the public). The day was rounded offby a dinner hosted in the Royal Citadel; home to the 29Commando Regiment Royal Artillery (figure 2).Following registration coffee was served, surrounded byposters displaying work by regional physicists andengineers. A good range of industrial sponsors andexhibitors displayed their products and services wheredelegates were having tea, coffee and lunch (figure 3). Thisfacilitated a convivial atmosphere unlike the normalinteractions between company and customer, and allowedthe companies to discuss issues that affect departmentsacross the region.The meeting was opened by the Trust’s Chairman,Commodore Steven Jermy RN, who emphasised the needfor innovative solutions to problems facing the NHS at thistime. He spelled out the serious constraints that the NHS isfinding itself under and provided a cautious but upbeatassessment of the future. The theme of innovation wascontinued throughout the meeting by three invitedspeakers from diverse areas of expertise: academia, RayJones (Plymouth University); government, Nick BucklandOBE (Technology Strategy Board, Swindon) (figure 4), andindustry, Darrel Mann (Systematic Innovation Ltd,Clevedon). Collectively the invited speakers challengeddelegates to consider their role within the innovationlandscape, and described how developing partnershipFIGURE 1.Attendees atconference.▼32 | SEPTEMBER 2011 | SCOPE

FIGURE 2.Conferencedinner.▼FIGURE 3.[LEFT]A manufacturer’sstand.▼FIGURE 4.[RIGHT]Nick Bucklandtalking.▼▼SCOPE | SEPTEMBER 2011 | 33

SCOPE | MEETING REPORTS▼working across public, private, academic and third sectorsis able to foster product and service innovation.Talks were on offer from the entire region with a goodmixture from both the engineering and physics fraternities.Amanda Brason (Cheltenham General Hospital) presentedher work of the fusion of nuclear medicine images and CTto locate anatomical areas of radiopharmaceutical uptake.In particular she presented some of the issues they facedand the solutions they found. Emma Podnieks (BristolGeneral Hospital) presented a detailed analysis ondosimetry from cone beam CT. In particular the issuewhere there is only a partial rotation was discussed; theclinical significance of this, and a method to accuratelyprovide effective dose calculations under this regime, werepresented. Matt Cann (Royal Devon and Exeter NHSFoundation Trust, Exeter) continued the theme ofdosimetry in cone beam CT with a talk on commissioningwork he undertook as part of his physics training on theVarian on-board imager.Laurie Barron (Plymouth Hospitals NHS Trust),demonstrated his electro-mechanical design of a dynamicheart phantom. This uses an ECG signal to accuratelyinflate a liquid-filled, heart-shaped latex balloon (figure 5).This innovative device accurately mimics the expansionand contraction of the human heart. This allows contrastfilledtubes attached to the latex heart to be used as adynamic image quality tool, which can directly comparedifferent reconstruction algorithms in CT and othermodalities where dynamic imaging is used. Ratherentertainingly, the audience was then given ademonstration of the heart at work.Michelle Scott-Cleasby (Royal Devon and Exeter NHSFoundation Trust, Exeter) spent some time providing aninnovative solution to a problem a number of hospitalshave; namely how to comply with legislation on noncoherentlight sources without the use of a spectrometer.Her solution was risk based and provided an excellentmethod to quickly assess numerous sources.Pam Bowen (Torbay Hospital, Torquay) was the secondradiotherapy speaker who discussed their experiencesstarting a new head and neck IMRT service, while RobertRoss (Royal Cornwall Trust, Truro) provided an interestingvisual discussion on water damage in gamma cameracrystals, and defects not usually seen by physicists andengineers. Ruth Ruddlesden (Royal United Hospital Bath)discussed issues around paediatric imaging and herattempts to optimise dose. Of particular interest was theissue over varying dose for similar procedures, and theneed to obtain clinical assistance in the optimisationprocess. Savvas Rizkalla (Plymouth Hospitals NHS Trust)talked about his experiences treating wet AMD withepimacular brachytherapy, a service he has recently beengiven the responsibility of starting, while Steve Perring(Poole Hospital NHS Trust) spoke about his work onoesophageal reflux. Of particular interest was that thestudy showed that proximal reflux is a good indication ofeffectiveness of anti-reflux surgery in suppressing chroniccough and that their work improved the assessment ofdistal and proximal pH by the use of two channelpH/impedance monitoring; thus providing goodinformation to improve patient care in their service.As is usual, the regional IPEM business meeting wasthen held, after which the Director of Healthcare Scienceand Technology, Plymouth, Andy Nevill, formally handedthe ‘baton’ to the head of the next organising department,Diane Crawford, Director of Medical Physics, Bristol.Finally, after appreciation for the presenters and sponsorswas expressed, the meeting was closed and delegates wereable to take part in departmental tours to round off thisyear’s event. nFIGURE 5.Laurie Barrontalking.▼34 | SEPTEMBER 2011 | SCOPE

Department of Medical PhysicsCombined Radiology/Nuclear Medicine PhysicistClinical Scientist – RadiologyPhysicist – Nuclear MedicinePhysicistBand 7£30,460 - £40,157 per annum, Ref: 344-6883CSK37.5 hours per weekApplications are invited for an innovative combined post set upbetween the Radiology Physics and Nuclear Medicine supportsections of the Department of Medical Physics at EKHUFT,based in Canterbury (Kent). In Radiology, duties will includework with equipment and applications in General Radiography,Advanced Radiology (e.g. Interventional, Cardiology), CT,Mammography and Dental, and may extend into other areassuch as Ultrasound and Medical Lasers. In Nuclear Medicine,work will cover support of a wide range of diagnostic andtherapeutic procedures.Work common to both specialities such as Quality Assurance,Radiation Safety and staff training will also be undertaken. Thispost is an excellent opportunity for a physicist to expand andrefine his/her skills and knowledge in a supportive professionalenvironment.Senior Nuclear Medicine PhysicistClinical scientist – NuclearMedicine PhysicistBand 8a£38,851 - £46,621 per annum Ref: 344-6882CSK37.5 hours per weekApplications are invited for the position of Senior MedicalPhysicist in Nuclear Medicine, based in Canterbury (Kent). Keyduties will include leading our scientific support to therapeuticand diagnostic services in this important specialisation,supporting our Nuclear Medicine consultants with clinical work,acting as a Medical Physics Expert, and helping to ensure thesafe and proper use of radioactive materials in relation toregulatory requirements. Encouragement and support will alsobe given to undertake research and development activities inNuclear Medicine and Medical Physics. Applicants who areaccredited to act as a Radiation Protection Adviser (RPA) will bewelcomed, though this is not essential. This post providesscope for a physicist with good specialist skills to help shapeand develop a very important Trust service. Recruitment at ahigher banding may be considered if appropriate.Situated in Kent, EKHUFT is now one of the largest NHS Trustsin the UK, with three major sites at Canterbury, Ashford andMargate.Canterbury is an excellent location to live, providing all thebenefits and facilities expected from an historic Cathedral City,along with rapid access to both the Kent countryside andcontinental Europe.Please do not hesitate to contact for further details about thispost or to arrange an informal visit. Enquiries in the firstinstance should be made to Mark Hanson, Director ofMedical Physics, using Tel: (01227 864148) or e-mail tomark.hanson@ekht.nhs.ukApplications for the post must be made on-line atwww.ekht.nhs.ukClosing date: 18th September 2011.East Kent Hospitals University NHS Foundation Trust is exemptfrom the Rehabilitation of Offenders Act 1974. All positionswithin the Trust working regularly or unsupervised with childrenor vulnerable adults will require an enhanced CRB disclosure.All other posts will require standard checks. The Trust iscommitted to safeguarding children and vulnerable adults.We positively promote flexible working practices.To ensure that our workforce reflects the populationwe serve, we welcome applications from all sections ofthe community.www.ekhuft.nhs.ukSCOPE | SEPTEMBER 2011 | 35

SCOPE | MEETING REPORTSANNUAL SCIENTIFIC MEETING OF THEIPEM SOUTH EAST GROUPMATTHEW BOLT 1 , THOMAS HAGUE 2 , PEDRUM KAMALI 1 AND EMMA WHITEHEAD 11Royal Surrey County Hospital NHS Foundation Trust2St George’s Healthcare NHS TrustROYAL SURREY COUNTY HOSPITAL NHS FOUNDATION TRUST 9th June 2011THE ANNUAL SCIENTIFIC MEETING of the IPEMSouth East Group was hosted by the Medical PhysicsDepartment at the Royal Surrey County Hospital on9th June 2011. This was excellently organised bycurrent IPEM Part II trainees with the day runningextremely smoothly from start to finish. Several of thecompanies who ensured the event could be held free ofcharge were present in the exhibition area, showcasingtheir latest developments and ensuring no-one wenthome without a few freebies.CAN WE AFFORD NOT TO HAVE PROTONTHERAPY IN THE UK?A warm welcome was given to all by Head of MedicalPhysics Andrew Nisbet (Royal Surrey CountyHospital, Guildford). The day’s programme was full,and got off to a good start with an upbeat and highlyentertaining talk given by Russell Thomas (NationalPhysical Laboratory, Teddington) on the future benefitsproton therapy may have, especially in paediatrictreatments. The topic of proton dosimetry wasdiscussed, including a description of the dosimetrychain of intercomparison that was establishedfollowing the inauguration of the first proton therapycentre in the UK. A thought-provoking conclusion wasdelivered where the financial implications of protontherapy were discussed, closing with the line: ‘Can weafford not to have proton therapy in the UK?’.ISSUES SURROUNDING PREVENTION ANDPROTECTIONFollowing the lunch break, Tom Jordan (Royal SurreyCounty Hospital, Guildford) gave a sobering talk onthe lessons learned from radiotherapy accidents,noting that reliance on software safety devices simplyis not adequate. It was clear that many lessons hadbeen learned through mistakes of the past, and it wasonly through vigilance of staff that some of these hadcome to light. Thankfully, solutions were found andradiotherapy is continuously becoming safer and moreeffective for the patient.An intriguing presentation was delivered by NedaShiravand (Queen Alexandra Hospital, Portsmouth),who discussed her recent project work investigatingthe effectiveness of eye shields for radiotherapy. It wascommented that these shields are often used whentreating superficial skin lesions close to theradiosensitive eyes and the project focussed onassessing the shield’s effectiveness against themanufacturer’s specification. A photograph takenduring the phantom study is presented in figure 1.RESEARCH INTO BREAST CANCER IMAGINGWITH X-RAYSKen Young (Royal Surrey County Hospital, Guildford)is Consultant Physicist and Head of the National CoordinatingCentre for the Physics of Mammography(NCCPM), and has played a leading role indeveloping the technical standards for mammographyin the UK and the rest of Europe. Professor Youngpresented ‘Research into breast cancer imaging with x-rays at NCCPM’. The background to this research isthe introduction of digital imaging technology in theNHS breast screening programme where 39 per cent ofx-ray systems are now digital.Digital breast tomosynthesis (DBT) is one of thelatest developments and the TOMMY research trial atsix clinical sites is comparing DBT to 2D imaging.Professor Young discussed the potential of DBT toimprove lesion detection and reduce recall rates. Thesepotential benefits arise from the system’s ability toreduce uncertainty due to overlapping tissuesmimicking or obscuring a lesion by using a limitedFIGURE 1.Ananthropomorphicphantom proveda useful toolwhen assessingeye shieldtransmission.▼36 | SEPTEMBER 2011 | SCOPE

FIGURE 2.Schematic ofdigital breasttomosynthesis(DBT).▼FIGURE 3.Simulatedclusters areinserted onto aclinical image.▼SCOPE | SEPTEMBER 2011 | 37

SCOPE | MEETING REPORTS▼number of projections of the breast (11–25) to constructtransverse slices at 1 mm spacing (figure 2).Recent work including an observer study measuringthe impact of detector performance and imageprocessing on cancer detection was also presented.Simulated calcification clusters were added into clinicalDR and CR images while adding the appropriate levelof blurring and image noise expected for these imagingsystems (figure 3). Eighty-one normal cases and 81abnormal cases (using 113 subtle added clusters) wereexamined by seven clinicians at six image qualitylevels. The results showed that calcification detectionwas sensitive to the quality of the images. It is expectedthat this data will be used to review the minimum andachievable performance standards in the UK and EUprotocols.NUCLEAR MEDICINEThe last session of the day was focussed towardsnuclear medicine. Leah Hunt (Medway MaritimeHospital, Gillingham) informed us about theimplementation of SPECT V/Q in her department,which is currently a common theme in nuclearmedicine departments across the region. BrianMcParland (GE Healthcare Medical Diagnostics,Amersham) gave us an insight into the difficultiesarising when determining the activity foradministration in paediatric PET studies due to therange of methods that can be used.An automated method of radiochromatography waspresented to us by Matthew Bolt (Royal Surrey CountyHospital, Guildford), describing the process he wentthrough to commission and implement theradiochromatogram scanner in the radiopharmacy atthe Royal Surrey County Hospital. The scanner will beused with thin layer chromatography (TLC) strips todetermine the radiochemical purity ofradiopharmaceuticals as an alternative to the ‘cut andcount’ method. The TLC strips are passed under aNaI(Tl) detector to obtain the activity profile across thestrip. We heard about the commissioning processwhere NEMA documents were used as a guide due tothe absence of current published material. The detectorlinearity (as shown in figure 4), sensitivity and spatialresolution were assessed to determine the capabilitiesof the detector. The scanner was deemed to be avaluable alternative for TLC and a QA programme wasestablished with simple and reproducible QC testsdesigned, enabling the resolution and sensitivity to bemonitored on a weekly basis.IN SUMMARYAfter the final talk, a prize was awarded to MichaelHughes (Oxford Radcliffe Hospitals) for the ‘Besttrainee presentation’. This was a tough decision thisyear due to the high standard of presentationsdelivered by each speaker. The winning talk wasenergetic and very interesting, discussing theimportance of dose rate for IMRT planning.Everyone left the meeting feeling better informedabout the continuous progression that is being madethroughout the region, with the prospect of holding themeeting on the beach in Brighton next year being metwith warm approval. nFIGURE 4.The first resultsfrom linearityand sensitivitytests duringcommissioningof theradiochromatogramscanner.▼▼38 | SEPTEMBER 2011 | SCOPE

MEETING REPORTS | SCOPEOUTCOME MEASURES IN ASSISTIVETECHNOLOGY: IPEM MEETINGKIT TZU TANG Leeds Teaching Hospital NHS TrustCARDIFF UNIVERSITY 21st June 2011THE MAIN PURPOSE OF THE MEETING was to discusscurrent practices and research that have been usingoutcome measures (OMs) and their related issues for usewithin the field of assistive technology (AT).AT includes a wide range of assistive, adaptive andrehabilitative devices for people with disabilities. This alsoconsists of the process used in selecting, locating and usingthese devices. Within clinical/rehabilitation engineering,AT includes seating and postural management; electronicassistive technology; functional electrical stimulation (FES);orthotics and prosthetics; mobility aids such aswheelchairs; gait analysis, and other aids for daily living.In the field of rehabilitation engineering, there is atendency to assume the benefits of AT usage are selfevident.However, with an increasing importance towardsevidence-based practice, there is a need for OMs that canprovide a reliable method of measuring the efficacy of anychosen clinical intervention. This would then enable a morerobust practice with significant evidence base. The maintypes of OMs are either objective measurements orqualitative/psycho-social measures (e.g. questionnaires),which could be used to inform choices of intervention,clinical governance, assess service quality and delivery.The meeting began with an opening by Paul O’Connell(Rookwood Hospital, Cardiff), who also chaired the firstsession. Firstly, Max Feltham (Oxford Brookes University)gave an overview on an alternative method (DataGait) toobjectively measure spatial temporal gait parameterswithout the need for the more expensive and timeconsuming3D gait analysis system. He was followed byGareth Adkins (ABM University Health Board, Swansea)who presented on the framework for OMs in AT that theRehabilitation Engineering Unit in Swansea was using toprioritise its work and development of using OMs. Currentand future research on OMs at Swansea was also discussed.After coffee, Gary Derwent (Royal Hospital for Neurodisability,London) detailed his work on the developmentof web-based software to support goal-attainment scalingin AT. Goal-attainment scaling (GAS) has been developedas a form of qualitative outcome measurement tool, whichcould be integrated into clinical practice by goal setting.Gary described his ongoing research into developing aweb-based tool to support clinicians to write, manage andanalyse goals in AT by using pre-set elements to ‘build’goals for each individual. Megan Dale (Cardiff and ValeUniversity Health Board, Cardiff) then described anothertype of qualitative outcome measurement tool, the patientreported outcome measures, which has been used in theNHS since 2009. This method could potentially be used inthe field of AT given that it is validated for the populationof interest.The last presentation in this session was given by Yat-Ting Kwan (Salisbury District Hospital), who talkedthrough the three alternative OM techniques that theNational Clinical FES Centre at Salisbury has recentlyadopted. The visual analogue scale, the BORG rate ofperceived effort scale replacing the physiological costindex (PCI) test, and the goal attainment scale have beenadded to the treatment pathway to measure patientspecific goals.Following lunch, there were a further threepresentations which looked at different OM in AT. HollyJenkins (Cardiff and Vale University Health Board,Cardiff) detailed a comparison study between PCI and thetotal heart beat index (THBI) for estimating gait efficiency,where THBI uses ECG data to determine the number ofheart beats per metre. Robert Lievesley (NuffieldOrthopaedic Centre, Oxford) followed this with a talk on apossible OM for computer access bit rate calculation,which is a measure of the amount of information a usercan successfully send to a computer in a certain period oftime using a brain computer interface. The lastpresentation was given by Mary McDonagh (CentralRemedial Clinic, Dublin), who shared her experience ofusing different OMs for their seating and mobility service.She outlined the advantages and disadvantages of eachmeasure used and barriers of using OMs in clinical seatingservices. One of the lessons learned from Mary’s work wasto start small and then build up; for example, focus on aspecific patient group or target a single intervention first.The day ended with Paul O’Connell leading an opendiscussion. This was a good opportunity to exchange ideasand facilitate a discussion for the way forward, such assuggestions for IPEM to promote alliances between similarservices to reduce duplication of effort; creation of aREBSIG working party and/or sub-group in this area andto provide guidance in best practice for OMs in AT. Thegroup also thought that OMs could be an integral part of aquality management system; however, currently OMstended to be measures of service delivery in therehabilitation engineering sector and not the outcome of anintervention. There were also some concerns over the waysin which FES services are funded differently. Some centresare having their funding withdrawn even though NICEhas recommended the use of FES based on evidence. Thismay suggest that there is an increasing need for OMswithin FES services in order to provide up-to-dateevidence of the efficacy of the intervention when applyingfor funding.Everyone acknowledged the fact that there is a realneed to carry out OMs in AT, but the difficulty is to knowwhere to start. It was thought that knowing your targetaudience and focus on a specific group first would beessential. Both objective and/or subjective measures couldbe used depending on its validity and the required aim.Although no ground-breaking new solutions becameapparent, the meeting was useful and raised importantconsiderations. It provided a platform where ideas of OMsin AT were exchanged and facilitated a discussion on thescope for future developments within this area. nSCOPE | SEPTEMBER 2011 | 39

SCOPE | MEETING REPORTSRADIATION PROTECTION ADVISERS(RPA) UPDATE MEETING 2011CHRIS WOOD Northampton General HospitalMANCHESTER CONFERENCE CENTRE 14th June 2011THE ANNUAL RADIATION PROTECTION ADVISERS(RPA) UPDATE organised by IPEM’s Radiation ProtectionSpecial Interest Group and held in Manchester drew anaudience of 140 delegates keen to hear what was currentin radiation protection.The morning session saw talks from the regulatorybodies, kicking off with Rob Wellens (Health and SafetyExecutive, London) providing an update on changes tothe Basic Safety Standards (BSS) Directive. The first pointto note is that this has changed from a ‘recast’ to a‘revision’, and as such all articles in the BSS are now opento negotiation. IPEM, through representatives onstakeholder working groups, are working to ensure thatthe implications on the healthcare sector are considered.The Health and Safety Executive will be offering a chanceto contribute to discussions by creating an electronic‘community of interest’ on their website.Bob Russ (Environment Agency, Bristol) then deftlytrod the minefield that is the review of the ExemptionOrders to give an update on progress. Given that this hasbeen described as ‘the biggest change in the regulation ofradioactive substances in 50 years’, this is certainly nomean feat and explains why the review has beenunderway since 2006. It is hoped that the regulations willcome into force by 1st October 2011, and a transitionalarrangement will be made to allow users to continue tooperate under the ‘old’ provisions until 1st April 2012.Should the radioactive material you use no longer becovered by an exemption order, an application for either anew permit or a variation to your existing permit willhave to be made during the transitional period.The prize for the funniest moment of the day wasawarded to a heavily pregnant Gillian Rodaks (Healthand Safety Executive, Aberdeen) for her impression of aNorth Sea oil rig worker who just realised that he hasinadvertently handled a 50 GBq Cs-137 source. Given thatthis was well before the watershed, and to spare theaudience’s blushes, Gillian gracefully omitted theprobable word(s) used.Whilst an oil rig in the North Sea is about as far as youcan imagine from the hospital environment, the failingscausing the incident (inadequate risk assessment,insufficient training, lack of procedures, lack of awarenessof local rules) are applicable to all work situations. In thisinstance the introduction of a simple procedure to checkthe source location could have spared the employerprosecution and a £300,000 fine.Back on dry land, the HSE have been kept busy withreports of staff doses exceeding the statutory limits. All ofthese notifications have come from staff membersmonitored using TLDs supplied by approved dosimetryservices. Lessons learned include liaising with thedosimetry service for their input and informing the HSEpromptly, unless it can be shown beyond reasonabledoubt that the dose limit was not actually exceeded.Pat Horton (Royal Surrey County Hospital, Guildford)gave the first of the day’s two talks concerningradiotherapy as he described progress on the rewrite ofthe IPEM report on radiotherapy room design (IPEMReport 75). In a field of rapidly advancing technology(tomotherapy, Cyberknife), new techniques (IMRT,particle therapy) and new building materials (Ledite,Verishield), a review of shielding requirements waswarmly welcomed by the audience.The working group hopes to make further use ofworkload data extracted from radiotherapy managementsystems in the future. These will provide factors for use indesign calculations and back up the assumptions made inthe previous report. Such management systems open upthe possibility of easily collecting data on workload, dutycycles, orientation factors and IMRT factors. In addition, itis hoped that in the future the calculations presented inReport 75 will be compared with Monte Carlo simulations.Stuart Green (University Hospitals Birmingham) gavea glimpse into the future as he gave an excellentpresentation on the radiation protection issues associatedwith proton therapy. Whilst proton therapy may offerimproved clinical outcomes by taking advantage of theproton’s favourable characteristics in tissues (figure 1),hardware issues and size may be the treatment’s limitingfactor at present (figure 2). Such treatments will have aconcomitant neutron dose, the biological effects of whichremain a research area, but Stuart argued that protontherapy units spare the patient from the leakage radiationand scatter dose associated with photon treatments.Issues that will trouble the RPA include the activationof machine components and neutron shielding. Given theclinical advantages of proton treatments, Stuart hopedthat the RPAs of the future will be kept busy as thetechnique becomes increasingly prevalent in the UK.Karen Fuller (Sheffield Teaching Hospital) gave acautionary tale involving an intra-oral x-ray unit thatspontaneously exposed. Two staff members were close tothe tube head when this occurred, but doses weresubsequently estimated to be fairly negligible (effectivedose

MEETING REPORTS | SCOPEFIGURE 1.Example of aproton therapytreatment.▼FIGURE 2.Proton therapygantry.▼SCOPE | SEPTEMBER 2011 | 41

SCOPE | INTERNATIONAL NEWSMEETINGS 2011IPEM MEETINGSMeeting Venue and dates More informationSpecifying, Evaluating and Selecting MedicalEquipmentNational Railway Museum, York13th SeptemberThis meeting on medical equipment procurement will explorehow to specify, how suppliers should respond to specificationsand how to evaluate the responses and make objectivedecisions, bearing in mind financial and other regulations7th Annual IPEM Medical EngineeringTechnologists Study DayYork Racecourse22nd SeptemberThe 7th Annual IPEM Medical Engineering Technologist StudyDay, in conjunction with DraegerLaser Output Measurement WorkshopWessex Specialist Laser Centre,Salisbury29th SeptemberThis workshop will include hands-on sessions measuring andmonitoring the output from a number of medical lasers/IPL, aswell as lectures and discussion sessionsOncology Management Systems and their Usein Cancer CareMIC Centre, London11th OctoberThis meeting is an opportunity for people working with oncologymanagement systems to share their experiences across a rangeof topics such as configuration, management, integration,upgrading, data extraction and other potentially innovative usesIPEM Report 32 Volume 7: Experiences withTesting CR and DRBritish Institute of Radiology, London21st OctoberOne year on from the publication of IPEM Report 32 Volume 7,this meeting will be a chance to discuss experiences with thebasic and quantitative tests, as well as optimising AEC set-upsPass or Fail: Determining Acceptable MedicalDevice GovernanceFairmont House, York1st NovemberThis meeting will provide an opportunity to hear directly fromrepresentatives of organisations with a medical devicegovernance remit, as well as a forum for debateMR Safety UpdateSociety of Chemical Industry, London9th NovemberThis meeting is intended to provide the MR workforce with apractical update on current issues in MR safetyElectrons: Dosimetry, Planningand TreatmentAustin Court, Birmingham10th NovemberThis scientific meeting will be a chance to focus on currentdevelopments and issues in electron beam therapy, includingdosimetry, treatment planning and deliveryOTHER UK MEETINGSAppropriate Healthcare Technology forDeveloping Countries17th Annual Scientific Meeting of the BritishChapter ISMRMBioengineering11IME, London7th SeptemberUniversity of Manchester7th–9th SeptemberQueen Mary, University of London12th–13th Septemberhttp://events.imeche.org/EventView.aspx?EventID=1036http://www.bii.manchester.ac.uk/bc-ismrm2011http://www.bioeng.org.ukSafety Acceptance Criteria: Is ALARP Enough?Safety & Reliability Society, Manchester15th Septemberhttp://www.sars.org.uk/conf.htmImproved Outcomes in Radiotherapy: ThePromise of New TechnologiesEngineers and Surgeons: Joined at the Hip IIIIET, London19th SeptemberRoyal College of Surgeons, London1st–3rd Novemberhttps://www.rcr.ac.uk/membersarea/multievents/displayEvent.asp?Type=Full&Code=COASM2011http://events.imeche.org/EventView.aspx?EventID=919Incontinence: The Engineering Challenge VIIIIME, London7th–8th Decemberhttp://events.imeche.org/EventView.aspx?code=s154513th International Radiation ProtectionAssociation (IRPA) CongressScottish Exhibition and ConferenceCentre, Glasgow13th–18th May 2012http://www.irpa13glasgow.com42 | SEPTEMBER 2011 | SCOPE

INTERNATIONAL NEWS | SCOPEMEETINGS 2011EUROPEAN MEETINGSMeeting Venue and dates More informationSensors and their Applications XVICork, Ireland12th–14th Septemberwww.eventsforce.net/iop/frontend/reg/thome.csp?pageID=36439&eventID=104&eventID=1045th European Conference of theInternational Federation for Medical andBiological EngineeringJoint ECCO 16, 30th ESTRO and 36th ESMOMultidisciplinary CongressIAEA: International Conference on ClinicalPET and Molecular Nuclear Medicine –Trends in Clinical PET andRadiopharmaceutical DevelopmentIAEA: International Conference on the Safeand Secure Transport of RadioactiveMaterial: The Next Fifty Years of Transport -Creating a Safe, Secure and SustainableFrameworkIAEA Workshop: Monte Carlo RadiationTransport and Associated Data Needs forBudapest, Hungary14th–18th SeptemberStockholm, Sweden23rd–27th SeptemberVienna, Austria8th–11th OctoberVienna, Austria17th–21st OctoberTrieste, Italy17th–19th Octoberwww.embec2011.com/?mod=content&cla=content&fun=access&id=84&mid=1&temp=basehttp://www.ecco-org.euhttp://www-pub.iaea.org/MTCD/Meetings/Announcements. asp?ConfID=38296http://www-pub.iaea.org/MTCD/Meetings/Announcements.asp?ConfID=38298http://www-nds.iaea.org/MC2011/MC2011.htmlxNORTH AMERICAN MEETINGSMedical ApplicationsWorld Molecular Imaging CongressSan Diego, CA7th–10th Septemberhttp://www.wmicmeeting.org/homeEmail: ami@ami-imaging.org7th Annual Harvard Medical SchoolBrachytherapy ReviewMICCAI 2011: 14th International Conferenceon Medical Image Computing and ComputerAssisted InterventionComputational Bioimaging: Special Track ofthe 7th International Symposium on VisualComputing (ISVC11)ASTRO’s 53rd Annual MeetingBoston, MA16th–17th SeptemberToronto, Canada18th–22nd SeptemberLas Vegas, NV26th–28th SeptemberMiami Beach, FL2nd–6th Octoberhttp://cme.med.harvard.edu/index.asp?SECTION=CLASSES&ID=00311359http://www.miccai2011.orgwww.isvc.nethttp://www.astro.org/Meetings/AnnualMeetings/index.aspxAAPM CT Dose SummitDenver, CO7th–8th Octoberhttp://www.aapm.org/meetings/2011CTS/default.aspEmail: karen@aapm.orgNuclear Medicine and PET Hands-OnWorkshop: Physics, Testing, andAccreditation8th Annual Memphis BioImaging SymposiumHouston, TX14th–16th OctoberMemphis, TN3rd–4th NovemberEmail: gmoore@mdanderson.orghttp://www.membis.orgRadiological Society of North AmericaAnnual MeetingChicago, IL27th November–2nd Decemberhttp://www.rsna.org▼SCOPE | SEPTEMBER 2011 | 43

SCOPE | INTERNATIONAL/MEMBERS’ NEWS▼MEETINGS 2011Meeting Venue and dates More informationNORTH AMERICAN MEETINGS CONTINUEDThe Process of Quality Assurance in ProstateBrachytherapy MD Anderson Cancer CenterHouston, TX3rd–4th Decemberhttp://www.mdanderson.org/education-andresearch/education-and-training/schools-andprograms/cme-conferencemanagement/conferences/cme/conference-managementthe-process-of-quality-assurance-in-prostatebrachytherapy.htmlSymposium: Practical Aspects of Stereotactic BodyRadiation Therapy (SBRT)12th Mexican Symposium on Medical PhysicsStanford, CA9th–10th DecemberOaxaca, Mexico20th–22nd March 2012http://xinglab.stanford.eduEmail: lei@stanford.eduhttp://www.hraeoaxaca.salud.gob.mx/SIMPOSIUM/Invitation.htmlEmail: flaviotrujillo@gmail.comNEW MEMBERS 2011Full name Job title Organisation TownCoral Stockley Senior Clinical Technologist Dorset County Hospital NHS FT DorchesterAndrew Day-Smith Rehabilitation Engineer Plymouth Hospitals NHS Trust PlymouthStephen Vincent Senior Electronics Technician Stoke Mandeville Hospital AylesburyWayne Jarvis Senior Electronics Technician Stoke Mandeville Hospital AylesburyJohn Hirons Technical Manager, CCISS University Hospitals Birmingham NHS FT BirminghamMark FieldsSenior NCO MDSS Workshop &TrainingRAF Henlow CamMark Powell Medical Physicist Royal Sussex County Hospital BrightonMohammad Saleem Medical Technical Officer Pinderfields General Hospital WakefieldDavid Turner Senior Healthcare Scientist The Leeds Teaching Hospitals NHS Trust LeedsBhupinder Rai Trainee Clinical Scientist University Hospital Coventry & Warwickshire CoventryJames Dicks Medical Physicist University Hospitals Birmingham NHS FT BirminghamKa Ho Chiu Electrical Technician Prince of Wales Hospital Hong KongPrasanasarathyNariyangaduLead Radiotherapy Physicist Mount Vernon Hospital NorthwoodRichard Twycross-Lewis Research Supervisor Mile End Hospital LondonJames Neill Egan Radiotherapy Scientist Betsi Cadwaladr University Health Board Rhyll44 | SEPTEMBER 2011 | SCOPE

INTERNATIONAL/MEMBERS’ NEWS | SCOPEMEETINGS 2011REST OFTHE WORLDMeeting Venue and dates More informationBasic Clinical Radiobiology: ESTRO EndorsedTeaching CourseIAEA: International Conference on Research Reactors– Safe Management and Effective Utilization32nd Annual Conference of the Association of MedicalPhysicists of IndiaInternational Conference on Biomedical Engineering12th International Conference on Electronic PatientImaging (EPI2k12)Rotorua, New Zealand30th October–3rd NovemberRabat, Morocco14th–18th NovemberVellore, India16th–19th NovemberManipal, India10th–12th DecemberSydney, Australia12th–14th March 2012http://www.nzradbio2011.orgEmail: nzradbio2011@tcc.co.nzhttp://www-pub.iaea.org/MTCD/Meetings/Announcements.asp?ConfID=38299http://www.ampicon2011.org.inEmail: info@ampicon2011.org.inhttp://uic.manipal.edu/icbmehttp://epi2k12.orgQualificationsNew memberor transferCategory Date electedHNC Medical Physics & Physiological Measurement, London Transfer Incorporated 7 Apr 11New member Incorporated 7 Apr 11BSc (Hons) Telecommunication & Electronics, Milton Keynes New member Incorporated 7 Apr 11New member Incorporated 7 Apr 11BA (Hons) Electronics & Computer Science, Milton Keynes New member Incorporated 7 Apr 11New member Incorporated 7 Apr 11BSc (Hons) Physics with Management Studies, Brighton New member Incorporated 7 Apr 11New member Incorporated 7 Apr 11BSc (Hons) Natural Sciences, Milton Keynes / MSc Medical Science, Milton Keynes New member Incorporated 7 Apr 11BSc (Hons) Physics, London / MSc Medical & Radiation Physics, Birmingham New member Associate 11 May 11BSc (Hons) Chemistry, Birmingham / PhD Bioinorganic Chemistry, Nottingham New member Associate 11 May 11MEng Biomedical Engineering, Hong Kong New member Associate 11 May 11BSc Physics, Chennai / MSc Medical Physics, Chennai New member Corporate 21 Apr 11BSc (Hons) Sport & Exercise Science, London / MRes Advanced InstrumentationSystems, London / PhD Medical Engineering, LondonTransfer Corporate 21 Apr 11BSc (Hons) Physics, Liverpool / MSc Medical Physics, Aberdeen Transfer Corporate 25 May 11SCOPE | SEPTEMBER 2011 | 45

SCOPE | BOOK REVIEWSWelcome toanother newissue of theScope bookreview section.In this issue, wepresent ourreaders with six interesting reviews: fivefrom the medical physics genre and onefrom the popular science genre.The first review is of the 2010published ICRU Report 83 (IMRT), by acolleague from my own centre here atPoole, Stephen Moloney. This is followedby Professor Angela Newing’s review ofRadiation Physics for Nuclear Medicine.Sarah Cade examines Tomographic ImageReconstruction and Quantification forPET/SPECT, and Julian Minns presents areview of Biomaterials for TissueEngineering Applications. Imaging fromthe Radiotherapy in Practice series ispresented by Tony Greener. Finally, MarcMiquel, our own Editor of Scope, haswritten a review (one of many!) of TheBeautiful Invisible.“It allows one to learn,analyse, reflect andcommunicate findings tomore than 3,500 IPEMmembersThe ‘Just Published!’”section contains agood mix of recent or soon to bepublished medical physics andengineering texts. The ‘New Reports’section contains some very interestingreports, including the new ICRU Report85 – Fundamental Quantities and Unitsfor Ionizing Radiation.As always, if you are interested inreviewing any of the new texts (or evenreports) listed in this issue, please dropus an email so we can send you details ofjoining our online workspace – Ubidesk.The workspace details a selection ofbooks we have available for review,reviewer guidelines, submission (ofreview) area, noticeboard and muchmore.Reviewing has its own perks (apartfrom taking some of your ‘free’ time!) – itallows one to learn, analyse, reflect andcommunicate findings to more than 3,500IPEM members, with an added bonus: itcounts towards your CPD! Please join us!Usman I. Lula(Usman.Lula@Poole.nhs.uk)Marium Naeem(Marium.Naeem@gstt.nhs.uk)Prescribing,Recording andReporting Photon-Beam Intensity-Modulated RadiationTherapyAs the title suggests, this report builds onthe advice given in ICRU Reports 50 and 62,regarding treatment specification for photonbeam radiotherapy. However, this title onlyapplies directly to one chapter.The report as a whole serves a differentpurpose. As the authors state, as well asproviding the information necessary tostandardise techniques, it broadly discussesall aspects of IMRT, describing in somedetail the physical, technical, treatmentplanning and clinical considerations.The introductory chapter gives a shorthistory of radiotherapy planning anddiscusses ICRU Reports 50 and 62, IMRTdelivery, imaging and margins. A chapter onoptimised treatment planning follows. Thereis an interesting explanation of the inverseplanning process, although some of theexamples are perhaps too specific to aparticular treatment planning system. Thechapter contains much repeated material – afeature of the first third or so of this report.The chapter also contains some errors in theexplanation of equations and diagrams. I feltthat the document improved in the thirdchapter and for its remainder. This is wherewe get to material relating to the document’stitle, presenting the quantities suggested foruse in reporting and prescribing IMRT, andgiving clear explanations as to why. Of these,the most notable are the PTV ‘nearminimum’and ‘near-maximum’ doses(D 98% and D 2% , respectively), which thereport recommends should replace theminimum and maximum doses. The ICRUreference point dose is also replaced with themedian dose (D 50% ).Chapter 4 gives an explanation of thevolumes that need to be defined intreatments. There is little new here, but thechapter does give a very good recap of thevolumes defined in ICRU 50 and 62 (GTV,CTV, PTV, etc.) with good examples andfigures. This would make an excellentintroduction to these concepts for someoneencountering them for the first time.Chapter 5 gives a useful, if brief, guideon dealing with some tricky situations ininverse planning, e.g. conflicting goals foroverlapping volumes. The report endswith two appendices, one on the physicalaspects of IMRT and another givingclinical examples. The former brieflycovers topics such as beam modelling,dose algorithms and commissioning/QA.The section on clinical cases is clearlyand comprehensively written. There areno obvious errors here and the examplecases are good. The definitions are verydetailed and readable. The text was foundto be generally well written andreferenced.Although its title does not reflect itscontents well, the report achieves the aimsset out in its early sections. There areelements of this report that are essentialreading for physicists, dosimetrists andclinicians in any department performingor planning to perform IMRT.There are some poorly written sections,particularly earlier on, and the figures arenot of a uniformly high standard.Fortunately, for most of the document thisis not the case and the report would makeuseful reading for those mentioned above.Due to the cost, I would notrecommend that an individual purchasesthis report, but a radiotherapy departmentshould have it in its library.Stephen Moloney and Joe Davies, PooleHospital NHS Foundation TrustPRESCRIBING, RECORDING AND REPORTINGPHOTON-BEAM INTENSITY-MODULATEDRADIATION THERAPYJOURNAL OF THE ICRU, VOLUME 10, NO 1 (2010),REPORT 83Publisher: Oxford University PressISSN: 1473-6691 (print) 1742-3422 (online)Pages: 106Radiation Physics forNuclear MedicineI found this book somewhat difficult tonavigate. It was produced following atraining course on ‘Radiation physics in46 | SEPTEMBER 2011 | SCOPE

BOOK REVIEWS | SCOPEnuclear medicine’ held in Milan in 2008,and is a collection of the lectures broughttogether as chapters in the book. It is thejob of book editors preparing material fromcourses and conferences for publication toiron out the differences of style of thevarious authors and to put the chapters inthe order that makes them hang together asa textbook. I do not think that these editorshave succeeded in either goal.The order of chapters is not what Iwould have chosen. The details of everyparticular technique in nuclear medicineare all available somewhere in the text, buta student wanting to read up on PET, forinstance, will find information about PETscanners and the isotopes used in Chapter5, but will have to wait until Chapter 8 tofind out what PET is and how it works.The same applies to SPECT. What works ina taught course, where students can askquestions and clarify details as they goalong, does not always hold true for abook.There is a wealth of useful informationhere with good diagrams and plenty of upto-datereferences. Any student wanting agrounding in nuclear medicine will findthe book useful once they have found theirway around it.Angela Newing, Gloucestershire NHSFoundation Trust (retired)RADIATION PHYSICS FOR NUCLEAR MEDICINEMARIE CLAIRE CANTONE AND CHRISTOPHHOESCHENPublisher: SpringerISBN: 978-3-642-11326-0HardbackPages: 285Tomographic ImageReconstruction andQuantification forPET/SPECTThis book is the publication of the author’sPhD thesis and as such does not flow in theway one would expect of traditionaltextbooks covering a similar topic. The bulkof the text is devoted to an in-depthcoverage of a very small area of the topic ofnuclear medicine image reconstruction. Thefirst chapters cover background and areview of the literature relating to the topic.Both of these chapters cover the essentialpoints but do not explain the basics and sowould be of limited use to readers withoutprior knowledge of the subject matter. Thereadability of the book is generally limitedby frequent grammatical errors and anumber of typographical errors. There arealso a number of places where the variablesused in equations have not been definedand the labelling of figures (such as graphaxes) is illegible or non-existent.In the text, the author proposes amedian-based prior for use in penalisedlikelihood image reconstruction andcompares the use of this prior to otherpriors such as quadratic priors. The bulk ofthe text analyses the performance of theproposed prior in terms of resolutionrecovery, partial volume correction andnoise characteristics. The use of the priorsin list mode reconstructions is alsodiscussed.This book is most likely to be of interestto researchers working in a similar area tothe author. However, it is noted that theauthor of the book has published a numberof journal articles on topics similar to thosecovered in this book, and so with arecommended retail price of £61 for thebook, it is unlikely to represent good valuefor money.Sarah Cade, Royal United Hospital, BathTOMOGRAPHIC IMAGE RECONSTRUCTION ANDQUANTIFICATION FOR PET/SPECT – NON-UNIFORM RESOLUTION AND PARTIAL VOLUMERECOVERY METHODSMUNIR AHMAD AND ANDREW TODD-POKROPEKPublisher: VDM Verlag Dr MullerISBN: 978-3-639-21421-5Pages: 196Biomaterials forTissue EngineeringApplicationsThis book is in three sections, and to quotethe editor’s opening remarks, ‘we askedseveral emerging experts who we thoughtmay contribute a fresh perspective on thistopic’. The three main sections deal with:1. the variety of types of materials … forengineering a range of tissues;2. the biomaterial component in theengineering of specific tissues (and manyexamples are given), and3. translation of these new tissues to theclinic, such as trial design.“We asked severalemerging experts who wethought may contribute afresh perspective on thistopicThe first”two sections mentioned couldreally be combined but the material withinthese sections is excellently produced withgood clear diagrams and an exhaustivereference list at the end of each chapter. Thelast section, a single chapter, is a majordisappointment which says the obviousabout material implant development andthe regulatory framework that exists. Itcould have had other chapters citing someexamples of materials in tissue engineeringthat have succeeded in being used in theclinical market and why they are successful,a big-let down and an opportunity missed.The biggest fault I found with this bookwas the total dominance of workperformed in the US by these so-called‘emerging experts’. With the exception oftwo groups in Canada, all of the work citesresearch performed in America withpractically no reference to any researchperformed outside the States. There ispioneering work being performed on stemcells with biomaterials in Europe, notablyLondon and Sweden, and biomaterials intissue engineering applications in Germanand Italian laboratories which are notdescribed or cited at all. Anyoneconsidering purchasing this book orconsidering it as a useful reference sourcein tissue engineering should bear this inmind.It is, however, a rich reference source ofStateside research in this area and issuperbly produced with high-qualityreproduction of the diagrams throughout.Julian Minns, University of Wales Institute,Cardiff, and Newcastle General Hospital(retired)BIOMATERIALS FOR TISSUE ENGINEERINGAPPLICATIONS: A REVIEW OF THE PAST ANDFUTURE TRENDSJASON A. BURDICK AND ROBERT L. MAUCKPublisher: SpringerISBN: 978-3-709-10384-5Pages: 564▼SCOPE | SEPTEMBER 2011 | 47

SCOPE | BOOK REVIEWS▼Imaging(Radiotherapy InPractice)If Tony Blair had chosen clinical oncologyas a career path rather than politics, onecould imagine his education mantra beingreplaced with imaging, imaging and moreimaging. The latest book in the popularRadiotherapy in Practice series covers thiscrucial area, attempting to bridge the gapbetween detailed imaging books andgeneral oncology texts.The book leads with basic descriptions ofthe most common imaging modalities, i.e.plain x-rays, ultrasound, CT, MR, nuclearmedicine and PET, providing the readerwith sufficient information to interpret thefollowing 19 chapters. Each of thesesubsequent site-specific chapters has beenjointly written by an oncologist and aradiologist, providing an authoritativeoverview covering clinical background,diagnosis and staging, imaging forradiotherapy planning and finallytherapeutic assessment and follow up. Thisstructure ensures that on the whole interchapterconsistency is maintained.Small variation in content is arguably tothe reader’s advantage with, for example,several chapters providing more detaileddiscussion of the tumour, node, metastases(TNM) clinical staging system. Theperformance of staging imaging tests areoften referenced in terms of their sensitivity(ability to pick up disease) and specificity(ability to exclude disease) providing auseful reminder that there is no perfectimaging modality. Additionally there arecautionary warnings of the dangers of overstaging which could negate potentiallycurable treatment options for some patients.The role of imaging in treatmentverification is only touched on in somechapters and the more recent advances suchas cone beam and megavoltage CT remainlargely unmentioned.Last but not least, there is a chapter onradiation protection issues when imagingpatients for radiotherapy. This provides avery useful synopsis of the basic doseindicators used in imaging along with aresumé of relevant legislation. Justificationand assessing the patient imaging dose isdiscussed in the context of a radiotherapyepisode along with tables of dose perexamination for a range of sites.The appendices provide further usefuldetail, covering research and imaging inradiotherapy along with useful radiationprotection data.As you would hope from a book onimaging, there are plenty of well-annotatedillustrations, with a central section ofcoloured images. The main remit of thebook, to provide guidance to oncologistsand radiologists on the use of imaging inthe management of patients withmalignancy, is achieved.I would recommend this book toradiotherapy physicists, dosimetrists andradiographers involved in treatmentplanning. It will also be of interest to otherimaging physicists requiring a conciseoverview of imaging for staging andtreatment planning in radiotherapy.Tony Greener, Guy’s and St Thomas’ NHSFoundation Trust, LondonIMAGING (RADIOTHERAPY IN PRACTICE)PETER HOSKIN AND VICKY GOHPublisher: OUP, OxfordISSN-13: 978-0199231324Pages: 336The BeautifulInvisible: Creativity,Imagination, andTheoretical PhysicsThe link between creativity, the arts andscience is an easy one to make; you caninstantly think of Leonardo Da Vinci,architecture, symmetry (if you haven’t,please read Marcus Du Sautoy’s FindingMoonshine) or the work by anatomists fromthe écorchés of Jacques Fabien Gautierd’Agoty to Paul Pfurtscheller ‘s amazinganimal charts. However, the general publicmight have more difficulty to link artisticcreativity to the apparently dry world ofphysics; only because we were badly taughtthe boring side of physics before reachingtheoretical physics, would argue GiovanniVignale.Endeavouring to narrate some of theideas of theoretical physics as a gallery of‘invisible paintings’ is a noble andpoetical concept that Vignale tackles inhis second book, The Beautiful Invisible.However, readers might find it a bit offputtingand very limiting to choose todescribe, right from the onset of the book,theoretical physics, the ‘science of theinvisible’, as a ‘modern form oftheology’. Last time I checked, you couldnot test theology with well-designedexperiments, nor could you easily predictfuture discoveries thanks to it.Vignale successfully sticks to hispromise not to teach but to introduceimportant ideas and concepts withminimal use of mathematics. However, Ifelt that the author’s constant referral toart and extensive use of quotes (RobertMusil definitely is his favourite) distractsfrom and weakens his objective andcentral aim, to demonstrate the creativityand imagination of his field of science.“The general publicmight have more difficultyto link artistic creativity tothe apparently dry worldof physicsNevertheless, the”book really comes tolife in the latter quantum chapters, thepace quickens and one can feel theauthor is back in his favouriteenvironment.The Beautiful Invisible is an easy andenjoyable book to read, it is inspirationalat times but more often than not, it lacksthe invisible spark that would make ittruly beautiful.Marc E. MiquelTHE BEAUTIFUL INVISIBLE: CREATIVITY,IMAGINATION, AND THEORETICAL PHYSICSGIOVANNI VIGNALEPublisher: OUP OxfordISSN-10: 9-780-19957-484-1Pages: 320Just Published!Physics MCQs for the Part 1 FRCR byShahzad Ilyas et al. (Cambridge UniversityPress) is a must-have revision resource forthe new format Part 1 FRCR exam,covering the complete curriculumincluding ultrasound and MRI. It is writtenby a team of specialist registrars who haverecently successfully passed the Part 1FRCR exam and a renowned medicalphysicist.48 | SEPTEMBER 2011 | SCOPE

BOOK REVIEWS | SCOPEComputed Radiation Imaging – Physicsand Mathematics of Forward and InverseProblems by Esam M. A. Hussein (ElsevierScience Publishing) addresses both thephysical and mathematical aspects of theimaging problem. It discusses the inherentphysical and numerical capabilities andlimitations of the methods presented forboth the forward and inverse problems.Nuclear Medicine Physics (The Basics), 7thRevision by Ramesh Chandra (LippincottWilliams & Wilkins) is resource for radiologyresidents and practitioners, nuclearcardiologists, medical physicists andradiologic technologists. It includes morethan 100 illustrations that underscoredifficult concepts, review questions at theend of each chapter to help you master thematerial, and more.Medical Image Processing by GeoffDougherty (Springer) examines theconceptual framework of image analysisand the effective use of image processingtools, using applications in many fields todemonstrate and consolidate specific andgeneral concepts, and to build intuition,insight and understanding.Practical Biomedical Signal AnalysisUsing MATLAB by Katarzyna Cieslak-Blinowska and Jaroslaw Zygierewicz (Taylor &Francis) bridges the gap between themethods and practice of biomedical signalanalysis for solving concrete problems.Lasers in Dermatology and Medicine byKeyvan Nouri (Springer) is an up-to-datereview of medical applications involvinglasers – a welcome and highly practicaladdition to the literature. Itscomprehensive content covers everythingfrom dermatology to gynaecology toneurosurgery.Biomechanics of the Brain by Karol Miller(Springer), a first in brain biomechanics,presents an introduction to brain anatomyfor engineers and scientists. Experimentaltechniques such as brain imaging andbrain tissue mechanical propertymeasurement will be discussed, as well ascomputational methods for neuroimageanalysis and modelling of braindeformations due to impacts andneurosurgical interventions.Handbook of Particle Detection andImaging by Claus Grupen and Irene Buvat(Springer) centres on detection techniquesin the field of particle physics, medicalimaging and related subjects.New Reportsn Fundamental Quantities and Units forIonizing Radiation: ICRU Report 85.Journal of the ICRU (OUP Publishing)2011; Volume 11, No. 1.n Medical Cyclotrons (including PETRadiopharmaceutical Production).IPEM Report 105; 2011.n Size-Specific Dose Estimates (SSDE) inPediatric and Adult Body CTExaminations. AAPM Report 204;2011.n Quality Assurance of US-guidedExternal Beam Radiotherapy forProstate Cancer. AAPM Report 154;2011.n Quality Assurance for RoboticRadiosurgery. AAPM Report 135;2011.n Health Risks from Radioactive Objectson Beaches in the Vicinity of theSellafield Site. HPA-CRCE-018; 2011.n Assessment of Personal Exposures toNon-laser Optical Radiation inEntertainment. HPA-CRCE-016; 2011.n Monitor: Newsletter of the PersonalDosimetry Service (formerly PersonalMonitoring Services). HPA; 2011.n Modernising Scientific Careers (MSC)Checklist (and associated material),www.NHSEmployers.org; 2011.n Implementation of the InternationalCode of Practice on Dosimetry inDiagnostic Radiology (TRS 457):Review of Test Results. IAEA HumanHealth Reports No. 4, STI/PUB/1498;2011.n Clinical Training of Medical PhysicistsSpecializing in Nuclear MedicineTraining Course Series No. 50. IAEA-TCS-50; 2011.CENTURY ONE PUBLISHINGIS THE UK’S BRIGHTESTAWARD-WINNINGCONTRACT PUBLISHINGAND ADVERTISING SALES AGENCY.WE WORK EXCLUSIVELYWITH MEMBERSHIPORGANISATIONS GENERATINGADVERTISING REVENUESAND MANAGINGALL OR PART OF THEPUBLISHING FUNCTIONTo plan your ad campaign inScope magazine contact:David Challenort: 01727 739 196e: dave@centuryonepublishing.ltd.ukw: www.centuryonepublishing.ltd.ukSCOPE | SEPTEMBER 2011 | 49

A HISTORY OF MEDICAL PHYSICSPIERRE PELLETAN AND THE ESTABLISHMENT OF MEDICAL PHYSICS, 1823–43FRANCIS DUCK has the third instalment in his series on the history of medical physics‘

HISTORICAL FEATURE | SCOPEAbook was published inParis in 1824 entitledTraité élémentaire dephysique générale etmédicale. It was the firstever textbook for acourse in medical physics. This is thestory of the author, Pierre Pelletan, andof his battles to unite the academicdisciplines of physics and medicine.PIERRE PELLETAN (1782–1845)Pierre Pelletan was born in Paris on 6thJanuary 1782. His father, Phillippe-JeanPelletan, was a leading doctor whowould later become a leading surgeonduring the Napoleonic era. His mother,Elisabeth, died when he was only 5years old, and he was only 12 whenRobespierre’s execution marked theend of the Terror. As normalityreturned, his father remarried: figure 1was painted at about this time.In spite of the instabilities during hischildhood, Pierre had sufficient talentto gain entry to the École Polytechniquein 1797. The next few years set thestage for the tensions that woulddominate his life. On the one handthere was his father, guiding his sontowards a successful career inmedicine; on the other, Pelletan’snatural inclination and talent as aninventor and entrepreneur. Theseconflicting forces would ultimatelybecome mutually destructive.Pelletan’s father supported theRevolution. In 1796 he was appointed,with Jean-Noël Hallé, 1 to the medicaland surgical section of the Institutnational, where his circle of colleaguesincluded leading scientists of the age.He joined the commission toinvestigate galvanism, working withJacques Charles (1746–1823), pioneer ofthe hydrogen balloon and creditedwith establishing the law ofproportionality of gas volume withtemperature. This contact may have ledto Pierre’s first brief academicappointment as Charles’ assistant. Butvery soon, in 1799, Pelletan’s fathersent his son off to be a military surgeonin the Napoleonic army. Pelletan was17, and his only medically relatedqualification was that he had taught acourse in chemistry. Nevertheless hecarried out his duties effectively, andwas later awarded the Croix d’honneurfor services to soldiers with typhus.FROM MEDICINE TO INDUSTRYOn his return to Paris, he commencedhis medical training, obtaining, in 1803,an internship at the Hotel-Dieu wherehis father was by then head of surgery.But then, in his first major break withhis father’s wishes, and halfwaythrough the 4-year surgical internship,he abandoned medicine and went offto open a soda factory in Rouen.From his teaching of chemistry,Pelletan would have been aware of theLeblanc process for making sodiumcarbonate (soda) from sodiumchloride. In 1791, Nicholas Leblanc(1742–1806) had been granted a patentfor producing soda, highly importantto the French cotton-dying industry.The Leblanc process emittedhydrochloric acid fumes, and therewere increasing complaints to theHealth Police (the Napoleonicequivalent of the HSE) of their effectson health and the environment.Pelletan devised a method to fix thegas, using a heated, winding, leadlinedpipe filled with limestone, and soprevent its escape. Leblanc latercommitted suicide, having lost controlof the industry he had founded.FROM INDUSTRY TO MEDICINEBy 1813 Pelletan had left his sodafactory behind and was back in Paris.Why? Perhaps his political antennaeand monarchist tendencies sensed thatNapoleon’s days were numbered?Perhaps he still wanted to please hisfather? Perhaps it was for the love of agood woman? On 10th July 1813 hemarried Sophie Barthés, the widow ofBaron Kinkelin, in Paris. The couplewould have no children of their own,but Sophie brought one son, Jules,whom Pierre later adopted. Fourmonths earlier, on 13th March,Pelletan had presented his doctoralthesis to the Faculty of Medicine: ‘Onthe influence of the laws of physicsand chemistry on the phenomena oflife’ (figure 2). The thesis is dedicatedto ‘Mon père et mon meilleur ami leChevalier Pelletan … En témoignage derespect, de reconnaissance et d’amourfilial’. (‘To my father and my bestfriend, Chevalier Pelletan… As a tokenof respect, in gratitude and with ason’s love’.) Pierre had come home.The president of the examining boardwas Pierre’s father.PIERRE PELLETAN’S THESISPelletan’s thesis is a remarkabledocument, and deserves a muchlengthier discussion than space allows.Characteristic of its time, it reducesphysics to Newtonian forces at adistance, and chemistry to questions ofaffinity. But Pelletan opposed the“Thenext fewyears setthe stagefor thetensionsthatwoulddominatehis life”FIGURE 1.Pierre Pelletan c.1790: attributedto Greuze (© Coll.Musée Hist MédParis). 3▼vitalist view of the physiologist XavierBichet (1771–1802), that sensitivity andcontractility are basic ‘vital’ propertiesof living matter, and instead assertedthe non-vitalist view, that all life canultimately be reduced to physical andchemical fundamentals, even thoughthe knowledge of how this may beachieved has not yet been discovered.This was quite unconventionalthinking for the time, and the vitalistswould not lose their grip onphysiology for many decades to come.But he challenges false models at amore fundamental level. ‘When thehuman mind meets an apparentlyinsurmountable obstacle’, he says, ‘itinvents an ingenious explanation. If itis widely accepted, this preventsfurther exploration, the contentedmind abandoning, for a dream, theslow, laborious work that leads toknowledge.’He goes on to discuss thecirculation. His analysis of arterialpulse propagation was much closer tothe true explanation than most at thattime, very similar to Thomas Young’sanalysis from a few years earlier. 2Pelletan also considers the effects oftube branching and tapering onarterial blood flow, distinguishingbetween speed and volume flow, andtheir development as the cross-sectionof the arterial tree alters with distancefrom the heart. He correctly attributesvenous flow to the action ofsurrounding muscles, criticising thethen widely-held view that it wascaused by capillary contractions. Hisevaluation of molecular transportacross the arterial wall was limited bycurrent knowledge of blood structureand composition, but he noted theimpossibility that fluids can besqueezed directly through the arterialwall by arterial blood pressure. It wasan uncompromising work, givingrational scientific arguments to try toexplain physiological phenomena.MEDICINE OR TECHNOLOGY?Pelletan was back in the mainstream ofmedicine in Paris. He obtained a postat the Val-de-Grace (a military hospital).He received the honorary title médecinordinaire to King Louis XVIII (figure 3).But he could not keep away from hisfirst love, technology and invention.Recalling his soda days, he publiciseda new method for making sulphuricacid, a necessary chemical in theLeblanc process. In 1817 he visitedLondon to gather information on thenewly-installed gas lighting in the city.▼SCOPE | SEPTEMBER 2011 | 51

SCOPE | HISTORICAL FEATURE▼52 | SEPTEMBER 2011 | SCOPE

Back in Paris, Pelletan reported severaltimes to l’Académie Royale des sciences in1816/17 on lighting systems using bothcoal-gas and hydrogen. The first coalgaslighting system in Paris wasinstalled in the Hôpital Saint Louis and,given Pelletan’s medical position, hemust surely have been involved.FAILURE AND SUCCESSHowever, a poignant and revealingletter written in 1819 by Pierre’s father 3gives a glimpse of the waning familyfortunes at this time. He explains to hisson why he is no longer able to helphim financially, because ‘intrigues andill-will have blighted my career, so Icannot even afford to marry off mydaughter and may be unable to ensureprovision for my widow’. He adds that‘you would have reached the peak ofreputation and comfort if you hadfollowed a sensible career’. Pierre hadstill not achieved this happy state and,for his father, things were about to get alot worse.The circumstances that caused theclosure of the Faculté de Médecine in1822 following Desgenette’s eulogy forHallé were described in part 2 of thisseries. 1 Phillippe-Jean Pelletan wasamongst the 11 faculty members wholost their positions and their pensionrights, leaving him, it was said, nobetter off than when he was a student.On the other hand, for his son, now40, this was his big break. On 30thNovember 1822, Pierre Pelletan wasappointed to be one of the interimadministrators to the faculty. Hallé’schair of Medical Physics and Hygienewas split, and, on 2nd February 1823,Pelletan was nominated by royalcommand as professor of medicalphysics. The next few years wereastonishingly productive, as if todemonstrate that he was as good as hisnewly acquired, better-establishedacademic colleagues.TRAITÉ DE PHYSIQUEPelletan was already working on adictionary of medical chemistry,published in two parts in 1822/3. Thefirst edition of his Traité de Physique 4appeared a year later. In three volumesand 994 pages he had written a physicstextbook for his first-year medicalstudents, including sections onproperties of matter, statics, mechanics,heat, optics, acoustics, electricity andmagnetism, supported by 168 figures.Two further editions followed (in 1829and 1838) in which he updated thesection on electrodynamics, and addedLaplace’s wave description of light tothe Newtonian corpusculardescription of the first edition. He alsoresponded to other criticisms. It wasobjected that mechanics was reallypart of mathematics, and had no placein a physics text. Pelletan’s responsewas to add a further section on themechanics of animal movement.Doctors wanted more medicalapplications. Pelletan added sectionson endo-osmosis, animal heat and thecirculation. He also described his ownresearch into acupuncture and the flowof heat (caloric) in the body. Here hisscientific contributions were lesseffective. He observed thatacupuncture needles becameelectrically charged on insertion, anddeveloped a theory of galvanicacupuncture. Claude Pouillet(1790–1868), then professor of physicsin Paris, pointed out that the chargewas absent when gold or platinumelectrodes were used, identifying thesource as electrode oxidation. Oncaloric, Pelletan states his law that ‘lifeonly exists under the influence of aflow of caloric (heat)‘. This theorydepended on the prevalent view in the1820s that oxidation in the lungs wasthe only source of body heat, fromwhich caloric flowed to all other partsof the body.Pelletan was a clear and eloquentspeaker. He designed equipment todemonstrate mechanical principles,once more showing his inventive mind(figure 4). Sometimes he contributed tocourses with Pouillet and Gay-Lussac,professors from the physicsdepartment, and occasionally overseasstudents attended his course whilststudying in Paris, because of its worldreputation for excellence in medicaltraining (figure 5).THE 1830 REVOLUTIONThe French had another revolution inJuly 1830. Charles X was replaced byLouis-Philippe I, ‘the citizen’s king’,and, as always happens with a changeof administration, appointments fromthe previous regime were scrutinised.Pelletan, now 48, had to re-apply forhis own post as Professor of MedicalPhysics. The other shortlistedcandidate was Charles Person, a bright28-year-old physicist who had recentlygained a medical degree. Examinationwas in public (the concours). Theinterview included two presentations,one on evaporation in vacuum and inair, and a second on the determinationof refractive index, with specialFIGURE 2.[TOP LEFT]Title page fromPierre Pelletan’sdoctoral thesis .▼FIGURE 3.[TOP RIGHT]Pierre Pelletan(© Coll. MuséeHist Méd Paris).▼FIGURE 4.[CENTRE]Detail from Traitéde Physique, 2ndedition. The twotrolleys are joinedby a spring-loadedsilk thread.Pelletan designedand used thisequipment todemonstrate therelationshipbetween force,mass and velocity.▼FIGURE 5.[BOTTOM LEFT]Certificate signedby Pelletandeclaring thatHenry Powellattended hismedical physicscourse in thesummer of 1831(WellcomeInstitute, London).▼FIGURE 6.[BOTTOM RIGHT]Detail from UKPatent 9068.Pelletan:Propelling Fluidsand Vessels, 1841.▼reference to eye tumours. Finally, thecandidates had to prepare, with 3hours’ notice, a lesson to ‘describe anddiscuss the phenomena associated withthe production of dew’. Writing later tothe Lancet, 5 a correspondent who waspresent considered that these topicswere ‘of the most abstruse and tryingnature … ably handled by bothcandidates’, even though Pelletan wasat the time suffering with arthritic pain.The selection committee wascomposed of eight professors from theFaculty of Medicine and four from theInstitute of Science. The decision wentin favour of Pelletan and againstPerson, the preferred candidate of theInstitute members. They weresufficiently annoyed by the selectionprocess that they successfullypetitioned the Ministry to take nofurther part in future selection of chairsof physics, chemistry or natural history.THE DAUPHIN’S HEARTThe other strange story from thisperiod has to do with the Dauphin’sheart. At the end of the previouscentury, following the execution ofLouis XVI, his young son Louis washeld in prison where he died.Pelletan’s father conducted theautopsy, and removed and preservedthe boy’s heart. By the late 1820s, thisrelic was held by the Bishop of Parisand, under threat during the 1830revolution, it was passed back to thefamily, either to Pierre or his halfbrotherGabriel. After many changes ofownership, the tissues were geneticallyevaluated in 2000, and a match wasestablished with the mitochondrialDNA of Marie Antoinette, so endingtwo centuries of speculation on theDauphin’s death. 6A PHILOSOPHY FOR MEDICALPHYSICSPelletan lost his father in 1829, and hiswife Sophie died in 1832. Thereafter hislife changed emphasis. The onlysubsequent medical publication wasthe third edition of the Traité dePhysique, which adds little more ofscientific substance to earlier editions.In it, however, Pelletan added adiscussion of the philosophy ofmedical physics. He states thatPhysique Médicale had been used as anofficial title for a number of years. Heis scathing about vitalism inphysiology, saying that it revives theoccult characteristics of the ancients,and argues that the rational approachused in physics is the only way to▼SCOPE | SEPTEMBER 2011 | 53

SCOPE | HISTORICAL FEATURE▼determine truth in physiology andmedicine. He imagines, perhaps for thefirst time, that there will be those whowill occupy themselves with medicalphysics, at least until all possibleconnections between physics andmedicine have been determined.PELLETAN AND THE INDUSTRIALREVOLUTIONMeanwhile, Pelletan pursued hisindustrial interests. He was fascinatedby steam propulsion for both boats andlocomotives, and worked on a numberof possible engine designs, usingcompressed air or steam. Pelletan iscredited with encouraging the leadingFrench railway engineer Seguin to usea blast-pipe steam-jet to enhance boilerdraft, as Stephenson had done in hisRocket in 1829. By January 1833Pelletan was carrying out trials atCherbourg on boat propulsion using asteam-jet, subsequently obtaining bothFrench and British patents (figure 6).He devised machines for the newsugar-beet industry, which haddeveloped in France following theearlier British blockade of sugarimports from the Caribbean. At thebeginning of the 1840s he visitedLondon several times, obtaining Britishpatents for a new means of gaslighting, and launching his owncompany. An advertisement, dated23rd August 1844 in the LondonMorning Chronicle, advises that ‘ThePatent Pelletan Light Company(temporary offices 248 Regent Street) isoffering for sale 4,000 shares of £20each, applications before 31st inst.’.The evidence from this periodshows Pelletan devoting his talents toFrench industry, trying to stop hiscountry from slipping too far behindBritain. He was frustrated, however, bya French establishment that still hadone foot in the pre-industrial era, andacademics that emphasisedphilosophy and theory of science,rather than its applications.A SAD END TO A CAREERAt the same time, Pelletan was stillemployed by the university to work inthe medical school. Given his extracurricularactivities, it is not surprisingthat he became increasingly isolatedfrom his colleagues. He applied tobecome a member of the Academy,both in physics and in medicine andsurgery, but was not even shortlisted.Things finally came to a head on 20thJuly 1843, when Pelletan was forced toresign from his post in the faculty,following ‘des spéculationsmalheureuses’. 7 Feeling rejected by hiscountrymen, he went into selfimposedexile in Belgium, settling inBrussels with his second wife, Louise,where he gave physics lectures at theConservatoire des Arts. 8 He died oftuberculosis in August 1845. Noeulogy was spoken for Pierre Pelletan.There was no published obituary. Laterbiographies are quite short. 7 A briefcomment by a senior physician in anaddress to medical students comparedPelletan unfavourably with anotherrecently-deceased professor. 9 Damningwith faint praise, he said that Pelletanwould be ‘remembered for his unusualtalents, for his lively mind and hiswide knowledge, and because he wasa friend to all his colleagues’.However, the doctor went on to tell hisaudience that they must love scienceabove talent and intelligence, andparticularly to love medicine, which hedescribed as the greatest of thesciences. Pelletan was neverunconditionally committed tomedicine, and so was considered to bea failure.“Theevidencefrom thisperiodshowsPelletandevotinghis talentsto Frenchindustry”PELLETAN’S CONTRIBUTIONSPelletan aspired to establish a newdiscipline of medical physics. Whilst hemade the first steps in this direction, henever achieved the academic status togain independence from his parentdisciplines. There is almost noreference to Pelletan’s work bycontemporary medical scientists ordoctors. Abandoned by his colleaguesin physics and from his own faculty,his isolation led inevitably to hisrejection. At his death, his colleaguesassigned him to obscurity, a false,harsh and ultimately prematurejudgement.Both medical physics and Pelletan’sinitiatives and ideas had longevity. Hisabsolute conviction, declared in 1813,that physics and chemistry must formthe only basis for physiology, emergedas mainstream thinking by the middleof the century, particularly in theGerman universities. Courses inmedical physics slowly becameestablished throughout Europe andacross the Atlantic, together withtextbooks to support them. One suchbook in Spain explicitly declared theauthor’s debt to Pelletan. 10 And anyconflict between physics and medicinearose from politics and personalities,and not from science. This remains astrue today as it was in Pelletan’s time.ACKNOWLEDGEMENTI am greatly indebted to Estelle Lambert, ofthe Bibliothèque interuniversitaire desanté, Paris, for providing copies ofPelletan documents, currently held in theMusée d'Histoire de la Médecine, Paris.ABOUT THE AUTHORFrancis Duck is Honorary ConsultantMedical Physicist in the Department ofMedical Physics and Bioengineering atthe Royal United Hospital Bath NHSTrust and visiting professor at theUniversity of Bath.Email: f.duck@bath.ac.ukREFERENCES1 Duck F. A history of medical physics. Defining medicalphysics: 1794–1822. Scope 2011; 20(2): 50–4.2 Young T. The Croonian Lecture. On the functions of theheart and arteries. Phil Trans 1809; 99: 1–31. See also PhilTrans 1808; 98: 164–86.3 Sonolet J, Poulet J. La dynastie médicale des Pelletans.Sem Hop Paris 1972; 48: 3513–20.4 Pelletan F. Traité Élémentaire de Physique Générale etMédicale. Paris: Gabon, 1824.5 Ballot. French medical concours. Lancet I 25th October1834: 159–60.6 www.france-pittoresque.com/spip.php?article35427 Hoefer JCF. Pelletan, Pierre. In Nouvelle biographiegénérale depuis les temps les plus reculés jusqu’a nosjours. Paris: Firmin Didot, 1862; 39: 498–9, and Wikipedia.8 Pelletan P. Douze leçons de physique générale. Brussels:Mertens, 1845.9 Anon. Avis aux abonnés de la Presse. La Presse, 7thNovember 1845.10 Ribero Serrano A. Tratado elemental de fisica general ymedica, estractado de las obras de MM. Pelletan Despretz,etc. Madrid: Hortelano, 1845.54 | SEPTEMBER 2011 | SCOPE

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