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Simona Vlad · Nicolae Marius Roman (Eds.)

Volume 59

International Conference
on Advancements of Medicine
and Health Care through Technology;
12th – 15th October 2016, Cluj-Napoca,
Romania
MEDITECH 2016
IFMBE Proceedings

Volume 59

Series editor
James Goh

Deputy Editors
Fatimah Ibrahim
Igor Lacković
Piotr Ładyżyński
Emilio Sacristan Rock
The International Federation for Medical and Biological Engineering, IFMBE, is a federation of national and transnational
organizations representing internationally the interests of medical and biological engineering and sciences. The IFMBE is a
non-profit organization fostering the creation, dissemination and application of medical and biological engineering knowledge
and the management of technology for improved health and quality of life. Its activities include participation in the formulation
of public policy and the dissemination of information through publications and forums. Within the field of medical, clinical,
and biological engineering, IFMBE’s aims are to encourage research and the application of knowledge, and to disseminate
information and promote collaboration. The objectives of the IFMBE are scientific, technological, literary, and educational.

The IFMBE is a WHO accredited NGO covering the full range of biomedical and clinical engineering, healthcare, healthcare
technology and management. It is representing through its 60 member societies some 120.000 professionals involved in the
various issues of improved health and health care delivery.

IFMBE Officers
President: James Goh, Vice-President: Shankhar M. Krishnan
Past President: Ratko Magjarevic
Treasurer: Marc Nyssen, Secretary-General: Kang Ping LIN
http://www.ifmbe.org

More information about this series at http://www.springer.com/series/7403

Simona Vlad Nicolae Marius Roman (Eds.)
•

International Conference on
Advancements of Medicine and Health Care
through Technology; 12th – 15th October 2016
Cluj-Napoca, Romania
MEDITECH 2016

123
Editors
Simona Vlad Nicolae Marius Roman
Faculty of Electrical Engineering Faculty of Electrical Engineering
Technical University of Cluj-Napoca Technical University of Cluj-Napoca
Cluj-Napoca Cluj-Napoca
Romania Romania

ISSN 1680-0737 ISSN 1433-9277 (electronic)

IFMBE Proceedings
ISBN 978-3-319-52874-8 ISBN 978-3-319-52875-5 (eBook)
DOI 10.1007/978-3-319-52875-5

Library of Congress Control Number: 2017930147

© Springer International Publishing AG 2017

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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
 Foreword

The 5th Conference on Advancements of Medicine and Health Care through Technology - MediTech2016 took place in Cluj-
Napoca in October 12–15, 2016. The Conference aimed to provide opportunities for Romanian and foreign professionals
involved in basic research, R&D, industry and medical applications to exchange their know-how and build up collaboration in
one of the most important fields of science and technology - medical engineering.
MediTech is intended to be an international forum for researchers and practitioners interested in the advance in, and
applications of biomedical engineering to exchange the latest research results and ideas in areas like hardware and software
technologies, medical devices, biosignal and image processing, biomaterials, biomechanics, telemedicine, etc. The importance
of this kind of scientific events was proven by the interest of the prestigious researchers from Romania and abroad who decided
to take part in the 5th edition of MediTech. Moreover, we were honored to receive the visit of Prof. Kang-Ping Lin, Secretary
General of IFMBE.
All papers submitted for presentation went through a review process and were evaluated by two reviewers. The papers
chosen to be presented at the conference were accompanied by manuscripts to be published in these Proceedings.
We would like to kindly thank the members of the Scientific and Organizing Committees for their hard work and dedication
and we hope that they will continue supporting MediTech.

MediTech2016 Conference Chair

Professor Nicolae Marius Roman
 Organization

Organizer

Romanian National Society for Medical Engineering and Biological Technology

Endorsed by

International Federation for Medical and Biological Engineering

Partners

Technical University of Cluj-Napoca, Romania

“Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
Medical University of Vienna, Austria
The University of Sheffield, United Kingdom
“Dr. Constantin Papilian” Military Emergency Hospital, Cluj-Napoca, Romania

Conference Chair
Nicolae Marius Technical University of Cluj-Napoca, Romania
Roman

Honorary Chair
Radu Vasile Ciupa Technical University of Cluj-Napoca, Romania

Scientific Advisory Committee

Laura Bacali (RO) Laura Grindei (RO)

Doina Baltaru (RO) Flavius Gruian (SE)
Maria Beudean (RO) Sorin Hintea (RO)
Corina Botoca (RO) Rodica Holonec (RO)
Remus Brad (RO) Rod Hose (UK)
Simion Bran (RO) Adrian Iancu (RO)
Macarie Breazu (RO) Beriliu Ilie (RO)
Lelia Ciontea (RO) Ioan Jivet (RO)
Radu Ciorap (RO) Mircea Leabu (RO)
Radu V. Ciupa (RO) Patricia Lawford (UK)
Hariton Costin (RO) Angela Lungu (RO)
Cecilia Cristea (RO) Eugen Lupu (RO)
Vanessa Diaz-Zuccarini (UK) Dan Mandru (RO)
Gabriele Dubini (IT) Avram Manea (RO)
Anca Galaction (RO) Alma Maniu (RO)
Stefan Gergely (RO) Raul Malutan (RO)
Zoltan German-Sallo (RO) Winfried Mayr (A)
VIII Organization

Amalia Mesaros (RO) Traian Petrisor (RO)

Dan D. Micu (RO) Petre G. Pop (RO)
Ioan Mihu (RO) Dan V. Rafiroiu (RO)
Dan Milici (RO) Corneliu Rusu (RO)
Petru Mircea (RO) Dan I. Stoia (RO)
Alexandru Morega (RO) Mihai Tarata (RO)
Mihaela Morega (RO) Vasile Topa (RO)
Marius Muji (RO) Mircea Vaida (RO)
Calin Munteanu (RO) Doru Ursutiu (RO)
Mihai S. Munteanu (RO) Liliana Verestiuc (RO)
Andrew Narracott (UK) Radu C. Vlad (RO)
Anca I. Nicu (RO) Simona Vlad (RO)
Maria Olt (RO) Daniel Volovici (RO)
Sever Pasca (RO) Dan Zaharia (RO)
Alessandro Pepino (IT)

Local Organizing Committee

Alexandru Avram Radu A. Munteanu

Radu V. Ciupa Anca I. Nicu
Rodica Holonec Maria Olt
Beriliu Ilie Dan V. Rafiroiu
Angela Lungu Nicolae Marius Roman
Calin Munteanu Debora E. Tomsa
Mihai S. Munteanu Simona Vlad

Invited Speakers

Kang-Ping Lin, IFMBE Secretary-General, Chung-Yuan Christian University, Taiwan

Heart, Heart Rate, & Heart Rate Variability with RSA Application

Helmut Hutten, Institute of Medical Engineering, Graz University of Technology, Austria

Innovations – From Good Ideas to Successful Products on the Market
Alessandro Pepino, University of Naples “Federico II”, Italy
The Discrete Event Simulation for Studying of Organizational Models in Health Care
Winfried Mayr, Medical University of Vienna, Austria
Interfacing neurons and muscles

Rod Hose - University of Sheffield, United Kingdom

ANSYS Healthcare Solutions
Lucio Tommaso De Paolis, University of Salento, Italy
Virtual Reality and Augmented Visualization in Medicine and Surgery
Mircea Gelu Buta, “Babeş-Bolyai” University of Cluj-Napoca, Romania
The Report between the Technics and Medical Clinic

Doru Ursuţiu, “Transilvania” University of Braşov, Romania

Online Technologies and Virtual Instrumentation in Sensing - Monitoring – Medicine. “Cloud Instrumentation and IoT
Organization IX

Mircea Leabu, University of Medicine and Pharmacy “Carol Davila” and “Victor Babeş” National Institute of Pathology,
Bucharest, Romania
Half a Century for Jumping to Live Cell Studies at Nanolevel Resolution

Mihai Tărâţă, University of Medicine and Pharmacy of Craiova, Romania

Advantages of Frequency Domain Processing, in Monitoring the Neuro-muscular Fatigue
Radu George Ciorap, University of Medicine and Pharmacy “Grigore T. Popa”, Iaşi, Romania
Medical Device Testing – a Key Issue for Patient Safety
Doina Baltaru, “Dr. Constantin Papilian” Emergency Military Hospital of Cluj-Napoca, Romania
Aspects of Medical Technology in Military Medical System

Sponsors

Laitek Medical Software

Comelf SA, Avena Medica SRL, Tehno Industrial SA, Cefmur SA, Temco SRL, Constelatia Construct SRL
 Contents

Clinical engineering assessment

Ultrasonographic Correlations and Challenges in Liver Hemangiomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

I. Grigorescu, Z. Sparchez, R. Badea, M. Dragoteanu, C.D. Piglesan, and D.L. Dumitrascu

Impact of Spectralis Optical Coherence Tomography in the Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

S.D. Nicoară

Laparoscopic Repair of Morgagni Hernia – Transfascial Suturing with Extracorporeal Knotting . . . . . . . . . . . . . . . 13

F. Graur, E. Moiș, N. Al-Momani, and N. Al-Hajjar

Ambulatory Heart Rate Variability Correlates with High-Sensitivity C - Reactive Protein in Type 2 Diabetes
and Control Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
D.M. Ciobanu, A.E. Crăciun, I.A. Vereşiu, C. Bala, and G. Roman

Heart Rate Dynamics Study on the Impact of “Mirror Therapy” in Patients with Stroke. . . . . . . . . . . . . . . . . . . . . 21
D. Andriţoi, C. Corciovă, C. Luca, D. Matei, and R. Ciorap

Assessment of Nerve Fibers Dysfunction Through Current Perception Threshold Measurement in Diabetic
Peripheral Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
G.V. Inceu, G. Roman, and I.A. Veresiu

Implantable Ports in Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

B. Micu, C. Micu, T-R. Pop, and N. Constantea

Robotic Splenectomy using the DaVinci Platform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

B. Micu, C. Micu, T-R. Pop, and N. Constantea

Classical Chemometrics Methods Applied for Clinical Data Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

R. Bleiziffer, M. Culea, C. Sarbu, P. Podea, S. Suvar, A. Iordache, and C. Mesaros

What do job adverts tell Higher Education about the ‘shape’ of Biomedical Engineering Graduates? . . . . . . . . . . . . 43
A.E. Ward, B. Baruah, A. Gbadebo, and N.J. Jackson

Ozone and Intense Electric Fields Applyance in Treating of External Wounds Become Overinfected . . . . . . . . . . . . 49
R.E. Suarasan, I. Suarasan, S.R. Budu, M.I. Suarasan, A. Maniu, and R. Morar

Comparative Analysis of Cardiovascular Risk Profile, Cardiac and Cervical Arterial Ultrasound in Patients
with Chronic Coronary and Peripheral Arterial Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
M.A. Stoia, A.D. Farcaș, F.P. Anton, A.I. Roman, and L.A. Vida-Simiti

Cardiovascular Risk Profile, Cardiac and Cervical Artery Ultrasound in Patients with Peripheral Artery Disease . . . . 59
A.D. Farcaș, M.A. Stoia, F.A. Anton, A.I. Roman, and L.A. Vida-Simiti

Medical devices, measurements and instrumentation

A Single-character Refreshable Braille Display with FPGA Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

M.C. Ignat, P. Faragó, S. Hintea, M.N. Roman, and S. Vlad
XII Contents

Assessing Microcirculation for Predictive Purposes with the Aim of Reducing the Amputation Rate in the Case
of Patients with Critical Lower Limb Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
O. Andercou, B. Stancu, A. Mironiuc, and H. Silaghi

An EIT Belt Reference Design with Active Electrodes and Digital Output . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
I. Jivet

Age Simulation Suits for Training, Research and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

H.L. Groza, S. B. Sebesi, and D.S. Mandru

Low Cost Command and Control System for Automated Infusion Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
B. Tebrean, S. Crisan, C. Muresan, and T.E. Crisan

Monitoring System for the Emotional States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

M. Cenușă, M. Poienar, L.D. Milici, and S.D. Pața

Low Cost Prototype for Viewing a Map of Vascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

D. Iudean, R. Munteanu jr., E.M. Bindea, D.F. Muresanu, and O. Selejan

Modular Multi-channel Real-time Bio-signal Acquisition System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

C. Kast, M. Krenn, W. Aramphianlert, C. Hofer, O.C. Aszmann, and W. Mayr

An ECG Front-End Device based on ADS1298 Converter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

C.M. Fort, A.M. Ciupe, and S. Vlad

New Approach for the Electrochemical Detection of Dopamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

M. Tertiș, A. Florea, A. Adumitrachioaie, D. Bogdan, C. Cristea, and R. Săndulescu

Aptamer-based Electrochemical Sensor for the Detection of Ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

B. Feier, I. Băjan, C. Cristea, and R. Săndulescu

Determination of the Electrical Parameters of Some ECG Electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

A.R. Iusan, N.M. Bîrlea, M. Paunescu, and A.M. Ciupe

How to Describe the Skin’s Electrical Nonlinear Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

N.M. Bîrlea, S.I. Bîrlea, and E. Culea

Case Study of Static and Dynamic Postural Balance of an Overweight Pregnant Woman . . . . . . . . . . . . . . . . . . . . 119
D. Cotoros, A. Stanciu, and I. Serban

Multipoint Wireless Network for Complex Patient Monitoring based on Embedded Processors . . . . . . . . . . . . . . . . 123
T. Sumalan, E. Lupu, R. Arsinte, and E. Onaca

Automated Titration of Oxygen Fraction in Inspiratory Mixture in Mechanical Ventilation of Life-size Mannequin . . . 127
M. Rožánek, P. Kudrna, and V. Králová

A Study of the Effects of Geometry on the Efficiency of Single Slot Microwave Ablation Antennas
Used in Hepatic Tumor Hyperthermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
V. Neagu

The Influence of an Orifice Plates as a Flow Sensors on the Removal of Carbon Dioxide in High Frequency
Oscillatory and Jet Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
P. Kudrna and M. Rožánek

Evaluation of the Electric and Magnetic Field near High Voltage Power Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Ș.F. Braicu, L. Czumbil, D. Șteț, and D.D. Micu
Contents XIII

Analysis of Pulse Wave During Magneto-Therapy Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

C. Luca, D. Andriţoi, C. Corciovă, and R. Ciorap

Three Element Windkessel Model to Non-Invasively Assess PAH Patients: One Year Follow-up . . . . . . . . . . . . . . 151
A. Lungu, D.R. Hose, D.G. Kiely, D. Capener, J.M. Wild, and A.J. Swift

Thermal Rehabilitation Influence upon the Comfort in Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

A. Abrudan, T. Rus, and R. Mare

Modelling the Passive Behavior of the Nervous Cell. Influence of Electric Parameters Variation . . . . . . . . . . . . . . . 159
M. Crețu, L. Darabant, and A. Răcășan

Simulation of Teeth Movement in the Case of Orthodontic Treatment Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 165

T. Coloşi, V. Mureşan, O. Nemeş, M. Olt, and N.M. Roman

Biomedical signal and image processing

Non-linear Analysis of Heart Rate Variability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Z. German-Sallo

Dependency of Tidal Volume on Mean Airway Pressure in High-Frequency Oscillatory Ventilation . . . . . . . . . . . . 177
J. Matejka and M. Rozanek

Towards a Trial-Based,Time-Scale Dynamic Detection of M1 and M2 Components from the EMG Stretch
Reflex Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
M. Tarata, M. S. Serbanescu, D. Georgescu, D.O. Alexandru, and W. Wolf

Discriminate Animal Sounds Using TESPAR Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

G.P. Pop

Robust Analysis of Non-Stationary Cortical Responses: Tracing Variable Frequency Gamma Oscillations
and Separating Multiple Component Input Modulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
A. Dăbâcan and R.C. Mureşan

Comparison of Classifiers for Brain Tumor Segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

L. Lefkovits, Sz. Lefkovits, M.F. Vaida, S. Emerich, and R. Măluțan

Abnormalities Identification in Mammograms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

L.D. Chiorean, M.F. Vaida, and C. Striletchi

Telemedicine and health care information systems

Interconnecting Heterogeneous Non-smart Medical Devices using a Wireless Sensor Networks (WSN)
Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
B. Iancu, R. Kovacs, V. Dadarlat, and A. Peculea

Algorithm with Heuristics for Kidney Allocation in Transplant Information System. . . . . . . . . . . . . . . . . . . . . . . . 213
S. Luscalov, L. Loga, D. Luscalov, A. Lăcătuș, G. Dragomir, and L. Dican

Exploring Hierarchical Medical Data stored as Multi-trees in a Relational Database. . . . . . . . . . . . . . . . . . . . . . . . 219

P. Olah, I. Movileanu, N. Suciu, M. Muji, M. Marusteri, D. Simionescu, and C. Avram

Development of a Complex Acquisition and Storage System of Medical Data Used in a Clinical Environment . . . . . 223
R. Pop Kun, M. Munteanu, D. Rafiroiu, D. Pop Kun, and R. Moga
XIV Contents

Elderly Fall Risk Prediction System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

O. Stan, L. Miclea, and A. Sarb

Particle Swarm Optimization Based Method for Personalized Menu Recommendations . . . . . . . . . . . . . . . . . . . . . 232
V. Chifu, R. Bonta, E. St. Chifu, I. Salomie, and D. Moldovan

Diet Generator for Elders using Cat Swarm Optimization and Wolf Search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
D. Moldovan, P. Stefan, C. Vuscan, V.R. Chifu, I. Anghel, T. Cioara, and I. Salomie

Telemonitoring Systems and Technologies for Independent Life of Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

S.B. Sebesi, H.L. Groza, and D. Mândru

Automatic Learning of Medical Text Annotation Rules – a Case Study on Endoscopies . . . . . . . . . . . . . . . . . . . . 248
R.R. Slavescu, M.N. Oltean, A.P. Torok, and K.C. Slavescu

Use of Machine Learning for Improvement of Similarity Searches of Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

B. Petrovan, B. Orza, and A. Vlaicu

Biomechanics, Robotics and Rehabilitation

Motor Imagery Brain-Computer Interface for the Control of a Shoulder-Elbow Rehabilitation Equipment. . . . . . . . . 259
A. Ianoși-Andreeva-Dimitrova, D.S. Mândru, M.O. Tătar, and S. Noveanu

Performance and Efficiency Feedback in Rehabilitation Program with Kinematic Analysis System – a Case Study
in Rehabilitation after Lumbar Discectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
S.A. Moldoveanu, D. Şardaru, L. Pendefunda, and C. Luca

Assistive Technology Product Innovation Through Undergraduate Projects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

A. Ward, I. Grout, L. Grindei, and D. Mândru

Health technology assessment

Baby Wearing Buying Decision-making - A Focus Group Exploratory Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

A. Constantinescu-Dobra and M.A. Coțiu

A Critical Analysis of Self-assessment Tools for Improving Workers’ Health and Work Performance . . . . . . . . . . . 283
S.C. Anca

Promoting a Dental Practice on Facebook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

A.I. Iancu and S.D. Cîrstea

Generation Z and Online Dentistry. An Exploratory Survey on the Romanian Market . . . . . . . . . . . . . . . . . . . . . . 291
A. Constantinescu-Dobra and V. Maier

Patient Satisfaction with Diabetes Care in Romania – An Importance-performance Analysis . . . . . . . . . . . . . . . . . . 297

M.A. Coțiu and A. Sabou

Analysis of Factors that Influence OTC Purchasing Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

S.D. Cîrstea, C. Moldovan-Teselios, and A.I. Iancu

Wireless Systems with Reduced PAPR Using K-means Modified PTS Implemented for Epilepsy Classification
from EEG Signals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Sunil Kumar Prabhakar and Harikumar Rajaguru
Contents XV

Efficient Wireless System for Telemedicine Application with Reduced PAPR Using QMF Based PTS Technique
for Epilepsy Classification from EEG Signals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Sunil Kumar Prabhakar and Harikumar Rajaguru

The Impact of Dizziness in Life’s Quality of Elderly Patients with Vestibular Disorders and Their Caregivers . . . . . 317
A. Maniu, G.S. Chiș, O.E. Harabagiu, R. Holonec, and A.I. Roman

Prioritization of Medical Devices for Maintenance Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

C. Corciovă, D. Andriţoi, C. Luca, and R. Ciorap

Development of Wireless Biomedical Data Transmission and Real Time Monitoring System . . . . . . . . . . . . . . . . . 327
C.M. Fort, S. Gergely, and A.O. Berar

Miscellaneous topics

Preparation, Characterization and Preliminary Evaluation of Magnetic Nanoparticles based on Biotinylated

N-palmitoyl Chitosan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
V. Balan, M. Butnaru, and L. Verestiuc

Cellular Nanostructures and Their Investigation. History and Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

C.M. Niculițe, A.O. Urs, E. Fertig, C. Florescu, M. Gherghiceanu, and M. Leabu

Chemical Stability of Vitamin B5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

D. Cașcaval, M. Poștaru, L. Kloetzer, A.C. Blaga, and A.I. Galaction

Study upon the Mechanical Properties of Most Used Dental Restoration Materials . . . . . . . . . . . . . . . . . . . . . . . . 345
D. Cotoros, A. Stanciu, and M.M. Scutariu

Principles to Build a Stochastic Model for a Minimal Biological Cell with Built-in Feedback
Reaction Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
D. Stoicovici, A. Cotetiu, M. Banica, M. Ungureanu, and I. Craciun

Microarray Gene Expression Analysis Using R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358

I. Petre and C. Buiu

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

Keyword Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365

 Part I
Clinical Engineering Assessment
 Ultrasonographic Correlations and Challenges in Liver Hemangiomas
I. Grigorescu1, Z. Sparchez2, R. Badea2, M. Dragoteanu2, C.D.Piglesan2 and D.L. Dumitrascu1
1
2nd Medical Department, „I.Hatieganu” University of Medicine and Pharmacology Cluj-Napoca, Romania
2
„Octavian Fodor” Regional Institute for Gastroenterology and Hepatology Cluj-Napoca, Romania
Abstract/"QDLGEVKXGU0"Itc{/uecng"wnvtcuqpqitcrj{"*WU+"
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ckou"qh"qwt"uvwf{"ygtg"vq"guvcdnkuj"kp"nkxgt"jgocpikqocu"rquuk/
dng" eqttgncvkqpu" dgvyggp" vwoqtcn" cpf" nkxgt" gejqigpkekv{=" vw/
oqtcn"uk|g"cpf"rtgugpeg"qh"ejtqpke"nkxgt"fkugcugu"*ENF+="rtgu/
gpeg" qh" rgtkvwoqtcn" tko/" vwoqtcn" cpf" nkxgt" gejqigpkekv{."
vwoqtcn" uk|g" cpf" rtgugpeg" qh" ENF0" OCVGTKCN" CPF"
OGVJQFU0"Vjg"uvwf{"kpxqnxgf"574"nkxgt"ocuugu"kp"492"rcvkgpvu"
ykvj" vjg" rtguworvkxg" fkcipquku" qh" dgpkip" nkxgt" vwoqt" ocuugu."
guvcdnkujgf" d{" codwncvqt{" WU." jqurkvcnk|gf" cv" vjg" Gogtigpe{"
Jqurkvcn" $Rtqh0" Ft0" Qevcxkcp" Hqfqt$" cpf" 4pf" Ogfkecn" Enkpke"
Enwl/Pcrqec"dgvyggp"4228/42370"Vjg"hkpcn"fkcipquku"ycu"guvcd/
nkujgf"dcugf"qp"vjg"tguwnvu"qh"kpxguvkicvkqpu"uwej"cu"WU"*itc{/
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jgocpikqocu0"Rtgugpeg"qh"uvgcvquku1pqpcneqjqnke"uvgcvqjgrcvkvku"
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ujqyu"vjcv"vjgtg"gzkuvu"oqfgtcvg"cuuqekcvkqp"dgvyggp"j{rgtgej/
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vkuvkecnn{" ukipkhkecpv" cuuqekcvkqpu" hqwpf" dgvyggp<" vwoqt/nkxgt"
gejqigpkekv{."j{rqgejqke"tko"cpf"vwoqt"uk|g/nkxgt"gejqigpkekv{0"
EQPENWUKQP0"Encuuke"WU"etkvgtkc"qh"jgocpikqoc"ycu"hqwpf"
kp":30:7'0"J{rq/"cpf"kuqgejqke"jgocpikqocu"oqfgtcvgn{"eqt/
tgncvg"ykvj"vjg"rtgugpeg"qh"c"j{rgtgejqke"tko0"Pq"uvcvkuvkecn"eqt/
tgncvkqp"ycu"hqwpf"dgvyggp"vjg"wpfgtn{kpi"ENF"cpf"vjg"jgocp/
ikqoc)u"gejqigpkekv{."pqt"ykvj"vjg"rtgugpeg"qh"cp{"vwoqtcn"tko0"
Keywords- jgocpikqoc."wnvtcuqwpf."gejqigpkekv{ " men), aged 36-82 years with malignant hepatic tumors. Their
I. INTRODUCTION
Gray-scale ultrasonography (US) is the first way of
detecting focal liver lesions, but with lower specificity in
establishing their etiology. Typical hemangiomas at US are
hyperechoic, well defined masses, without peritumoral rim,
without Doppler signal [1], but there exist also atypical forms
(especially if the tumor is grafted on chronic liver disease-
CLD): heterogeneous and/or hypoechogenicity hemangio-
mas, or with hyperechoic rim. Preoperative US, although
sometimes their etiology is difficult to establish as gray-scale
US has low specificity in characterizing liver tumors [2]; in
© Springer International Publishing AG 2017
S. Vlad and N.M. Roman (eds.), International Conference on Advancements of Medicine and Health Care through Technology;
12th - 15th October 2016, Cluj-Napoca, Romania,
IFMBE Proceedings 59,
DOI: 10.1007/978-3-319-52875-5_1
such cases, complementary explorations like: liver scintigra-
phy, angioscintigraphy, contrast-enhanced CT and MR, or
even invasive methods (puncture-biopsy, diagnostic laparos-
copy) with histological examination, are mandatory. Alt-
hough the typical aspect of hemangioma at US is of nodular
hyperechoic, well defined mass, without peritumoral rim,
without Doppler signal [1], there exist also atypical forms:
heterogeneous and/or hypoechogenicity hemangiomas, or
with hyperechoic rim [3].
The aims of our study were to establish in liver hemangi-
omas possible correlations between tumoral and liver echo-
genicity; tumoral size and presence of chronic liver diseases
(CLD); presence of peritumoral rim- tumoral and liver echo-
genicity, tumoral size and presence of CLD. "
II. MATERIAL AND METHODS
The study involved in the experiment group 270 patients
(156 women, 114 men), aged 25-81 years, with the presump-
tive diagnosis of benign liver tumor masses, established by
ambulatory US, hospitalized at the Emergency Hospital
"Prof. Dr. Octavian Fodor" and 2nd Medical Clinic Cluj-Na-
poca between 2006-2015. There were found 352 liver masses
in these 270 patients, 30 of them having concomitant other
tumor tumors, and 52 being with multiple hemangiomas (he-
mangiomatosis).
The control group consisted of 60 patients (38 women, 22
diagnosis at admittance consisted of hepatocellular carci-
noma (HCC) (12), metastasis (7), cholangiocarcinoma (3),
hemangioma (2), hamartoma (1), tumor of unknown etiology
(28) and the rest in other extra-hepatic pathologies.
Investigation of patients in this retrospective study was
performed using ultrasonographs Logiq 7 (GE, USA),
Si2000 Sonoline with transducers having 3,5MHz (for pre-
operative diagnosis) and 7,5MHz frequency (for intraopera-
tive diagnosis), tomographic scintillation SPECT Orbiter
Siemens camera, computed tomography (CT) and magnetic
resonance imaging (MRI), along with clinical and biological
examination.
All patients (both the experiment and the control group)
underwent abdominal US examination in gray scale and color
3
4 I. Grigorescu et al.

Doppler. Most of the patients (56%) underwent at least 2 existence with other masses was found in 30 (11.11%) pa-
types of imaging investigation in order to establish the final tients: simple hepatic cysts (17), fatty-free areas (4), focal
diagnosis. Planar liver scintigraphies and SPECT with sul- nodular hyperplasia (3), HCC (2), patchy areas of steatosis
phur-colloid (n=211), „in vivo” labeled-RBC scintigraphies (2), hepatic hydatid cyst (1) and metastasis of gastric car-
(n=189) and liver angioscintigraphies (n=184) were per- cinoid (1).
formed. 72 patients underwent CT (1 native and 71 with con-
trast) and 28 MRI with contrast. Diagnostic laparoscopy was Table 1 US parameters in hemangiomas
performed in 15 patients, surgical resection in 22, US-guided
Gejqigpkekv{
puncture-biopsies in 42 and histological examination in 69
-high 220
patients. The final diagnosis was established based on the re- -low 41
sults of all these investigations corroborated with clinical and -isoechoic 6
biological examinations.From the statistical point of view, in -mixt 3
Gejquvtwevwtg
order to establish possible associations between echogenicity
-homogeneous 189
of the tumor and the liver, respectively tumor's size and the -heterogeneous 81
presence of liver diseases, we used the statistical software in -calcifications 4
order to obtain the Hi-square test and Fisher's exact test, co- Fgnkokvcvkqp
efficients of contingency and Cramer's coefficients; p val- -clear 256
-imprecise 3
ues<0.05 were considered to have statistical significance. Es- -polycyclic 10
timation of possible association between the presence of Rgtkvwoqtcn"tko
hypo-/hyperechoic peritumoral rim and tumoral and liver -hyperechoic 7
echogenicity, tumoral size and the presence of CLD was done -hypoechoic 5
Fqrrngt"ukipcn"
through the same tests and correlation coefficients mentioned
-absent 146
above. -weak 11
-present 26
-central 1
-peripheral 7
III. RESULTS -central+ peripheral 1
-spotted-like 11
US parameters in the 270 patients finally diagnosed with -arterial type -
hemangioma revealed the features shown in Table 1. -venous type 6
-mixed type 6
There have been identified hemangiomas ranging in size
from 0,3-24cm at US. Hemangiomas were located in the right
lobe (298), left lobe (115), caudate lobe (4) and in both lobes
(80).
As shown in Table 1, the presence of hyperechogenicity
and homogeneous structure inside the tumor is not a univer-
sally valid criterion in the diagnosis of hemangioma.
The typical image of well-defined (94.81% of cases), hy-
perechoic mass (81.48% of cases), without Doppler signal
(54.07% of cases), was detected in most hemangiomas
(Fig.1). Hypoechoic masses (Fig.2) associated with the pres-
ence of a heterogeneous structure and hyperechoic rim raised
problems of differential diagnosis in 7 cases, requiring sup-
plementary investigations. Out of all 274 cases with US-
presumption of hemangiomas, 270 patients proved to have
finally hemangiomas, 3 HCC (and coexistence with one he-
mangioma in one case), 1 cholangiocarcinoma and coexist-
ence with metastases (from gastric carcinoid); in 21 cases it
Fig.1 US: typical hemangioma
was not possible to differentiate US from other tumors (1 li-
poma, 1 pheochromocytoma, 1 area of calcification, 3 metas-
tases, 2 regenerative nodules, 2 focal nodular hyperplasias, 3
patchy areas of steatosis, 6 HCC, 2 hemangiosarcomas). Co-

IFMBE Proceedings Vol. 59

Ultrasonographic Correlations and Challenges in Liver Hemangiomas 5

NASH), 39 hypoechoic masses (with maximum percentage

on: steatosis and NASH, followed by cirrhosis, normal liver,
chronic hepatitis) and 5 isoechoic and 2 with mixed echo-
genicity (hypo- and hyperechoic) (Table 2).
When comparing echogenicity and echostructure of heman-
giomas, we observed differences between the 2 groups of pa-
tients, namely those without liver disease and those with
CLD. Also, the presence/absence of peritumoral and rim's
echogenicity according to the size of hemangioma are shown
in Table 3.
Diagnosis of hemangioma was suspected only in 93.70 %
(253/270) cases of all patients with final diagnosis of heman-
gioma, the rest being diagnosed by US as: lipoma (1), metas-
tasis (3), tumors of unknown etiology (5), regenerative nod-
ule/HCC (1), steatosis, patchy steatosis (1), focal nodular
hyperplasia (1), pheochromocytoma (1), benign tumor with
arterial-venous shunt (1), malignancy (2), and in one case US
did not detected any mass (isoechoic).
Fig.2 US: atypical hemangioma
Absence of Doppler signal (146/157), spotted presence Table 3 Tumoral and rim's echogenicity according to the size of hemangi-
(11/157) were identified in all hemangiomas located in the oma
right lobe (157), the left lobe being difficult to explore due to Hemangiomas: size≥2cm size<2cm
artifacts produced by the cardiac cycle; in one case, exacer- hyperechoic 136 77
bated and tortuous vascularisation pattern (arterial and ve- hypoechoic 30 9
nous type) rose the suspicion of neoplasia, but puncture-bi- isoechoic 5 0
mixt 2 0
opsy confirmed the diagnosis of hemangioma. with hypoechoic rim 4 1
There were identified multiple hemangiomas in 52 cases with hyperechoic rim 6 1
(19.25%), their increased echogenicity and multicentricity
raising problems of differential diagnosis with liver metasta- The presence of hypoechoic rim was described in 4/220
ses. cases (0.018%) of histologically proven hemangiomas. The
hyperechoic rim was present in 14.89% of the cases (repre-
Table 2 US characteristics of hemangiomas grafted on normal liver and on senting 7/47 patients). There were no differences regarding
different CLD the predominance of peritumoral hypoechoic rim in the two
subgroups of hemangiomas grafted on normal liver and CLD
Hemangiomas on: normal liver steatosis+ NASH + cirrhosis (Table 4); the predominance of hyperechoic rim was ob-
chronic hepatitis (al- served in iso- and hypoechoic hemangiomas. The peritu-
coholic+ viral)
hyperechoic 126 45 28 moral rim depending on the size of the hemangioma was
hypoecoic 17 16 3 more commonly seen in hemangiomas ≥2 cm, but without
isoechoic 2 3 0 any statistical significance.
mixt 2 0 0 Hi-square test of independence finds no association be-
homogeneous 114 5 tween tumor echogenicity and hypoechoic rim in patients
inhomogeneous 38 65 with hemangiomas (χ2 =1.125 < 7.81, p=0.650); but it
hypoechoic rim 2 2 1 showed that there was only moderate association between hy-
hyperechoic rim 3 3 0
poechoic rim and hyperechoic tumor in patients without he-
Legend: NASH- nonalcoholic steatohepatitis
mangioma (p=0.004). Fisher 's exact test shows that there ex-
Of all 17 cavernous hemangiomas, US described 14 ists moderate association between hyperechoic rim and
(82.35%) as such, two of them being thrombosed, and in one hypoechoic hemangiomas (Cramer coefficient=0.37,
case as atypical cavernous hemangioma. p=0.001) and between hyperechoic rim and isoechoic heman-
Out of 270 patients explored by US, we detected 52 cases giomas (p<0.05).
of hemangiomatosis, 17 cavernous hemangiomas, 213 hy- The association between the presence of the hypoechoic
perechoic masses (being grafted in descending order on: rim and hepatic echogenicity or tumor size is shown in Table
chronic hepatitis, cirrhosis, and normal liver, steatosis and 4.

IFMBE Proceedings Vol. 59

6 I. Grigorescu et al.

Table 4 Correlation of hypo- and hyperechoic rim with hemangioma’s US alone established the diagnosis of hemangioma in 44%
echogenicity and size, echogenicity of liver and presence of CLD cases and US together with scintigraphic methods in 36%
cases; other imaging and invasive techniques (contrast-en-
Criteria: hypoechoic hyperechoic
rim rim
hanced-US, computed tomography, magnetic resonance,
puncture-biopsy, diagnostic laparoscopy, histology) were
Gejqigpkv{"qh"jgocpikqoc
necessary to corroborate with the previous methods in the rest
hyperechoic 5/270 1/270
isoechoic 0 3/270
of 20% patients. Figure 3 shows the methods used in
hypoecoic 0 3/270 corroboration, being both imaging and invasive, that
mixt 0 0 contributed to the final diagnosis of hemangioma.
Gejqigpkv{"qh"nkxgt
normal 4/270 5/270
increased 1/270 2/270
Uk|g"qh"jgocpikqoc
< 2cm 1/270 1/270
> 2cm 4/270 6/270
Rtgugpeg"qh"ENF
yes 3/270 4
no 2/270 3
Legend: CLD- chronic liver diseases

Fisher's exact test shows no association between liver

echogenicity and hypoechoic rim (p=0.205) or hyperechoic
rim (p=0.273) of hemangiomas. Fisher's exact test shows no
Fig.3 Imaging and invasive technics used in the diagnosis of hemangioma
association between hemangioma size and hypoechoic Legend: Scinti-scintigraphy, RMN-MRI, PBH-punction biopsy, histo-
(p=0.659) or hyperechoic rim (p=0.427) of hemangiomas. histology, OP-surgery, laparo-diagnostic laparoscopy
Presence of steatosis/nonalcoholic steatohepatitis (NASH)
in 69 images from our study revealed the following patterns
of hemangiomas: hypo- (16/69 cases), isoechoic (2/69 cases) IV. DISCUSSION
and heterogeneous (51/69 cases).
The association between the presence of the hyperechoic The value of different US methods (pre- and intraopera-
rim and tumoral size and the presence of CLD is shown in tory), computed tomography (CT), magnetic resonance
Table 4. Fisher's exact test shows no association between the (MR), differ depending on etiology of the tumor. US repre-
presence of underlying CLD and hypoechoic (p=0.328) or sents the first method of detection of hemangiomas.
hyperechoic (p=0,468) rim.Statistical parameters of the US The issue of differential diagnosis of hyperechoic masses
method used in the diagnosis of hemangiomas are shown in grafted on CLD is difficult, as far as it was shown that 15-
Table 5. 50% of focal lesions grafted on cirrhosis initially interpreted
as hemangiomas, are actually HCC [4, 5]. The chance of pre-
existence of a vascular malformation (hemangioma) grafted
Table 5 US sensitivity, specificity, positive and negative predictive laues on CLD is about 50%, but it is always necessary to corrobo-
in the diagnosis of hemangioma
rate with complementary methods (CT, MR, „in vivo” la-
US diagnosis of hemangioma: beled-RBC SPECT) in order to exclude a HCC. Transfor-
Presence of CLD Size of hemangioma mation of hypoechoic nodule in a hyperechoic mass can be
No (n=155) Yes (n=115) <2cm (n=95) ≥2cm (n=175) explained by necrosis and interstitial fibrosis; in these cases
Ug"*'+ 94.48 94.78 98.95 92.57 is not possible to differentiate from a typical small hyperech-
(90.08-97.75) (88.99-98.06) (94.27-99.97) (87.63-95.99) oic hemangioma [6].
Ur"*'+ 94.12 84.21 94.87 85.51
Literature mentioned the typical "low-flow" hemangioma
(83.77-98.77) (72.13-92.52) (82.68-99.37) (74.96-92.83)
RRX"*'+ 98 92.37 97.92 94.19 in cases of hyperechoic well defined masses, without peritu-
(94.27-99.59) (86.01-96.45) (92.68-99.75) (89.57-97.18) moral rim, and the "high-flow" hemangioma, which are com-
PRX"*'+ 85.71 88.89 97.37 81.94 monly hypoechoic and with atypical aspect in gray-scale US
(73.78-93.62) (77.37-95.81) (86.19-99.93) (71.11-90.02) [7]. There have been described both qualitative and quantita-
Legend: Se-sensitivity, Sp-specificity, PPV-positive predictive value, NPV-
negative predictive value, CLD- chronic liver diseases
tive differences regarding the presence of Doppler signal in
color and Power Doppler, being cited both lack and presence

IFMBE Proceedings Vol. 59

Ultrasonographic Correlations and Challenges in Liver Hemangiomas
of increased (especially peripheral, but also central) vascular
signal, suggestive for the diagnosis of hemangioma [8].
Hemangioma occurs as hyperechoic masses, which some-
times presents central thrombi, cystic areas and intratumoral
calcifications, due to the thrombotic formation in time, cystic
degeneration and calcification, or intratumoral necrosis.
These atypical features make difficult sometimes the differ-
ential diagnosis with malignant tumors [9, 10].
A special mention concerns the hemangiomas grafted on
steatosis, showing various aspects of echogenicity (from
hypo, to hyperechoic) and of CT density (hyperdense-native,
isodense-arterial phase); in these cases MR and/or histologi-
cal examination are mandatory, and sometimes fine needle
aspiration biopsy is useful in order to clarify the diagnosis
[9]. This might explain the 69 images from our study in pa-
tients with: steatosis/nonalcoholic steatohepatitis (NASH),
which were hypo- (16/70 cases), isoechoic (2/70 cases) and
heterogeneous (91,66% cases); cirrhosis with 3/21 hypo- and
18/21 hyperechoic hemangiomas; chronic viral and toxic
hepatitis, with 3/30 hypo- and 27/30 hyperechoic masses.
The attempt to establish an association between the tu-
mor's echogenicity and presence of CLD, or tumor size has
not shown any statistical significance; we found a good cor-
relation (p = 0.001) between hyperechoic rim and hypo- and
isoechoic hemangiomas.
Spotted presence of Doppler signal was identified in 7%
(11/157) of our cases, the rest of the masses in the right lobe
being without vascular signal. The model of the spotted
mixed type of vascularisation (both arterial and venous) was
encountered also in literature, but in a greater proportion (14
%) [11].
US is able to detect, within the 40% cases with hyperech-
oic rim in literature (where differential diagnosis with metas-
tases from insulinomas is required), atypical forms as solid
tumors with hypoechoic areas and with the described features
in periphery [12].
We could establish the diagnosis of atypical hemangiomas
in 19 of our cases, that would qualify as: heterogeneous
(n=7), having hypoechoic inhomogeneous structure, hy-
perechoic rim, and size of 2,7-9cm (average 4,51cm); heman-
giomas with calcification (n=4) and multilocular cavernous
hemangioma (n=8).
Corroboration of US with dynamic CT and „in vivo” la-
beled-RBC SPECT have shown a high sensitivity, specific-
ity, and high diagnostic accuracy [13], similar to the data in
our study.
Limits of the study were: the impossibility of follow-up in
all focal lesions and histopatological documentation for all,
and the varying experience of the examiner.
IFMBE Proceedings Vol. 59
7
V. CONCLUSION
Classic criteria of hyperechoic, well defined tumor and
without Doppler signal was found in 81.85% hemangiomas,
US proved to have increased specificity for masses <2 cm
(94.87%) and grafted on normal liver (94.12%). Hypo- and
isoechoic hemangiomas moderately correlate with the pres-
ence of a hyperechoic rim. No statistical correlation was
found between the underlying CLD and the hemangioma's
echogenicity, nor with the presence of any tumoral rim.
Presence of hemangiomas grafted on CLD is a challenge
for the physician, as it is important for the differential diag-
nosis with HCC or even metastases, especially when atypical
hemangiomas are hypoechoic. A good correlation of US pa-
rameters with other imaging methods (scintigraphy, CES), in
case of atypical features, can avoid liver biopsy and enables
to establish a correct positive diagnosis.
CONFLICT OF INTEREST"
The authors declare that they have no conflict of interest
and there is no disagreement in this new approach of imaging
assessment of hemangiomas.
STATEMENT OF HUMAN RIGHTS"
The procedures were in accordance with the ethical stand-
ards of the responsible local and national committee on hu-
man experimentation and with Helsinki Declaration of 2000.
REFERENCES "
1. Badea R. Ficatul. In: Badea R, Mircea PA, Dudea S, Stamatian F
(2000)Tratat de ultrasonografie clinică- vol.I Principii, abdomen,
obstetrică şi ginecologie. Ed. Medicală Bucureşti:105-175
2. Harvey CJ, Albrecht T (2001) Ultrasound of focal liver lesions. Eur
Radiol 11:1578–1593
3. Farrell MA, Charboneau JW, Reading CC (2000) Sonographic
pathologiccorrelation of the hyperechoic border ofan atypical he-
patic hemangioma. J Ultrasound Med 20:169–170
4. Repiso A., Gomez Rodriguez, R., Gonzales de Frutos C. et al.
(2007) Angioma like liver lesions in patients with chronic liver dis-
ease. Rev. esp. enferm. dig. 99(5): 259-263
5. Caturelli E, Pompili M, Bartolucci F et al. (2001) Hemangioma-
like Lesions in Chronic Liver Disease: Diagnostic Evaluationin Pa-
tients1.Radiology 220:337–342
6. Sheu JC, Chen DS, Sung JL et al. (1985) Hepatocellular carcinoma:
US evolution in the early stage. Radiology 155:463–467
7. Galanski M. Jördens S, Weidemann (2008) Diagnose und Differ-
entialdiagnose benigner Lebertumoren und tumorähnlicher Läsio-
nen. Chirurg 79:707-721
8. Choi BI, Kim TK, Han JK et al. (1996) Power versus Conventional
Color Doppler Sonography: Comparison In the Depiction of Vas-
culature in Liver Tumors. Radiology 200:55-58
8 I. Grigorescu et al.

9. Vilgrain V, Boulous L, Vullierme MP et al. (2000) Imaging of 13. Weimann A, Ringe B, Klempnauer J et al. (1997) Benign liver tu-
atypical hemangiomas of the liver with pathological correlation. mors: differential diagnosis and indications for surgery. World J
Radiographics 20: 379–397 Surg 21:983-990
10. Shimizu S, Tadatoshi T, Kosuge T et al. (1992) Benign tumors of
the liver resected because of a diagnosis of malignancy. Surg Gy- Author: Ioana Grigorescu
necol Obstet 174:403-407 Institute: 2nd Medical Department, „Iuliu Hatieganu” University of
11. Bartolotta TV, Midiri M, Quaia E (2005) Liver haemangiomas Medicine and Pharmacology Cluj-Napoca, Romania
undetermined at grey-scale ultrasound: contrast-enhancement pat- Street: Clinicilor Str. 2-4
terns with SonoVue and pulse-inversion US. Eur Radiol 15:685– City: Cluj-Napoca
693 Country: Romania
12. Moody A, Wilson S (1993) Atypical hepatic hemangiomas: a sug- E-mail: ioanaducagrigorescu@gmail.com
gestive sonographic morphology. Radiology 188:413-417

IFMBE Proceedings Vol. 59

 Impact of Spectralis Optical Coherence Tomography in the Clinical Practice
S.D. Nicoară
"Iuliu Haìieganu" University of Medicine and Pharmacy/Ophthalmology, 8. V. Babes str., 400012, Cluj-Napoca, Romania
Abstract—"Qrvkecn"Eqjgtgpeg"Vqoqitcrj{"*QEV+"ku"c"tgnc/
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Ocewnct"Gfgoc0
I. INTRODUCTION
Optical Coherence Tomography (OCT) is a high resolu-
tion, non-invasive imaging method that started to be used in
the clinical practice in 1990s. The first application of OCT
technology was in the field of ophthalmology and the imag-
es resembled the histological sections of the retina. Howev-
er, the pictures depict the result of the scanned tissues' opti-
cal properties, not the tissues themselves [1].
OCT concept developed at Massachusetts Institute of
Technology, at the beginning of 1990s. The first
commercial device was made by Carl Zeiss (Jena,
Germany) in 1996. The first OCT applications referred to
quantitative and qualitative information about the
peripapillary area of the retina and the coronary arteries [2].
OCT uses light, as opposed to ultrasonic biomicroscopy
(UBM) that uses ultrasounds, with the aim to visualize eye
structures. Light speed is 1 million times higher than sound
speed. By consequence, resolutions lower than 10 μ microns
are obtained in the posterior pole of the eye with OCT
technology. For many years, UBM offered resolutions in the
range of 150 μ. By using high frequencies, resolutions of 20
μ are possible with UBM technology. The ultrasound waves
used in UBM are markedly attenuated by the biological
tissues and therefore, are limited to the examination of
anterior eye structures [3].
OCT exam is very comfortable for the patient, as it does
not require the direct contact with the eye.
© Springer International Publishing AG 2017
S. Vlad and N.M. Roman (eds.), International Conference on Advancements of Medicine and Health Care through Technology;
12th - 15th October 2016, Cluj-Napoca, Romania,
IFMBE Proceedings 59,
DOI: 10.1007/978-3-319-52875-5_2
II. DESCRIPTION OF THE DEVICE
A. Overview
Spectralis is a multimodal platform that uses the confocal
laser technology, in order to obtain color and spectral opti-
cal coherence tomography (OCT) images of the eye struc-
ture. Two different laser wavelengths catch simultaneously,
the OCT and the fundus image of the eye [3].
The principle of Spectral Domain OCT (SD-OCT) is
based on the Fourier equation, as compared to Time Do-
main OCT (TD-OCT) that developed on the ground of in-
terferometry. In TD-OCT, an interferometer measures se-
quentially, the delay of light echoes that are reflected by the
retinal microstructures. In SD-OCT, a spectrometer evalu-
ates simultaneously, the light reflected by retinal micro-
structures. In TD-OCT, 6 radial scans are performed,
whereas in SD-OCT, 65.000 scans are made within an area
of 6 mm diameter. Acquisition time is about 60 times faster
with SD-OCT devices and the axial resolution varies be-
tween 3 - 7 μ, as compared to TD-OCT ( 10 -15 μ) [3].
Eye tracking function is used to neutralize the errors in-
duced by involuntary eye movements. Spectralis is able to
detect changes within 1 - 2 microns, at the depth of 289
microns, and it is able to filtrate and select the high resolu-
tion images, in order to identify the finest details. The auto
re-scan function is very important for the patient's follow-
up, as it places the subsequent scans precisely at the initial
examination site. The deep layers can be examined with the
enhanced-depth OCT function (EDI-OCT) [3].
B. Investigation possibilities
Spectralis offers the following imaging possibilities for
the eye: spectral domain OCT (SD-OCT), infrared (IR), red
free, fundus autofluorescence (FAF), confocal multicolor
3D, wide field (55˚), SD-OCT for the diagnosis and moni-
toring of glaucoma, anterior segment imaging [3].
C. Technical characteristics
Domain: Spectralis operates in the spectral domain OCT,
based on the Fourier equation.
Minimal scan speed: 40000 A-scans /second
Laser light sources:
9
10
A super luminescent diode λ 870 nm acquires the images.
IR light (λ 815 nm) allows the visualization of detailed
images of the eye fundus.
A green laser (λ 518 nm) ensures the obtaining of confo-
cal, 3D images of the retina, with multicolor technology.
A blue laser (λ 486 nm) is used for identifying fundus au-
to fluorescence (FAF) and obtaining the red free images.
The blue light makes it possible to identify fundus auto
fluorescence, based on the fluorescent properties of
lipofuscin. With red free light, specific structures are visual-
ized: nerve fiber layer, epiretinal membranes and retinal
cysts.
The simultaneous, confocal, 3D collection of the imaging
data with three different types of lasers (red, green and blue)
allows to evaluate various retinal layers on a single image.
The device also offers the possibility to combine the
above mentioned acquiring modalities, in various ways,
according to the investigated retinal condition: IR and FAF,
OCT and IR, OCT and FAF, OCT and red free, OCT and
3D multicolor confocal eye fundus examination [3].
D. Examination modules
Anterior segment: By the use of a high resolution 3D ex-
amination lens, images with 7 μ axial resolution and 30 μ
lateral resolution can be obtained. The scanning depth in the
tissue is of 1.9 mm.
Multicolor confocal 3D module: It allows the visualiza-
tion of the 3D, color image of the eye fundus, simultaneous-
ly with the transverse section through the retina. Thus, dif-
ferent retinal structures are evaluated on one single image.
Scanning with multiple laser wavelengths allows the de-
tailed evaluation of the retinal structure: superficial, middle
and deep retinal layers.
Wide field module: It makes possible to view the retinal
periphery, by OCT and fundus image, using a non-contact,
55˚ lens. The high resolution visualization of the macula,
optic nerve and retinal periphery is achieved in a single
image. The scanning models are: radial 55˚ central and
volume 55ºx25º (for the diabetic patients) /55ºx40º /25ºx5 º
central.
Glaucoma module: It allows the complete analysis of
glaucoma, with the evaluation of the neuro-retinal rim,
retinal nerve fiber layer (RNFL) and asymmetry regarding
the posterior pole and the ganglion cell layer.
The optic nerve head (ONH) analysis is made using the
Bruch's membrane opening as the anatomical frontier for
the rim. The neuro-retinal rim is measured between Bruch's
membrane opening and the nearest point of the internal
limiting membrane (ILM).
During scanning, the device lines up automatically, the
fovea with the central axis of Bruch's membrane opening.
IFMBE Proceedings Vol. 59
S.D. Nicoară
Future scans and sectors are placed exactly on the previ-
ous sites, which is very important for the accurate monitor-
ing of the disease progression.
Various scans are available: 24˚ radial scan, circular
scans with 3,5 mm/4,1 mm/4,6 mm diameter, volume scans
of 30ºx25º/30ºx15º /15ºx15 º, circular scan of the RNFL at
12˚, with 768 analyzed points [3].
III. SPECTRALIS OCT IN THE DIAGNOSIS AND MONITORING OF
MACULAR DISORDERS
Optical Coherence Tomography is widely used in the as-
sessment and monitoring of macular diseases. We illustrate
the contribution of Spectralis in the clinical practice with
selected cases from our own experience. The patients were
included in this study in accordance with the Helsinki Dec-
laration of 1975, as revised in 2000 and 2008.
A. Age related Macular Degeneration (AMD)
AMD is one of the retinal conditions that benefited the
most from the progress in of OCT technology. The main
advantage of the OCT imaging is the quantification of the
retinal thickness, allowing to monitor the anti-VEGF treat-
ment efficacy in wet AMD. OCT is also able to identify the
location of the fluid in neovascular AMD: intraretinal, sub-
retinal or sub-Retinal Pigmented Epithelium (RPE) [4].
According to OCT imaging, the choroidal neovascular
membranes (CNV) in wet AMD were classified into 3
types. In type 1 (occult neovascularization), CNV is located
under the retinal pigmented epithelium (RPE), in type 2
(classic neovascularization), it is located above the RPE and
in type 3, there is a retinal angiomatous proliferation (RAP).
In large RPE detachments, breaks in the RPE layer can
occur. The rupture of the RPE layer appears as a clearly
demarcated region of RPE absence, adjacent to a region of
RPE elevation. The reversed shadow effect is identified.
Often, especially in type 2 CNVs, the interruption of the
RPE layer is identified. In type 2 CNV, the neovascular
membrane is located in the subretinal space and it pene-
trates through the RPE/Bruch's membrane complex. RAP is
a rare form of wet AMD that originates in abnormal neo-
vascular tissue from the deep retinal layers [5].
The response to anti-VEGF therapy is translated into the
OCT imaging, by the diminishing/disappearance of the
intra/sub-retinal fluid and by the decrease of the PEDs size
and of the macular thickness [2].
Impact of Spectralis Optical Coherence Tomography in the Clinical Practice 11

B. Vitreo-macular interface disorders

Fig. 1. Classic form of neovascular AMD
Figure 1 presents the combined IR-OCT image of the ret-
ina in a patient with wet age related macular degeneration
(AMD). The neurosensitive retina is detached by fluid (su-
perior arrow) originating in a fibro-vascular membrane
under it (inferior arrow). The retinal pigmented epithelium
(RPE) layer is irregular and disrupted in the area of lesion.
The fluid has no reflectivity (it appears black on the black-
white image). This aspect corresponds to the classic neo-
vascular membrane which responds better to anti-VEGF
therapy, as opposed to occult membranes which are located
under the RPE. OCT has a major role in locating precisely
the neovascular membrane in relationship with the RPE and
the neurosensory retina.
Vitreo-macular interface disorders benefited from the ad-
vances in OCT technology, in terms of the diagnosis preci-
sion and surgical indication [3]. In figure 4, an advanced
stage of vitreo-macular traction syndrome is presented.
Along time, it led to the disorganization of the macular
retina, which is dissected by liquid spaces and cysts. There-
fore, the resistance of the retinal tissue is considerably di-
minished. In this situation, the dissection of the vitreo-
macular interface, in order to relieve the traction, is risky, as
it may lead to the break and detachment of the retina.
Fig. 4. Retinal disorganization following an advanced vitreo-macular
interface syndrome
Figure 5 depicts the fellow eye of the same patient. Ob-
viously, the vitreo-macular traction is less advanced, but
there are modifications of the retinal structures: the macular
thickness is increased and a hole within the retina is identi-
fied. Surgery in this situation is indicated, in order to pre-
vent the progression of the disease.

Fig. 2 RTM map in a patient with classic form of neovascular AMD

In figure 2, the retinal thickness map (RTM) in the same

patient as in figure 1, is presented. The thickness of the
macula is significantly increased in the macular area located
infero-temporally from the fovea. This is signalized by
white and red colors.
OCT is able to identify early stages of AMD, named Fig. 5. Fellow eye in the same patient as in figure 3
drusen, as elevations and irregularities of the RPE line (fig-
ure 3).
RTM proves the increased macular thickness and offers
precise values for this parameter, within the macular area
(figure 6).

Fig.3. Drusen

IFMBE Proceedings Vol. 59

12 S.D. Nicoară

870 nm) is used to acquire the OCT images. The simultane-

ous, confocal, 3D collection of the imaging data with three
different types of lasers (red, green and blue) allows to
evaluate the structure of various retinal layers on a single
image.

Fig. 6. RTM for the same eye as in figure
C. Diabetic maculopathy
Diabetes is the main cause of visual impairment in the
group of working age population. Maculopathy is the main
cause of vision decrease in the diabetic patients. Progress in
OCT technology allows early diagnosis and treatment of
diabetic macular edema, which is crucial for vision preser-
vation [6]. The main mechanism of macular edema caused
by diabetes is represented by the microangiopathy at the
level of the retinal capillaries [3,6]. Figure 7 presents in-
traretinal microaneurysms (hyperreflective dots) that leak,
as proved by the non-reflective material (liquid) elevating
the neuro-sensory retina.
Fig. 7. Diabetic macular edema
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
REFERENCES
1. Huang D, Swanson EA, Lin CP et al. (1991) Optical coherence
tomography. Science, 22: 1178-1181
2. Simona- Delia Ţălu, New Insights into the Optical Coherence
Tomography –Assessement and Follow-Up of Age-Related
Macular Degeneration, in "Age-Related Macular Degeneration -
Etiology, Diagnosis and Management - A Glance at the Future",
(2013) InnTech, Rijeka, ed. Giuseppe Lo Giudice
3. Duker JS, Waheed NK, Goldman DR (2014) Handbook of retinal
OCT, Elsevier, London
4. Lim LS, Mitchell P, Seddon JM et al. (2012) Age-related macular
degeneration. Lancet, 379: 1728–38
5. Talu SD, Talu S, Use of OCT Imaging in the Diagnosis and
Monitoring of Age Related Macular Degeneration, in Age Related
Macular Degeneration. The recent advances in basic research and
clinical care (2012) Inn Tech, Rijeka, ed. Gui-Shuang Ying.
6. Menke M, Lala C, Framme C, Wolf S. The Ever-Evolving Role
of Imaging in DME Management (2012) Retin Physician, 9 (4):
24-32.
Author: Simona Delia Nicoara
Institute: "Iuliu Hatieganu" University of Medicine and Pharmacy
Street: 8, Victor Babes street, 400012
City: Cluj-Napoca
Country: Romania
Emai: simonanicoara1@gmail.com

The liquid within the neuro-sensory retina is responsible

for the considerable macular thickening, as shown in figure
8 (the maximal macular thickness appears of 600 μ).

Fig. 8. Macular thickening in diabetes

IV. CONCLUSIONS
Spectralis is a very useful tool in the diagnosis and moni-
toring of macular diseases. A super luminescent diode (λ

IFMBE Proceedings Vol. 59

Another random document with
no related content on Scribd:
Before Kingman, on the desk, were pages of stock market reports.
On a blackboard, a jagged line denoted the vacillation of Venus
Equilateral Preferred. This phase of his plan was working to
perfection. Gradually, he was buying share after share out of
uninterested hands by his depredations. Soon he would have
enough stock to stage a grand show, and then he could swing the
thing his way.
His worry was not with this affair.
He gloated over that. His belief that he could beat this Venus
Equilateral crowd if he fought them on his ground with his weapon
was being corroborated. That, plus the fact that he was using some
of Venus Equilateral's own thunder to do the job, was giving him to
think that it was but a matter of time.
And the poor fools were not aware of their peril. Oh, some bird was
trying to buck him, but he was not prepared as Kingman was, nor
had he the source of information that Kingman had.
No, the thing that worried him was—
And there it came again! A wild, cacophonous wailing, like a whole
orchestra of instruments playing at random, in random keys. It shook
the very roots of the body, that terrible caterwauling, and not only did
it shake the body, and the mind, but it actually caused loose plates to
rattle in the bulkhead, and the cabinet doors followed in unison. The
diapason stop was out for noon, and the racket filled the small
control room and bounced back and forth, dinning at the ears of
Kingman as it went by. It penetrated to the upper reaches of the ship,
and the crew gritted their teeth and cursed the necessity of being
able to hear orders, for cotton plugs would have been a godsend and
a curse simultaneously. Anything that would blot that racket out
would also deafen them to the vital orders necessary to the
operation of the ship in this precarious poising maneuver.
Two hundred sheer watts of undistorted audio power boomed forth in
that tiny room—two hundred watts of pure, undistorted power to
racket forth something that probably started out as sheer distortion—
And yet—
Faintly striving against that fearful racket there came a piping, flat-
sounding human voice that said: "Kingman! V.E. Preferred just hit
eighty-nine!"
Kingman scowled and punched on the intership teletype machine.
Using the communicator set with that racket would have been
impossible.
The radio man read the note that appeared on his 'type, and smiled
grimly. He saw to his helio-mirror and sighted through a fine
telescope at a spot on Venus, three thousand miles below. The helio
began to send its flashing signal to this isolated spot near the Boiling
River, and it was read, acknowledged, and repeated for safety's
sake. The radio man flashed "O.K." and went back to his forty-
seventh game of chess with the assistant pilot.
The helio man on the Boiling River read the message, grinned, and
stepped to the telephone. He called a number at Northern Landing,
and a tight beam sped across the northern quarter of Venus to a
man connected with the Venus Stock Market. The man nodded, and
said to another: "Buy fifteen hundred—use the name of Ralph
Gantry this time."
The stock purchased under the name of Ralph Gantry was signed,
sealed and delivered exactly fifteen minutes before the ticker
projection on the grand wall of the Exchange showed the V.E.
Preferred stock turn the bottom curve and start upward by hitting
eighty-nine!
Back in the Terran Electric spaceship Kingman's ears were still beset
by the roaring, alien music.
He was sitting in his chair with his head between his hands, and did
not see the man approaching the instrument panel with a pair of
side-cutters in one hand. The man reached the panel, lifted it slightly,
and reached forward. Then Kingman, hearing a slight imperfection in
the wail of the speaker, looked up, jumped from his chair, and
tackled the engineer.
"You blasted fool!" blazed Kingman. "You idiot!"
The music stopped at his third word, and the scream of his voice in
the silence of the room almost scared Kingman himself.
"Mark, I'm going nuts. I can't stand that racket."
"You're going to stand it. Unless you can get something to cut it out."
"I can't. I'm not brilliant enough to devise a circuit that will cut that
noise and still permit the entry of your fellow on Luna."
"Then you'll live with it."
"Mark, why can't we take that relay apart and work on it?"
"Ben, as far as I know, that relay is what Channing and his gang
would give their whole station for—and will, soon enough. I don't
care how it works—or why!"
"That's no way to make progress," objected Ben.
"Yeah, but we've got the only detector for driver radiation in this part
of the universe! I'm not going to have it wrecked by a screwball
engineer who doesn't give a care what's going on as long as he can
tinker with something new and different. What do we know about it?
Nothing. Therefore how can you learn anything about it? What would
you look for? What would you expect to find?"
"But where is that music coming from?"
"I don't know. As best as we can calculate, driver radiation
propagates at the square of the speed of light, and that gives us a
twenty-four minute edge on Venus Equilateral at the present time.
For all I know, that music may be coming from the other end of the
galaxy. At the square of the speed of light, you could talk to Centauri
and get an answer in not too long."
"But if we had a chance to tinker with that relay, we might be able to
find out what tunes it and then we can tune in the Lunar station and
tune out that cat-melody."
"I'm running this show—and this relay is going to stay right where it
is. I don't care a hoot about the control circuit it breaks; these
controls are set, somehow, so that we can detect driver radiations
and I'm not taking any chances of having it ruined."
"Can't you turn the gain down, at least?"
"Nope. We'd miss the gang at Luna."
The speaker spoke in that faint, flat-toned human voice again. It was
easy to see that all that gain was necessary to back up the obviously
faint response of Kingman's detector. The speaker said: "Kingman!
Addison got power through the Channing Layer!"
That was all for about an hour. Meanwhile, the mewling tones burst
forth again and again, assaulting the ears with intent to do damage.
The messages were terse and for the most part uninteresting. They
gave the market reports: they intercepted the beam transmissions
through the Terran Heaviside Layer before they got through the
Lunar Relay Station, inspected the swiftly-moving tape and
transmitted the juicy morsels to Kingman via the big driver tube that
stood poised outside of the landed spaceship.
Kingman enjoyed an hour of celebration at Addison's success, and
then the joy turned to bitter hate as the message came through
telling of the ozone that resulted in the passage of the solar beam
through the atmosphere. The success of the beam, and the utter
impossibility of using it were far worse than the original fact of the
beam's failure to pass the Channing Layer.
So Kingman went back to his stock market machinations and applied
himself diligently. And as the days wore on, Kingman's group
manipulated their watered stock and ran the price up and down at
will, and after each cycle Kingman's outfit owned just one more bit of
Venus Equilateral.
Terran Electric would emerge from this battle with Venus Equilateral
as a subsidiary—with Kingman at the helm!
Walt Franks entered Channing's office with a wild-eyed look on his
face. "Don! C²!"
"Huh! What are you driving about?"
"C². The speed of light, squared!"
"Fast—but what is it?"
"The solar beam! It propagates at C²!"
"Oh, now look. Nothing can travel that fast!"
"Maybe this isn't something!"
"It has energy, energy has mass, mass cannot travel faster than the
limiting speed of light."
"O.K. It can't do it. But unless my measurements are all haywire, the
beam gets to Sol and back at C². I can prove it."
"Yeah? How? You couldn't possibly measure an interval so small as
two times sixty-seven million miles—the radius of Venus' orbit—
traversed at the speed of light, squared."
"No. I admit that. But, Don, I got power out of Sirius!"
"You WHAT?" yelled Channing.
"Got power out of Sirius. And unless I've forgotten how to use a
micro-clock, it figured out from here to Sirius and back with the
bacon in just about ninety-three percent of the speed of light
squared. Seven percent is well within the experimental error, I think,
since we think of Sirius as being eight and one-half light years away.
That's probably not too accurate as a matter of fact, but it's the figure
I used. But here we are. Power from Sirius at C². Thirty-five billion
miles per second! This stuff doesn't care how many laws it breaks!"
"Hm-m-m. C², hey? Oh, lovely. Look, Walt, let's run up and take a
whirl at Wes Farrell's detector. I'm beginning to envision person-to-
person, ship-to-ship service, and possibly the first Interplanet
Network. Imagine hearing a play-by-play account of the Solar
Series!"
"Wool gathering," snorted Walt. "We've gotta catch our detector first!"
"Wes has something. First glimmer we've had. I think this is the time
to rush into it with all eight feet and start pushing!"
"O.K. Who do we want?"
"Same gang as usual. Chuck and Freddie Thomas, Warren, Wes
Farrell, of course, and you can get Jim Baler into it, too. No, Walt,
Christine Baler is not the kind of people you haul into a screwdriver
meeting."
"I was merely thinking."
"I know. But you're needed, and if she were around, you'd be a total
loss as far as cerebration."
"I like her."
"So does Barney Carroll."
"Um! But he isn't here. O.K., no Christine in our conference. I'll have
Jeanne call the screwballs on the communicator."
They dribbled into Farrell's laboratory one by one, and then Don
said:
"We have a detector. It is about as efficient as a slab of marble; only
more so. We can get a tinkle of about ten micromicroamps at twenty
feet distance from a driver tube using eight KVA input, which if we
rate this in the usual spaceship efficiency, comes to about one-half
G. That's about standard, for driver tubes, since they run four to a
ship at two G total.
"Now, that is peanuts. We should be able to wind a megammeter
around the peg at twenty feet. Why, the red ionization comes out of
the tube and hits our so-called detector, and the amount of ozone it
creates is terrific. Yet we can't get a good reading out of it."
Walt asked: "Wes, what worked, finally?"
"A four-turn coil on a ceramic form, in series with a twenty
micromicrofarad tuning condenser. I've been using a circular plate as
a collector."
"Does it tune?"
"Nope. Funny thing, though, it won't work without a condenser in the
circuit. I can use anything at all there without tuning it. But, darn it,
the coil is the only one that works."
"That's slightly ridiculous. Have you reconstructed all factors?"
"Inductance, distributed capacity, and factor 'Q' are all right on the
button with two more I made. Nothing dioding."
"Hm-m-m. This takes the cake. Nothing works, you say?"
"Nothing in my mind. I've tried about three hundred similar coils, and
not a wiggle since. That's the only one."
Chuck Thomas said: "Wes, have you tried your tube-amplifier
system ahead of it?"
"Yes, and nothing at all happens then. I don't understand that one,
because we know that any kind of input power will be re-beamed as
similar power. I should think that the thing will amplify the same kind
of stuff. I've used a solar beam miniature with a driver-alloy dynode
in it, but that doesn't work either."
"Shucks," said Thomas.
Don stood up and picked up the coil. "Fellows, I'm going to make a
grand, old college try."
"Yes?" asked Walt.
"I've got a grand idea, here. One, I'm still remembering that business
of making the receptor dynode of the same alloy as the transmitter
cathode. I've a hunch that this thing is not so much an inductor, but
something sour in the way of alloy-selectivity. If I'm right, I may cut
this in half, and make two detectors, each of similar characteristics.
Shall I?"
"Go ahead. We've established the fact that it is not the physico-
electrical characteristics of that coil," said Wes. "I, too, took my
chances and rewound that same wire on a couple of other forms. So
it doesn't count as far as inductance goes. So we can't ruin anything
but the total make-up of the wire. I think we may be able to re-
establish the wire by self-welding if your idea doesn't work. Now,
unless we want to search the three planets for another hunk of wire
to work like this one did, without knowing what to look for and
therefore trying every foot of wire on three planets—"
"I'll cut it," said Channing with a smile. His cutters snipped, and then
fastened one end of the wire to the coil, stripping the other portion off
and handing it to Chuck Thomas, who rewound it on another form.
"Now," said Don, "crank up your outfit and we'll try this hunk."
The beam tubes were fired up, and the smell of ozone began to
make itself prominent. Channing cranked up the air-vent capacity to
remove the ozone more swiftly. The men applied themselves to the
detector circuits, and Wes, who recognized the results, said: "This
hunk works. About as good as the whole coil."
Channing replaced the first coil with the second. Wes inspected the
results and said: "Not quite as good, but it does work."
Walt nodded, and said: "Maybe it should be incandescent."
"That's a thought. Our solar beam uses an incandescent dynode."
Channing removed the second coil and handed it to Freddie. "Take
this thing down to the metallurgical lab and tell 'em to analyze it right
down to the trace of sodium that seems to be in everything. I want
quantitative figures on every element in it. Also, cut off a hunk and
see if the crystallographic expert can detect anything peculiar, that
would make this hunk of copper wire different from any other hunk.
Follow?"
"Yup," said Freddie. "We'll also start making similar alloys with a few
percent variation on the composition metals. Right?"
"That's the ticket. Wes, can we evacuate a tube with this wire in it
and make it incandescent?"
"Let's evacuate the room, I like that stunt."
"You're the engineer on this trick. Do it your way."
"Thanks. I get the program, all right. Why not have Chuck build us a
modulator for the driver tube? Then when we get this thing
perfected, we'll have some way to test it."
"Can do, Chuck?"
"I think so. It's easy. We'll just modulate the cathode current of the
electron guns that bombard the big cathode. That is the way we
adjust for drive; it should work as a means of amplitude-modulation."
"O.K.," said Channing. "We're on the rails for this one. We'll get
together as soon as our various laboratories have their answers and
have something further to work with."

Above Venus, Mark Kingman was listening to the wailing roar of

alien symphony and cursing because he could hardly hear the voice
of his Lunar accomplice saying: "V. E. Preferred just hit one hundred
and two!"
Fifteen minutes before the peak hit Northern Landing, share after
share was being dumped, and in addition, a message was on its way
back to Terra. It went on the regular beam transmission through
Venus Equilateral, carefully coded. It said:
"HAVE SUFFICIENT STOCK AND ADDITIONAL
COLLATERAL TO APPLY THE FIRST PRESSURE.
APPLY PHASE TWO OF PLAN.
KINGMAN."
In the ten hours that followed, Venus Equilateral stock went down
and down, passed through a deep valley, and started up again.
Kingman's crowd was offering twice the market for the preferred
stock, and there was little to have. It took a short-time dip at three
hundred, and the few minutes of decline smoked a lot of stock out of
the hands of people who looked upon this chance as the right time to
make their money and get out.
Then the stock began to climb again, and those people who thought
that the price had been at its peak and passed were angrily trying to
buy in again. That accelerated the climb, but Kingman's crowd,
operating on Venus and on Mars and on Terra, were buying only,
and selling not one share of Venus Equilateral.
Terran Electric stock took a gradual slide, for Kingman's crowd
needed additional money. But the slide was slow, and controlled, and
manipulated only for the purpose of selling short. Terran Electric
stock eventually remained in the hands of Kingman's crowd, though
its value was lessened.
Venus Equilateral Preferred hit four hundred and sixty-eight, and
hovered. It vacillated around that point for another hour, and the
market closed at four hundred and sixty-nine and three-eighths.
Kingman looked at his watch and smiled. He reached forth and cut
the dinning sound of the cacophony with a vicious twist of the gain
knob. Silence reigned in the spaceship; grand, peaceful silence.
Kingman, his nerves frayed by the mental activity and the brain-
addling music-from-nowhere, took a hot shower and went to bed.
He locked the panel of the control room first, however. He wanted no
engineer tinkering with his pet relay.

Cartwright came into Channing's living room with a long face. "It's
bad," he said. "Bad."
"What's bad?"
"Oh, I, like the rest of the fools, got caught in his trap."
"Whose trap?"
"The wild man who is trying to rock Venus Equilateral on its axis."
"Well, how?"
"They started to buy like mad, and I held out. Then the thing dropped
a few points, and I tried to make a bit of profit, so that we could go on
bolstering the market. They grabbed off my stock, and then, just like
that! the market was on the way up again and I couldn't find more
than a few odd shares to buy back."
"Don't worry," said Channing, "I don't think anyone is big enough to
really damage us. Someone is playing fast and loose, making a
killing. When this is over, we'll still be in business."
"I know, Don, but whose business will it be? Ours, or theirs?"
"Is it that bad?"
"I'm afraid so. One more flurry like today, and they'll be able to tow
Venus Equilateral out and make Mars Equilateral out of it, and we
won't be able to say a word."
"H-m-m-m. You aren't beaten?"
"Not until the last drop. I'm not bragging when I say that I'm as good
an operator as the next. My trouble today was not being a mind
reader. I'd been doing all right, so far. I've been letting them ride it up
and down with little opposition, and taking off a few here and there
as I rode along. Guessing their purpose, I could count on their next
move. But this banging the market sky-high has me stumped, or had
me stumped for just long enough for me to throw our shirt into the
ring. They took that quick—our shirt, I mean."
"That's too bad. What are you leading up to?"
"There are a lot of unstable stocks that a guy could really play hob
with; therefore their only reason to pick on us is to gain control!"
"Pirates?"
"Something like that."
"Well," said Channing in a resigned voice, "about all we can do is do
our best and hope we are smart enough to outguess 'em. That's your
job, Cartwright. A long time ago Venus Equilateral made their
decision concerning the executive branch of this company, and they
elected to run the joint with technical men. The business aspects and
all are under the control of men who know what they are fighting. We
hire business men, just like business men hire engineers, and for the
opposite purpose. You're the best we could get, you know that. If
those guys get Venus Equilateral, they'll get you, too. But if you do
your best and fail, we can't shoot you in the back for it. We'll all go
down together. So keep pitching, and remember that we're behind
you all the way!"
"Can we float a bit of a loan?"
"Sure, if it's needed. I'd prefer Interplanetary Transport. Keg Johnson
will do business with us. We've been in the way of helping them out
a couple of million dollar losses; they might be anxious to
reciprocate."
"O.K. I have your power of attorney, anyway. If I get in a real crack,
I'll scream for I. T. to help. Right?"
"Right!"
Cartwright left, and as he closed the door, Channing's face took on a
deep, long look. He was worried. He put his head between his hands
and thought himself into a tight circle from which he could not
escape. He did not hear Walt Franks enter behind Arden and
Christine.
"Hey!" said Walt. "Why the gloom? I bear glad tidings!"
Channing looked up. "Spill," he said with a glum smile. "I could use
some glad tidings right now."
"The lab just reported that that hunk of copper wire was impure. Got
a couple of traces of other metals in it. They've been concocting
other samples with more and less of the impurities, and Wes has
been trying them as they were ready. We've got the detector working
to the point where Freddie has taken the Relay Girl out for a run
around the station at about five hundred miles and Wes is still getting
responses!"
"Is he? How can he know?"
"Chuck rigged the Relay Girl's drivers with a voice modulator, and
Freddie is jerking his head off because the acceleration is directly
proportional to the amplitude of his voice, saying: 'One, two, three,
four, test.' Don, have you ever figured out why an engineer can't
count above four?"
"Walt, does it take a lot of soup to modulate a driver?" asked Arden.
"Peanuts," grinned Franks. "This stuff is not like the good old radio;
the power for driving the spaceship is derived mostly, from the total
disintegration of the cathode and the voltage applied to the various
electrodes is merely for the purpose of setting up the proper field
conditions. They draw quite a bit of current, but nothing like that
which would be required to lift a spaceship at two G for a hundred
hours flat."
He turned back to Channing. "What's the gloom?"
Don smiled in a thoughtful fashion. "It doesn't look so good right now.
Some gang of stock market cutthroats have been playing football
with Venus Equilateral, and Cartwright says he is sure they want
control. It's bad; he's been clipped a couple of hard licks, but we're
still pitching. The thing I'm wondering right now is this: Shall we toss
this possibility of person-to-person and ship-to-ship communication
just at the right turn of the market to bollix up their machinations, or
shall we keep it to ourselves and start up another company with this
as our basis?"
"Can we screw 'em up by announcing it?"
"Sure. If we drop this idea just at the time they're trying to run the
stock down, it'll cross over and take a run up, which will set 'em on
their ear."
"I don't know. Better keep it to ourselves for a bit. Something may
turn up. But come on down to Wes' lab and give a look at our new
set-up."
Channing stood up and stretched. "I'm on the way," he said.
Farrell was working furiously on the detector device, and as they
entered, he indicated the meter that was jumping up and down. Out
of a speaker there was coming the full, rich tones of Freddie
Thomas' voice, announcing solemnly: "One, two, three, four, test."
Wes said, "I'm getting better, Chuck has been bettering his
modulator now, and the detector is three notches closer to whatever
this level of energy uses for resonance. Evacuation and the
subsequent incandescence was the answer. Another thing I've found
is this—" Farrell held up a flat disk about six inches in diameter with
one sawcut from edge to center. "As you see, the color of this disk
changes from this end of the cut, varying all the way around the disk
to the other side of the cut. The darned disk is a varying alloy—I've
discovered how to tune the driver-radiation through a limited range.
We hit resonance of the Relay Girl's driver system just off the end of
this disk. But watch while I turn the one in the set."
Farrell took a large knob and turned it, Freddie's voice faded, and
became toneless. Farrell returned the knob to its original position
and the reception cleared again. "Inside of that tube there," said
Farrell, "I have a selsyn turning the disk, and a small induction loop
that heats the whole disk to incandescence. A brush makes contact
with the edge of the disk and the axle makes the center connection.
Apparently this stuff passes on a direct line right through the metal,
for it works."
"Have you tried any kind of tube amplification?" asked Don.
"Not yet. Shall we?"
"Why not? I can still think that the relay tube will amplify if we hook
up the input and output loads correctly."
"I've got a tube already hooked up," said Walt. "It's mounted in a
panel with the proper voltage supplies and so on. If your resistance
calculation is correct, we should get about three thousand times
amplification out of it."
He left, and returned in a few minutes with the tube. They busied
themselves with the connections, and then Don applied the power.
Nothing happened.
"Run a line from the output back through a voltage-dividing circuit to
the in-phase anode," suggested Walt.
"How much?"
"Put a potentiometer in it so we can vary the amount of voltage. After
all, Barney Carroll said that the application of voltage in phase with
the transmitted power is necessary to the operation of the relay tube.
In transmission of D. C., it is necessary to jack up the in-phase
anode with a bit of D. C. That's in-phase with a vengeance!"
"What you're thinking is that whatever this sub-level energy is, some
of it should be applied to the in-phase anode?"
"Nothing but."
The cabinet provided a standard potentiometer, and as Don
advanced the amount of fed-back voltage, Freddie's voice came
booming in louder and louder. It overloaded the audio amplifier, and
they turned the gain down as Channing increased the in-phase
voltage more and more. It passed through a peak, and then Don left
the potentiometer set for maximum.
"Wes," he said, "call Freddie and tell him to take off for Terra, at
about four G. Have the gang upstairs hang a ship beam on him so
we can follow him with suggestions. Too bad we can't get there
immediately."
"What I'm worrying about is the available gain," said Wes. "That thing
may have given us a gain of a couple of thousand, but that isn't
going to be enough. Not for planet-to-planet service."
"Later on we may be able to hang a couple of those things in
cascade," suggested Walt.
"Or if not, I know a trick that will work—one that will enable us to get
a gain of several million."
"Yeah? Mirrors, or adding machines? You can't make an audio
amplifier of a three million gain."
"I know it—at least not a practical one. But, we can probably use our
audio modulator to modulate a radio frequency, and then modulate
the driver with the RF. Then we hang a receiver onto the detector
gadget here, and collect RF, modulated, just like a standard radio
transmission, and amplify it at RF, convert it to IF, and detect it to AF.
Catch?"
"Sure. And that gives me another thought. It might just be possible, if
your idea is possible, that we can insert several frequencies of RF
into the tube and hang a number of receivers on the detector, here."
Arden laughed. "From crystal detection to multiplex transmission in
ten easy lessons!"
"Call Chuck and have him begin to concoct an RF stage for tube-
modulation," said Don. "It'll have to be fairly low—not higher than a
couple of megacycles so that he can handle it with the stuff he has
available, but as long as we can hear his dulcet voice chirping that
'one, two, three, four, test,' of his, we can also have ship-to-station
two-way. We squirt out on the ship beam, and he talks back on the
driver transmitter."
"That'll be a help," observed Wes. "I'd been thinking by habit that we
had no way to get word back from the Relay Girl."
"So had I," confessed Walt. "But we'll get over that."
"Meanwhile, I'm going to get this alloy-selectivity investigated right
down to the last nub," said Don. "Chuck's gang can take it from all
angles and record their findings. We'll ultimately be able to devise a
system of mathematics for it from their analysis. You won't mind
being bothered every fifteen minutes for the first week, will you,
Wes? They'll be running to you in your sleep with questions until they
catch up with your present level of ability in this job. Eventually they'll
pass you up, and then you'll have to study their results in order to
keep up."
"Suits me. That sounds like my job, anyway."
"It is. O.K., Arden, I'm coming now."
"It's about time," smiled Arden. "I wouldn't haul you away from your
first love excepting that I know you haven't eaten in eight or nine
hours. I've got roast knolla."
"S'long, fellows," grinned Channing. "I'm one of the few guys in the
inner system who can forget that the knolla is the North Venus
brother to a pussy cat."
"I could feed you pussy cat and you'd eat it if I called it knolla," said
Arden. "But you wouldn't eat knolla if I called it pussy cat."
"You can't tell the difference," said Walt.
"Tell me," asked Wes, "what does pussy cat taste like?"
"I mean by visual inspection. Unfortunately, there can be no
comparison drawn. The Venusians will eat pussy cat, but they look
upon the knolla as a household pet, not fit for Venusian
consumption. So unless we revive one of the ancient Martians, who
may have the intestinal fortitude—better known as guts—to eat both
and describe the difference, we may never know," offered Walt.
"Stop it," said Arden, "or you'll have my dinner spoiled for me."
"All the more for me," said Don. "Now, when I was in college, we
cooked the dean's cat and offered it to some pledges under the
name of knolla. They said—"
"We'll have macaroni for dinner," said Arden firmly. "I'll never be able
to look a fried knolla in the pan again without wondering whether it
caterwauled on some back fence in Chicago, or a Palanortis
Whitewood on Venus."
She left, and Channing went with her, arguing with her to the effect
that she should develop a disregard for things like their discussion.
As a matter of interest, Channing had his roast knolla that evening,
so he must have convinced Arden.
Walt said: "And then there were three. Christine, has our little pre-
dinner talk disturbed your appetite?"
"Not in the least," said the girl stoutly. "I wouldn't care whether it was
knolla or pussy cat. I've been on Mars so long that either one of the
little felines is alien to me. What have you to offer?"
"We'll hit Joe's for dinner, which is the best bar in sixty million miles
today. Later we may take in the latest celluloid epic, then there will
be a bit of mixed wrestling in the ballroom."
"Mixed wres—Oh, you mean dancing. Sounds interesting. Now?"
"Now, Wes, what are you heading for?"
"Oh, I've got on a cockeyed schedule," said Wes. "I've been catching
my sleep at more and more out-of-phase hours until this is not too
long after breakfast for me. You birds all speak of 'Tomorrow,' 'Today,'
and 'Yesterday' out here, but this business of having no sun to come
up in the morning, and the electric lights running all the time has me
all bollixed up."
"That daily nomenclature is purely from habit," said Walt. "As you
know, we run three equal shifts of eight hours each, and therefore
what may be 'Morning' to Bill is 'Noon' to James and 'Night' to Harry.
It is meaningless, but habitual to speak of 'Morning' when you mean
'Just after I get up'! Follow me?"
"Yup. This, then, is morning to me. Run along and have fun."
"We'll try," said Walt.
"We will," said Christine.
Farrell grinned as they left. He looked at Walt and said: "You will!"
Walt wondered whether he should have questioned Wes about that
remark, but he did not. Several hours later, he wondered how Wes
could have been so right.

Venus Equilateral, Preferred, started in its long climb as soon as the

markets opened on the following day. Cartwright, following his orders
and his experience, held onto whatever stock he had, and bought
whatever stock was tossed his way. Several times he was on the
verge of asking Interplanetary Transport for monetary assistance, but
the real need never materialized.
Kingman alternately cursed the whining music and cheered the
pyramiding stock. About the only thing that kept Kingman from going
completely mad was the fact that the alien music was not
continuous, but it came and went in stretches of anything from five to
fifty minutes, with varied periods for silence in between selections.
Up and up it went, and Kingman was seeing the final, victorious coup
in the offing. A week more, and Venus Equilateral would belong to
Terran Electric. The beam from Terra was silent, save for a few items
of interest not connected with the market. Kingman's men were
given the latest news, baseball scores, and so forth, among which
items was another message to Channing from the solar beam
project engineer, Addison. They had about given up. Nothing they
could do would prevent the formation of ozone by the ton as they
drew power by the kilowatt from Sol.
On Venus Equilateral, Channing said: "Ask Freddie what his radio
frequency is."
Ten minutes later, at the speed of light, the ship beam reached the
Relay Girl and the message clicked out. Freddie read it and spoke
into the microphone. The Relay Girl bucked unmercifully, as the
voice amplitude made the acceleration change. Then at the speed of
light, squared, the answer came back in less than a twinkle.
"Seventeen hundred kilocycles."
Channing began to turn the tuner of the radio receiver. The band
was dead, and he laughed. "This is going to be tricky, what with the
necessity of aligning both the driver-alloy disk and the radio receiver.
Takes time."
He changed the alloy disk in minute increments, and waved the
tuner across that portion of the band that would most likely cover the
experimental error of Freddie Thomas' frequency measurement. A
burst of sound caught his ear, was lost for a moment, and then
swelled into perfect tune as Don worked over the double tuning
system.
"Whoa, Tillie," said Walt. "That sounds like—"
"Like hell."
"Right. Just what I was going to say. Is it music?"
"Could be. I've got a slightly tin ear, you know."
"Mine is fair," said Walt, "but it might as well be solid brass as far as
this mess is concerned. It's music of some kind, you can tell it by the
rhythm. But the scale isn't like anything I've ever heard before."
"Might be a phonograph record played backward," suggested Wes.
"I doubt it," said Channing seriously. "The swell of that orchestra
indicates a number of instruments—of some cockeyed kind or other
—the point I'm making is that anything of a classical or semi-
classical nature played backwards on a phonograph actually sounds
passable. I can't say the same for jamstead music, but it holds for
most of the classics, believe it or not. This sounds strictly from
hunger."
"Or hatred. Maybe the musicians do not like one another."
"Then they should lambaste one another with their instruments, not
paste the sub-ether with them."
Channing lit a cigarette. "Mark the dial," he said. "Both of 'em. I've
got to get in touch with the Thomas Boys."
Walt marked the dials and tuned for the Relay Girl. He found it
coming in not far from the other setting. Chuck was speaking, and
they tuned in near the middle of his speech.
"—this thing so that it will not buck like a scenic railway finding the
fourth derivative of space with respect to time. For my non-technical
listeners, that is none other than the better known term: Jerkiness.
We applied the modulation to the first driver anode—the little circular
one right above the cathode. I don't know whether this is getting out
as it should, so I'm going to talk along for the next fifteen minutes
straight until I hear from you. Then we're switching over and
repeating. Can you hear me?"
Channing cut the gain down to a whisper and put a message on the
beam, confirming his reception. Ten minutes later, Chuck changed
his set speech, and said: "Good! Too bad we haven't got one of
those receivers here, or we could make this a two-way with some
action. Now listen, Don. My idiot brother says that he can make the
beam transmit without the drive. Unfortunately, I am not a drive
expert like he is and so I can not remonstrate with the half-wit. So,
and right now, we're cutting the supply voltage to the final focussing
anode. Whoops! I just floated off the floor and the mike cable is all
tangled up in my feet. This free stuff is not as simple as the old
fiction writers claimed it was. Things are floating all over the place
like mad. The accelerometer says exactly zero, and so you tell me if
we are getting out. We're going back on one G so that we can sit
down again. That's better! Though the idiot—it's a shame to be
forced to admit that one of your family is half-witted—didn't wait until
we were in position to fall. I almost landed on my head—which is