This Capsule Endoscopy Structured Terminology (CEST) is a copyrighted work, protected by United States and worldwide copyright laws and treaties. Users of the CEST are hereby granted a free license to use, copy or distribute the CEST in connection with supporting a structured terminology for capsule endoscopy, subject to the following conditions:1. This copyright and terms of use notice must be displayed on each and every copy of the CEST, on all manuals and other materials used in connection with the CEST, including without limitation electronic media (i.e., disks, CD-ROMs, etc.), and in all text files loaded onto electronic media or the Internet. Such copyright and terms of use notice shall not be removed, obscured, modified or otherwise hidden. All references to the CEST, in whole or in part, shall properly cite the CEST as the source for such reference. Proper citation shall read "Capsule Endoscopy Structured Terminology (CEST), Endoscopy 2005; 37: 951-959 (February 16, 2002 (9 Given Imaging Ltd.)".2. The CEST shall not be used, in whole or in part, to harm or degrade the reputation of Given Imaging or any participant in the Given Capsule Standard Working Group (the "GCSWG").3. Neither Given Imaging nor any participant in the GCSWG shall be liable for any errors or omissions contained in the CEST, or for any use you or any third party may make of the CEST. Given Imaging reserves the right to make changes to the CEST without notice. The information contained in the CEST is provided on an "as is" basis without any warranties, express or implied, including but not limited to the results or effects obtained through use of information, or that it is fit for any use intended or can be used without infringing the copyright or other proprietary rights of any third party. All express and implied warranties, including those relating to title, non-infringement, merchantability or fitness for a particular purpose, are hereby expressly disclaimed and excluded with respect to any information provided hereunder.

Background and Study Aims: Capsule endoscopy (CE) is an effective means of investigating the small bowel in patients with gastrointestinal diseases. Computerized reports are frequently used in endoscopy, and the Minimal Standard Terminology (MST) has been promoted by endoscopy societies as the official vocabulary for endoscopy. The aims of this study were to design a lexicon for CE reports based on the principles of the MST and to validate lists of terms for describing findings and reasons for performing a CE by cross-matching them with the results of CE procedures collected during ongoing clinical studies.Materials and Methods: A consensus-based Capsule Endoscopy Structured Terminology (CEST) was developed by experts involved in CE studies. Lists of terms suitable for CE were designed for the various sections of an endoscopic report. They were then correlated with the corresponding MST lists for duodenal and intestinal endoscopy. The results of 766 CE procedures, collected in an electronic case record form (eCRF), were analyzed to provide lists of reasons for performing the procedures and of the findings. The eCRF provided only a limited number of items for each data field, along with free-text facilities. Only descriptions pertaining to the small bowel were analyzed. Lists of terms were then reviewed by two experts to group obvious synonyms. The accuracy of the CEST was defined beforehand as the capability to describe 90% of entries.Results: A total of 766 CE procedures were analyzed. The eCRF included 824 entries as reasons for the examination in 655 CEs (1.3 per procedure). These represented 122 different expressions. After grouping of synonyms, 28 expressions remained. Among them, 10 were matched with terms from the list of reasons for performing CE offered in the CEST. These were the most frequently used, accounting for 768 entries in this field (93.2%). All eCRFs contained at least one description of findings. A total of 109 CE procedures were classified as normal (14.3%). A total of 2624 entries for abnormal findings were recorded for 657 procedures (4.0 per procedure). In all, 213 different expressions were used to describe abnormal findings. After grouping of synonyms, 52 expressions remained. Among these, 27 were matched with terms from the list of findings in the CEST, covering 2403 entries (91.6%).Conclusions: In this study, CEST terms were capable of describing more than 90% of the reasons for performance and of the findings in an unselected set of CE procedures. CEST is therefore suitable for use as the standard lexicon for CE reports. Adopted as a standard, it could significantly improve the quality of the data collected and reported in CE studies.

Vague and insignificant forms of speech and abuse of language, have so long passed for mysteries of science: and hard and misapplied words, with little or no meaning, have by prescription, such a right to be taken for deep learning and height of speculation, that it will not be easy to persuade either those who speak them or those who hear them, that they are but the covers of ignorance, and hindrance of true knowledge.John Locke, An Essay Concerning Human Understanding The importance of precise language in medicine cannot be overestimated. All medical activity arises from the ability to observe and communicate intelligibly. Endoscopists view the GI tract and create text and images that reflect their observations and transmit this information to others who are also involved in the care of the patient. The increasing fragmentation of care, pressure for increased productivity, and lack of rapid access to the patients' clinical reports make effective automation crucial to the future of medicine. Although modern computing and communication technology holds great promise, its role in medicine has been limited by the absence of lexical and data exchange standards. Most endoscopy units generate reports that combine text and images but endoscopists are unable to easily retrieve and transmit the report or link the report to any other part of the patient record (e.g., pathology or radiology). The aim of standardization is to improve the work of the endoscopist by decreasing the cost of creating reports and improving the ability to retrieve, interpret, and communicate endoscopic findings. The Minimal Standard Terminology (MST) is the result of a global effort to establish a common structure and vocabulary for electronic endoscopic reports. Standardization of the endoscopic lexicon would accomplish several goals. First, standard lists of terms help developers and users avoid the commitment of substantial time and energy to create menus for generating the content of a report and to label images. Systems that permit users to create and modify lists of terms without imposing restrictions quickly accumulate long menus of terms that are redundant and poorly defined. The MST provides both a lexicon and method for documenting observations in an efficient and less ambiguous manner. Several vendors base parts of their report generator on the concepts found in the MST and their products are achieving commercial acceptance. Second, the ability to search for and retrieve images and reports based on specific findings requires a uniform classification system. Databases can store vast quantities of information, but unless the data are organized, the search for and retrieval of specific cases becomes impossible. The MST provides a method for classification that enables the practitioner to retrieve cases based on the use of specific terms that identify the findings. For example, the MST requires that a polyp have specific attributes including size in centimeters and the characteristics of its attachment, for example, pedunculated or sessile. If a practitioner wanted to retrieve a list of all polyps found in the past 2 years that were sessile and greater than 1 cm in diameter, the completeness and accuracy of the search would depend on how the data were stored. If the information was stored as free text, as in a dictated procedure note, a search would yield only those documents where the number 1, sessile, and polyp were found in any combination. If the information was stored in a database that utilizes the MST with the search terms stored in unique searchable fields, the result would be a list of all patients with sessile polyps greater than 1 cm in diameter. Thus, functions such as patient recall for procedures are greatly facilitated because searches can be carried out on a regular basis and the process of patient notification can be automated based on practice defined criteria. Ambiguous terms, imprecise descriptions, and inadequate classification systems do not permit aggregation of data for either routine practice purposes or the creation of large research databases. Third, endoscopic education is significantly enhanced by the creation of more precise textual and visual definitions of terms used in endoscopy. Every educator is familiar with the proliferation of idiosyncratic descriptions used by trainees that derive from the preferences and habits of attending physicians, for example, a snakeskin appearance of the gastric mucosa, feline esophagus. The MST together with images, definitions, and the Internet will enable endoscopists to improve education by making available to the trainee national and international experience as well as the consensus of experts through links to peer reviewed on-line databases and data repositories. International endoscopic societies have devoted considerable time and energy to the issue of standardization of endoscopic reporting.1Maratka Z Terminology, definitions and diagnostic criteria in digestive endoscopy.3rd ed. Normed Verlag, Bad Homburg, Germany:1994Google Scholar The European Society of Gastrointestinal Endoscopy (ESGE) created a Committee of Terminology in 1976. The American Society for Gastrointestinal Endoscopy (ASGE) established an ad hoc Computer Committee to consider the role of computers in endoscopic practice in 1981.2ASGE Computer Committee American Society for Gastrointestinal Endoscopy Computer Syllabus.May, 1984Google Scholar The proposed terminology systems met with limited acceptance because they were unwieldy, not easily implemented in automated reporting systems, not widely available, and not supported by ongoing education and maintenance. As the technology of image management progressed and systems were built that used improved graphical user interfaces, another attempt was made to create a terminology system capable of addressing the needs of the practitioner. This effort was begun by the ESGE in 1991 and continued with the participation of the ASGE and Japanese Society of Gastrointestinal Endoscopy (JSGE) in 1993. The effort had eminently practical goals. First, the terminology system had to be easily implemented in a report generator and therefore needed to be limited to the most common findings without duplicate and redundant terms. Second, the terms used had to be acceptable to practicing endoscopists. Third, the terminology system had to be logical so that it could be learned and used easily. Fourth, the concept of a minimum set of descriptors of a lesion had to be established to assure the quality of the description. The result of this effort was MST version 1.0, which was published as a Working Party Report for the World Congresses of Gastroenterology and Digestive Endoscopy in Los Angeles in 1994.3Crespi M Delvaux M Schapiro M Venables C Zweibel F Working Party Report by the Committee for Minimal Standards of Terminology and Documentation in Digestive Endoscopy of the European Society of Gastrointestinal Endoscopy. Minimal standards for a computerized endoscopic database.Am J Gastroenterol. 1996; 91: 191-216PubMed Google Scholar Although MST 1.0 was based on extensive review by multiple panels of practicing endoscopists, it had never been used as a component of report generating software. In Europe, the European Commission sponsored testing under the auspices of the GASTER project (GI endoscopy Applications for Standards in Telecommunication, Education, and Research) and in the United States testing was performed with grant support from the American Digestive Health Foundation. A total of 23,658 examinations were performed including EGD, colonoscopy, ERCP, and flexible sigmoidoscopy. The total number of terms used in the examinations equaled 69,377 and of these, approximately 94% were in the MST. Detailed review of non-MST terms enabled the committee to revise the terminology, incorporate the results of testing, and produce MST 2.0.4Cass OW Korman LY Brugge W Harford W Roberts I Testing of the minimum standard terminology in the United States [abstract].Gastrointest Endosc. 1998; 47: AB27Google Scholar, 5Delvaux M Crespi M the Computer Committee of ESGE Minimal Standard Terminology in Digestive Endoscopy. Version 2.0.Endoscopy. 2000; 32: 159-188Crossref Google Scholar, 6Delvaux M Crespi M Armengol-Miro JR Hagenmuller F Teuffel W Spencer KB et al.Minimal standard terminology for digestive endoscopy: results of prospective testing and validation in the GASTER project.Endoscopy. 2000; 32: 345-355Crossref PubMed Scopus (44) Google Scholar, 7American Society for Gastrointestinal Endoscopy (ASGE).http://www.asge.orgDate: December 19, 2000Google Scholar, 8Gastrointestinal Endoscopy Applications for Standards in Telecommunication, Education, and Research (GASTER).http://www.gaster.org/MST20/mst2.0.htmlDate: 2000Google Scholar, 9Organization Mondiale d'Endoscopie Digestive (OMED).http://www.omed.org/minimal.htmDate: December 19, 2000Google Scholar The list of terms in the MST represents unique concepts that are used to identify a finding. A finding may represent a single observation such as a polyp or an aggregation of observations that the endoscopist recognizes as a unique entity such as Barrett's epithelium. A trained endoscopist recognizes that Barrett's esophagus is a change in the color (shades of red) of the mucosa combined with an increased distance between the proximal extent of the gastric folds and the squamocolumnar junction. To accommodate the conflict between defining pure observations versus aggregating concepts the MST list of terms was developed with several guiding principles. A term should be readily understood, as unambiguous as possible, and used frequently. This concept of frequency is important in that it avoids cluttering with terms that describe rare observations. These limited lists facilitate the creation of "pick" lists that can be implemented as selection menus in automated reporting systems. As a rule of thumb, if the term occurs in less than 0.1% of abnormal findings it was not included in the MST. Particular attention was paid to avoiding redundant descriptions and synonyms that could not be translated into other languages or did not add significant discrimination between concepts. The MST organizes the individual concepts or terms into a hierarchy of specific categories to facilitate their use and implementation in reporting systems. Each category can be considered an axis along which an observation is positioned. An example is given in Figure 1. Thus, any finding will include a site, a term, and one or more attributes that increase the descriptive precision to a level judged to be necessary by an expert panel. Each attribute has a value that is taken from a predefined list of one or more concepts. The utility of this approach is that it builds quality control into the report by specifying a minimum description. Figure 2 illustrates an algorithm used to create a minimum description of an endoscopic finding and the terms that are to be used to document the observation. It is important to recognize that the MST does not limit the extent of the endoscopist's description of the finding. Report generators easily permit linkage of extended descriptions to a specific finding thereby assuring that a relationship between findings and attributes is maintained. Database software is designed to rapidly process these kinds of relationships once they are defined. The MST establishes the finding as a core biological observation and then specifies a set of minimal attributes that modify that core concept. Consequently, the list of terms provided in the MST 2.0 is organized with a hierarchy that links terms and attributes and offers specific lists of terms for use in the various parts of the report. In the course of creating an endoscopic report and submitting a claim for reimbursement, practitioners are required to classify the endoscopy according to coding systems: CPT and ICD9-CM. At the end of each procedure the endoscopist must select a CPT code that indicates what was done and an ICD code that defines the indication for the procedure and what was found. Automation of these processes would improve the accuracy of the codes. The MST lexicon can and is being used to create algorithms that accurately select codes or a choice of codes for the practitioner. The MST provides a standard list of diagnostic and therapeutic procedures, a proposed list of common diagnoses, and reasons for endoscopy. Terms from these lists can easily be linked to CPT or ICD codes. For example, if the term polyp was used to identify a lesion in the colon, the MST defines a list of diagnostic and therapeutic procedures that can be applied. If the practitioner selects polypectomy using a snare then the system could, with proper design, automatically generate the CPT code for the procedure. In addition, because a polyp was found, the appropriate ICD code(s) could be selected for review before completion of the report. Because the MST provides these lists, the development of coding capabilities within a system is facilitated. The MST must also be able to integrate into existing lexicons and data structures to facilitate the creation of automated records and to improve the quality of large databases of clinical data created as a result of the electronic medical record. Establishing relations to existing lexicons and coding systems permits the vocabulary of gastrointestinal endoscopy to be widely distributed via accepted vocabulary and coding standards. Coding systems such as SNOMED, Systematized Nomenclature of Human Medicine, are becoming more important as medical records become automated.10College of American Pathologists Systematized nomenclature of pathology.1st ed. : College of American Pathologists, Chicago1965Google Scholar The goal of SNOMED is to create a comprehensive nomenclature for indexing the entire medical record including signs, symptoms, diagnosis, and procedures. SNOMED contains 156,602 unique concepts that, when linked to the MST, would permit endoscopic records to be automatically cross-indexed to other parts of the medical record. The purpose of the MST is not to specify how a computer program will interact with the endoscopist. The MST and other public standards make available lists of terms, report structures, and data exchange standards that can be used to develop products that better meet the needs of the user.11Korman LY Standardization in endoscopic reporting: implications for clinical practice and research.J Clin Gastroenterol. 1999; 28: 217-223Crossref PubMed Scopus (8) Google Scholar, 12Korman LY Digital imaging in endoscopy.Gastrointest Endosc. 1998; 48: 318-326Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar All restricted vocabularies, the MST included, do not have the descriptive flexibility of natural language. The relative rigidity of a restricted terminology system in endoscopy is counterbalanced by the speed, ease, decreased cost, and quality of the information recorded in the endoscopic report. At a glance, the hierarchy of terms that is proposed by the MST appears to limit commercial and other developers to building interfaces that accommodate the algorithms suggested by the MST. However, for the developer the advantages are multiple: (1) the significant effort necessary to create and maintain these lists is avoided; (2) designers can focus their efforts on improving ease of use based on commonly accepted methods of reporting; (3) single educational programs and materials based on the MST can be developed and distributed, thereby reducing the costs of education; (4) fellowship program directors can use MST-based guidelines to teach trainees to write reports; and finally (5) a standard and common format creates the opportunity for endoscopists to participate in outcomes research by contributing their data to projects such as the Clinical Outcomes Research Initiative (CORI). Creating a standard requires a strategy for dissemination, adoption, and maintenance. The ASGE, ESGE, and JSGE through their various committees have reviewed and approved the MST (personal communication, M. Fujino, Chair Computer Committee, Japanese Society for Gastrointestinal Endoscopy). These societies are taking steps to insure that the MST vocabulary will be implemented in endoscopic reporting systems and that it will become the lexicon of endoscopy. Each society has established MST Editorial Boards to support and promote the MST within the context of the World Organization of Endoscopic Societies (OMED) Terminology Committee. To achieve the goal of broad dissemination of the MST the societies have agreed to: •place the MST in the public domain with few restrictions to its use. Copyright restrictions are necessary to maintain its integrity but software developers can use the MST without incurring expensive royalty fees•produce a book of definitions and images corresponding to the MST•define a mechanism for users to determine whether purchased systems use the MST in their databases (conformance statement)•use the World Wide Web to gather suggestions and opinions from the community of endoscopists for modifications to the MST•develop educational material for future trainees and training program directors that emphasize the need for precise and effective reporting of endoscopic findings and recommendations•cooperate with equipment manufacturers and software developers to produce standards that serve the practical needs of endoscopists. The advance of technology will require new ways of thinking about old problems and new ways of communicating. With the cooperation of the global endoscopic community, the work on standardization begun at the end of the last century will find its place in the new millennium.

The wider use of computers for the management of endoscopic data and the use of electronic endoscopes for the production of high quality endoscopic images has made the standardization of terminology and images formats necessary in digestive endoscopy reports. The European Society for Gastrointestinal Endoscopy and the American Society for Gastrointestinal Endoscopy have combined their efforts to propose a Minimal Standard Terminology for Computerized Databases in Endoscopy. This terminology is based on the following principles: no term describing findings less frequent than 1%, of the daily practice, and no term based on subjective impressions. The Minimal Standard Terminology has been developed according to the natural process of constructing an endoscopic report in natural language and deals with the following: reasons for performing the examination, endoscopic findings, endoscopic diagnosis, additional therapeutic and diagnosis procedures (biopsies, etc.). It is subdivided according to the main organs examined with an endoscopy. Until now, the Minimal Standard Terminology was tested in many centers and was shown to accurately cover 95% of routine examinations for the upper gastrointestinal tract, colonoscopy and cholangio-pancreatography. It is currently being tested in an a prospective way in several centers in Europe (with a grant from the European Commission DGXIII-C4) and in the USA (with grant from the AHDHF).

Gastrointestinal endoscopy is a visual clinical discipline. Modern digital imaging technology and the development of imaging and communication will make the work of the endoscopist widely available as part of the electronic medical record. Videoendoscopy systems can now create text and images that are the components of an electronic record. Most modern endoscopy systems include both image processors and microcomputers capable of capturing, storing, retrieving, and printing these endoscopic images. The ability to create an electronic file representing the endoscopic record and integrating that file into a broader electronic record is limited by the absence of fully developed standards for medical information systems. Fortunately, developments in fields outside medicine, in particular Internet technology, will contribute substantially to the development of a multimedia electronic record. This multimedia electronic record will consist of text, images, and waveform data. The concept of multimedia is widespread in modern computing and is responsible for the rapid expansion of Internet technology. The Internet is capable of easily transmitting text, images, full-motion video, and sound (waveform).1Fraser HS Kohane IS Long WJ. Using the technology of the World Wide Web to manage clinical information.BMJ. 1997; 314: 1600-1603Crossref PubMed Scopus (23) Google Scholar This multimedia capability requires an elaborate and evolving set of standards. The network communication standard is called transfer control protocol/Internet protocol (TCP/IP), and all devices on the Internet must use this standard for communication. All Web pages transmitted on the Internet use a format called hypertext transfer protocol (HTTP) which specifies the way text and images are displayed by Internet browsers. This elaborate system of standards and protocols is maintained by a host of organizations balancing the need to rapidly advance the technology and avoid dominance of the technology by any proprietary interest. Medicine confronts a similar problem in that it must develop and support an information infrastructure capable of linking disparate systems, maintaining security, and adapting to changing needs. At present, the vast majority of endoscopic imaging systems are unable to share information with other medical information systems. These limitations are similar to those confronted by other image-oriented specialty societies such as radiology and cardiology. To circumvent these problems professional societies, manufacturers, and federal agencies have combined to develop standards designed to improve both interconnection and interoperation among medical information systems. This effort has led to the development of the Digital Imaging and Communication Standard in Medicine (DICOM Standard).1Fraser HS Kohane IS Long WJ. Using the technology of the World Wide Web to manage clinical information.BMJ. 1997; 314: 1600-1603Crossref PubMed Scopus (23) Google Scholar This standard was developed as a result of a collaboration between the American College of Radiology (ACR) and National Electrical Manufacturers Association (NEMA).2Digital Imaging and Communications in Medicine (DICOM). The National Electrical Manufacturers Association, Rosslyn (VA)1997: PS3.1-PS3.12Google Scholar, 3Bidgood Jr, WD Horii SC Prior FW Van Syckle DE. Understanding and using DICOM, the medical image communication standard.J Am Med Inform Assoc. 1997; 4: 199-212Crossref PubMed Scopus (256) Google Scholar It is anticipated that the adoption of DICOM and other medical information system standards will advance the integration of information technology into the practice of medicine. Imaging the gastrointestinal tract using a videoendoscope requires several basic steps (Fig. 1): illumination by fiberoptic light transmission, surface reflectance, magnification using a lens system, charged coupled transfer device conversion of the reflected photons to a signal, reconstruction of the signal, and projection onto a monitor.4Sivak MV. Video endoscopy.Clin Gastroenterol. 1986; 15: 205-234PubMed Google Scholar High-speed microcomputers equipped with digital image capture (frame grabber) and network boards linked to video-processors permit these images to be captured, stored, printed, and transmitted. The physical quantities of the colors that represent an image are chromaticity defined by wavelength and luminance defined by the amount of light. The colors produced by a videoendoscope are continuous values. In the digital domain, color must be divided from this continuous or analog value to a discrete digital value. These digital values are derived from a system of three-dimensional coordinates that define color space. Color picture publishing represents a color as a combination of three different colors: cyan, magenta, yellow (CMY). The cones of the human eye and most computer graphics systems represent color as a combination of red, green, and blue (RGB). Thus, any color at a point in space may be identified by a value on a scale representing the amount of red, green, and blue. An alternative system is to use hue, saturation, and intensity (HSI) as measures of color. Hue is the amount of pure color, saturation is a measure of the amount of whiteness, and intensity is the degree of brightness. Each coordinate system has properties that may make it more useful for a particular application. For example, most signals that come from cameras are transmitted as a combination of red, green, and blue. As a result many image capture boards are based on RGB signals. Image processing is easier when color is represented as HSI because calculations may need to be applied only to one HSI axis as opposed to three RGB axes. Figure 2 represents the relationship between CMY, RGB, and HSI color space. The number of unique colors that can be represented by the coordinate system depends on the length of each axis. Because the digital world is binary, that is, on or off, the number of possible values is represented by an exponent of 2 or 2x. If a color is represented in RGB space by 8 unique binary digits (bits), then there are only 28 = 256 colors to choose from. Increasing the number of digits representing a color increases the color range, that is, 16 or 24 bits define 216 = 65,536 and 224 = 16,777,216 colors, respectively. An image is presented as a continuous signal which is converted or transduced by an analog-to-digital device. To create a digital image a specific device in the computer called a frame grabber or capture board converts the color signal into a digital form. The resulting digital values are mapped to specific locations and stored as a two-dimensional array of numbers. The frame grabber performs two functions: sampling and quantification. Sampling captures evenly spaced data points that represent the image. Quantification assigns each data point a binary value. The evenly spaced data points for an image represents specific two-dimensional locations called picture elements or pixels.5Crane R. A simplified approach to image processing. Prentice Hall, Upper Saddle River (NJ)1997Google Scholar The pixel is the basic unit of a digital image and each pixel stores the value produced by quantification (Fig. 3). It is easiest to think of the value at a specific pixel location as a measure of intensity. A black and white (gray scale) image digitized by an 8-bit image capture board is represented by 256 shades of grey because 28 = 256 with black = 0 and white = 256. Color is more complex. The range of colors depends on the number of bits that can be stored at the pixel location. Thus, an 8-bit frame grabber can capture 8 bits/pixel or 256 colors/pixel, a 16-bit frame grabber 16 bits/pixel or 65,536 colors/pixel, and a 24-bit frame grabber 24 bits/pixel or 16.7 million colors per pixel. Figure 4 represents an endoscopic image with 24-, 16-, and 8-bit color ranges.It is important to recognize that the color range of an endoscopic image is small. It is for this reason that there appears to be little difference between frame grabbers that capture 16 and 24 bits/pixel. The sampling process will have a significant effect on the resolution of the image. Sampling density is simply the number of pixels into which an image is divided by the frame grabber. The greater the number of pixels/unit area, the higher the resolution of the image. For an image of a given size, sample density can be defined by the dimension of the image in pixels. For example, 640 × 480 represents an image that is 640 pixels wide and 480 pixels high. If this same image is sampled at 1024 × 768, then the number of pixels/unit area is higher and the resolution is greater. Sampling becomes important when images are enlarged because there is a discrete separation between adjacent points in the image. Thus zooming an image which has been sampled at a low density quickly reveals the pixel, a phenomenon called pixelation. In addition to width and height a digital image is represented by color as the third axis. The relationship between the image size and depth can be seen in Figure 5.The larger the image size and the greater the color depth, the bigger the digital file that is produced. This has significant implications for image management. Larger images reveal more detail, but they require greater computer resources for management. Larger images require more space for storage, faster networks for transmission, and more powerful processors for manipulation. Figure 6 illustrates the effect of changing the height and width of the sampling process without changing the color depth.Figure 6Image size as a function of dimension.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Each frame grabber has sampled the endoscopic image with the same color depth but with different dimensions. The result is that the file size of the smallest image is one tenth the size of the largest image. The smallest image occupies one tenth the disk space and will be transmitted in one tenth the time. However, if the smallest image were enlarged to the size of the largest image, the resolution would be reduced. In some clinical situations size will not make a difference; a large mass may be easily identified at low resolution. But subtle findings such as the granularity of the mucosa may not be identifiable. The degree of resolution is also dependent on how the image is processed. If a small-dimension image is printed, lower resolution may be sufficient. However, if it is being enlarged to examine fine details, higher resolution may be necessary. The image produced by the video signal of an endoscope also has a specific aspect ratio, which is the relationship between height and width. This relationship can be altered by both the capture and display process. An image will be distorted if there is a significant difference between the capture and display aspect ratio. Image compression is a computational processing technique that results in a reduction of the size of an image file.5Crane R. A simplified approach to image processing. Prentice Hall, Upper Saddle River (NJ)1997Google Scholar These techniques allow large image files to be compressed for storage or transmission. Full-motion video images require a display rate of 30 frames/second. If each frame is 0.5 megabytes, then one second of digital video contains 15 megabytes of data. Disk storage would be rapidly exceeded, and image transmission even on high-speed networks would be slow. Compression is measured as a ratio of the size of the original data divided by the compressed data. There are two basic types of image compression: lossless and lossy. Lossless compression encodes and decodes the image exactly; no data is lost. Lossy compression allows redundant and nonessential information to be lost. Lossless compression has a lower compression ratio because all data is retained. A simple example of compression is run length encoding (RLE). This technique takes advantage of the presence of repetitive data. For example: AAAACCCCCCDDDDDDDFFGGGGGGHHHHHH = 4A5C7D2F6G6H. Common techniques for image compression based on different algorithms include the following: JPEG produced by the Joint Photographic Experts Group, MPEG (“M” for motion), and wavelet. One of the uncertain issues in medical imaging is the degree to which images can be compressed without loss of clinically useful information. Images are captured and stored using specific file formats. The file format represents the precise manner in which the data captured are organized. The header provides data about how the file is organized. The image file contains the image data organized by pixel. Files are not equivalent and need to be translated. Examples of image file format are: .tga, .tif, .bmp, .jpg, .gif. In endoscopy most capture boards use .tga or .tif file formats. A network is a system of linked computers arranged in a specific manner or topology. For software applications to operate correctly on these networks, several layers of standards must exist (Fig. 7).Each layer is precisely defined so that any vendor complying with the standard can plug their system into the network. This level of standardization is critical for the development of modern hospital information systems. Hospital information systems have moved away from centralized mainframe computers to networks of decentralized systems that support the operation of various departments. The challenge confronted by the medical community is how to integrate these disparate systems so that information can move easily and securely. Endoscopic information systems must comply with these standards for data to become part of these networks. When images reside on a single system there is no need for a common communication standard. However, the advent of large-capacity, portable media such as portable disks, writeable CD-ROMs, and high-speed computer networks require a common format for data exchange. Several barriers impede the development of the electronic medical record and the integration of endoscopic images into that record. These restrictions include the following:1.Complexity of the healthcare enterprise. Medical information systems must support real world activities to be effective, and the extraordinarily complex, changing nature of healthcare makes systems development a daunting and expensive task.2.Inadequate technologic infrastructure. The basic requirement of a comprehensive solution is the development of effective communication technology. The quantity and nature of the data required and the disparate sources of the data can only be supported by systems that connect a broad range of computing devices. Thus, issues of speed, accessibility, and security work to restrict and impede development.3.Capital investment. Rapid change in technology and the high cost of development inhibit corporate investment. Construction and execution of large data processing programs are notoriously difficult to do and are usually late and over budget. No single organization including federal and state governments are capable of developing and supporting this approach.4.Standards development. In spite of the efforts of numerous organizations to develop common standards for information systems, there is no uniformity in approach, support, or dissemination. The ACR and the National Electrical Manufacturers Association (NEMA) formed a joint committee early in 1983 to develop a standard means of interconnection for medical imaging devices. To accomplish this task, the standard would include a dictionary of the data elements needed for proper image display and a hardware specification for physically connecting the devices. The goal of the ACR-NEMA effort was to (1) promote communication of digital image information regardless of device manufacturer, (2) facilitate the development and expansion of picture archiving and communication systems (PACS) that can also interface with other systems within the hospital information system, and (3) allow the creation of diagnostic information databases that can be interrogated by a wide variety of devices distributed geographically. The DICOM Standard is recognized in the United States, Europe, and Japan as the standard for digital imaging in medicine. DICOM relies on explicit and detailed models of how the “things” (patients, images, reports, etc.) involved in imaging operations are described and how they are related. These models are called entity-relationship (or E-R) models and are a way to be sure that manufacturers and users understand the basis for developing the data structures used in DICOM. Figure 8 shows an example of an E-R diagram. This model is used to create information object definitions (IOD) for all of the imaging modalities covered by DICOM.In looking at an E-R diagram it is important to note that it is not a flowchart that describes the steps of information movement; rather, it shows the relationships and hierarchies of information elements. Arrows are added to diagrams so that the direction of relationships is not misinterpreted. These diagrams are used to show the assumptions made in developing the components of the DICOM standard. An information object is a combination of information entities, and each entity consists of specific modules. A service class defines the service that can take place on an information object, for example, print, store, retrieve. In DICOM a service is combined with an information object to form a service/object pair (SOP). For example, storing a CT scan or printing an ultrasound is a SOP. A device that conforms to the DICOM standard can perform this function. Thus, in a DICOM conforming network the devices must be capable of executing one or more of the operations the SOP definition prescribes. Each imaging modality has an IOD. The result is that different imaging modalities such as CT, MR, digital angiography, ultrasound, endoscopy, pathology; imaging workstations; picture archiving systems; and printing devices can be networked and execute a high level of cooperation. In addition, these imaging networks can be connected to other networks found in a hospital or facility. The modules that comprise an information entity are precisely defined and may be common to multiple entities. The patient entity in Figure 8 is common to all IOD. However, the image entity must be capable of supporting different imaging modalities. An IOD that supports endoscopy will of necessity include modules unique to endoscopy and distinct from a CT IOD. The patient information entity (IE) defines the characteristics of a patient who is the imaging subject of one or more procedures that produce images. The patient IE is modality independent, that is, it is common to all imaging modalities. The patient IE consists of only one module which is illustrated in Table 1.Table 1DICOM patient information entity module attributesAttribute nameTagTypeAttribute descriptionPatient's name(0010,0010)2Patient's full legal name.Patient ID(0010,0020)2Primary hospital identification number or code for the patientPatient's birth date(0010,0030)2Birth date of the patientPatient's sex(0010,0040)2Sex of the named patient; enumerated values: M = male F = female O = otherReferenced patient sequence(0008,1120)3A sequence which provides reference to a patient SOP class/instance pair; only a single reference is allowed; encoded as sequence of items: (0008,1150) and (0008,1155)Referenced SOP class UID(0008,1150)1CUniquely identifies the referenced SOP class; required if referenced patient sequence (0008,1120) is sentReferenced SOP instance UID(0008,1155)1CUniquely identifies the referenced SOP instance; required if referenced patient sequence (0008,1120) is sentPatient's birth time(0010,0032)3Birth time of the patientOther patient ID(0010,1000)3Other identification numbers or codes used to identify the patientOther patient names(0010,1001)3Other names used to identify the patientEthnic group(0010,2160)3Ethnic group or race of the patientPatient comments(0010,4000)3User-defined additional information about the patient Open table in a new tab Each module is a table consisting of four elements: attribute name, tag, type, and attribute description. The attribute name and description define the attribute precisely. The attribute tag uniquely identifies that attribute among all of the many other attributes present. The tag (0010,0010) always identifies the fact that this is the patient name. The attribute type specifies whether this attribute is mandatory or optional. For example, it is not necessary for an image to be transmitted with the patient's name. In fact, DICOM requires only a few mandatory attributes that give the study a unique identifier, define the modality (e.g., CT, MR, ultrasound) and provide information about the image (e.g., pixel data and number of rows and columns). DICOM also provides a dictionary that specifies the form in which the value of each attribute must be presented. The patient name attribute (0010,0010) uses person name (PN) as its value representation. PN contains five components in the following order: family name, given name, middle name, name prefix, and name suffix. Thus any system that complies with DICOM knows that (0010,0010) is a person name and that the format of the information transmitted is defined by the DICOM standard. It is not sufficient to define a standard. It is also necessary to develop a mechanism to enable vendors and purchasers to understand whether the system conforms to the standard. DICOM defines a conformance statement that must be associated with a specific implementation of the DICOM Standard. It specifies the service classes, information objects, communication protocols, and media storage application supported by the implementation. The conformance statement is provided by the vendor and identifies the system capabilities. The American Society for Gastrointestinal Endoscopy (ASGE) in collaboration with other medical and surgical societies such as the European Society for Gastrointestinal Endoscopy (ESGE), American College of Radiology, the College of American Pathologists, the American Academy of Ophthalmology, and the American DentalAssociation have defined a new supplement to the DICOM Standard. This supplement to the DICOM Standard specifies a DICOM image IOD for visible light (VL) images. This standard will enable specialists working with color images to exchange images between different imaging systems using direct network connections, telecommunications, and portable media such as CD-ROM and magneto-optical disk. The DICOM Standard for endoscopy is part of a larger standard for color images in medicine which has been provisionally approved by the DICOM committee. The current version will go through a process of public comment and testing. This period ensures that any interested party may review the document and suggest changes to a committee that is responsible for creating the final version. This process is time-consuming, but it ensures that the standard is comprehensive and meets the needs of a broad group of users. The endoscopy community through the ASGE and ESGE has also suggested that the DICOM standard be expanded to incorporate other information associated with the imaging study. These expanded standards would include image labels and overlays, sound and waveform. The goal of a true multimedia report will only be achieved when these standards have been thoroughly tested and implemented as part of the daily clinical activities of gastrointestinal endoscopists throughout the world. The cooperation of endoscopists, professional, societies, and industry is absolutely necessary for improved endoscopic information systems and will result in improved patient care. We thank the ASGE, Ollie Cass, MD, James Barthel, MD, and members of the Informatics Committee, L. J. Hunyadi, and the vendor community, Michel Delvaux, MD (ESGE), and Dean Bidgood, MD (ACR), for their work in developing the standards for gastrointestinal endoscopy.

The interest of the international gastrointestinal endoscopy community in developing standards for endoscopic reporting resulted in a standard lexicon for describing endoscopic findings. It became clear that in order to facilitate the widespread use of this lexicon, a messaging standard which could link images to text had to be adopted. The DICOM 3.0 Standard (digital imaging and communication in medicine) was extended by the introduction of the Visible Light Supplement and the SNOMED-DICOM microglossary. These two standards should expand the ability of DICOM to accommodate endoscopic images and the clinical description of these images.

Colonoscopy (C) is mostly performed under conscious sedation.The benefit of the most often used combination of low-dose iv midazolam (M) and pethidine (P) on patient tolerance and pain and its cardiorespiratory risks remain poorly defined.To respond to these issues, a randomized double-blind placebocontrolled study was performed.Methods: 150 outpatients undergoing routine colonoscopy were randomly assigned to receive either (1) low-dose midazolam (35 ug/kg) and pethidine (700 ug/kg in 48 patients, 500 ug/kg in 102 patients), (2) M and placebo P, or (3) placebo M and P. The following parameters were assessed by patients on visual analogue scales (VAS 0-100 ram=points; 0 = excellent, 100 = unbearable): anxiety, discomfort to colonic lavage, tolerance and pain during the procedure; on verbal scales: satisfaction and willingness to repeat C. Amnesia was measured by a standardized 10 item recall ofwor~ and images.Endoscopists indicated patient tolerance and ease of examination on VAS, and C duration.Backward stepwise regression and analysis of covariance were performed.Oxygen saturation (pulse oximeter), blood pressure (BP) and pulse rate were coutinously monitored and digatally stored.Results: Tolerance did not improve significantly more in group 1 as compared with group 2 (7 points;95% CI -2-17) and group 3 (2 poiuts,95% CI -7-12).Similarly, pain was not significantly alleviated in group 1 as compared to the other groups.There was no dif~nmce in patient satisfaction.Male sex (p<0.001) and shorter duration of C (p=0.004), but not amnesia, were associated with better tolerance and less pain.Furthermore, pain improved with better acceptance of colonic lavage (p=0.045)andnon-manual profession of the patients (p<0.001).Verbal and visual amnesia were observed in 60% and 95% of the patients, resp.Patients needing additional medication (19%) were evenly distributed between the 3 groups.Oxygen desaturation < 90% occurred in 33% with a similar frequency in all groups.Hypotension (mean BP < 60 mm Hg) was observed in 11%.BP decreased to a similar extent in all groups during C.No adverse outcome occurred.Conclusions: The combination of M and P does not improve patient tolerance and pain during colonoscopy, thus questioning actual sedation practice.However, as compared to the single drug, cardiorespiratory parameters are not altered more frequently when using a combination arM and P.

Insulin‐like growth factor‐I is a polypeptide hormone structurally related to insulin. It is a potent mitogen that promotes growth and differentiation in many tissues. A role for insulin‐like growth factor‐I in wound healing is suggested by its rapid rise in levels and increased insulin‐like growth factor‐I messenger RNA expression in tissue after wounding. We designed our study to characterize possible changes in insulin‐like growth factor‐I receptor binding during wound healing. Surgical wounds created on the abdominal skin of anesthetized New Zealand White rabbits were either left open or closed primarily. Size‐ and weight‐matched specimens were harvested at wounding time (day 0), and at 1, 4, 7, 38, and 50 days after wounding. Preliminary experiments showed that the greatest difference in specific binding occurred between day 0 and day 7. 125I‐insulin‐like growth factor‐I binding studies were performed on frozen tissue specimens and autoradiography was performed and analyzed by computerized densitometry. Scatchard analysis of the binding data showed a single class of insulin‐like growth factor‐I binding sites whose affinity that is, binding constant (Kd = 0.6 × 10−9) did not change significantly over time; in contrast there was a threefold increase in the number of receptors per milligram tissue in day 7 wound tissue versus normal skin harvested at day 0 (17.3 ± 2.6 × 1010 versus 4.7 ± 2.5 × 1010, respectively, p < 0.05). Binding inhibition experiments showed that 125I‐insulin‐like growth factor‐I binding was most specific to insulin‐like growth factor‐I with insulin‐like growth factor‐I > insulin‐like growth factor‐II > insulin. This increase in binding was due to upregulation of insulin‐like growth factor‐I receptors rather than increased levels of insulin‐like growth factor‐I binding protein as less than 20% of the threefold increase in binding at day 7 could be attributed to insulin‐like growth factor‐I binding protein in membrane‐free extracts. The presence of specific, high‐affinity insulin‐like growth factor‐I receptors in the skin and their upregulation at day 7 after wounding suggest that insulin‐like growth factor‐I plays an important role during wound healing.

The effects of corticotropin-releasing factor (CRF) on human lung cancer cell lines was investigated. Corticotropin-releasing factor increased the cAMP levels in a dose-dependent manner; CRF (100 nM) elevated the cAMP levels approximately elevenfold using NCI-H345 cells and increased the gastrin-releasing peptide (GRP) secretion rate by approximately 70%. Similarly, sauvagine, a structural analogue of CRF, elevated the cAMP levels with a half-maximal effective dose (ED50) of 20 nM. The increase in cAMP caused by CRF and sauvagine was reversed by α-helical CRF(9–41). Corticotropin-releasing factor had no effect on cytosolic calcium but stimulated [3H]arachidonic acid release from NCI-H1299 cells with an ED50 of 30 nM. The increase in [3H]arachidonic acid release caused by 100 nM CRF was significantly reversed by 1 or 10 μM α-helical CRF(9–41). Also, CRF stimulated the clonal growth of NCI-H345 and H720 cells and the growth increase caused by CRF was reversed by α-helical CRF(9–41). These data suggest that CRF may be a regulatory peptide in lung cancer.

Background: The composition of the extracellular matrix (ECM) as well as insulinlike growth factor I (IGF-I) receptor density vary along the crypt-villus axis. We determined whether components of the ECM influence IGF-I receptor expression in IEC-18 rat small intestine crypt cells. Methods: IEC-18 cells were cultured on plastic, collagen type IV, Matrigel, and laminin at the plateau and proliferative growth phases. Receptor affinity (Kd) and number (Bmax) were determined by competitive binding of 125I-IGF-I in the presence of increasing concentrations of unlabeled IGF-I. Receptor isolation was performed by affinity cross linking. Messenger RNA (mRNA) for IGF-I receptor was quantified by Northern analysis. Results: Specific binding of IGF-I>IGF-II>insulin was observed. A 130,000-molecular weight protein was identified by cross-linking, consistent with the α subunit of the IGF-I receptor. Scatchard analysis revealed no effect of ECM on IGF-I binding affinity. In contrast, the Bmax was 18% lower for plateau-phase cells cultured on Matrigel vs. plastic and was 42% lower for cells cultured on laminin vs. collagen type IV. The Bmax for proliferative growth phase cells was decreased when cultured on Matrigel vs. plastic and was 10-fold less than for cells cultured at the plateau growth phase. Northern analysis revealed that IEC-18 cells cultured on Matrigel had less mRNA for IGF-I receptor than cells cultured on plastic. Conclusions: The rate of cell proliferation and the composition of the ECM influence IGF-I receptor expression in IEC-18 cells.

The ability of VIP analogues to interact with small cell lung cancer (SCLC) cells was investigated. Specific I-125-VIP binding to SCLC cell line NCI-H209 was inhibited with high affinity by VIP, PACAP, VIPhybrid (VIPhyb) and thymosin alpha1 (THNalpha1) (IC50 = 10, 20, 700 and 10000 nM respectively) but not thymosin beta4. I-125-I-VIP bound specifically to 3 out of 5 SCLC biopsy specimens. VIP but not VIPhyb or THNalpha1 elevated the cAMP levels 4-fold using cell lines NCI-H345 and H209. Also, VIPhyb and THNalpha1 inhibited SCLC growth using a clonagenic assay. These data suggest that VIPhyb and THNalpha1 interact with SCLC cells and inhibit proliferation.

Insulinlike growth factor I is a potent mitogen with insulinlike metabolic effects. Insulinlike growth factor I is synthesized in the liver, intestine, and other organs. Insulinlike growth factor I receptors are widely distributed and structurally similar to insulin receptors. Frozen sections of rabbit gastrointestinal tract were incubated in buffer containing 40 pmol/L [125I]insulinlike growth factor I. Binding was saturable, temperature- and time-dependent, and reversible. Saturation binding experiments showed a single class of high-affinity receptors (Kd = 0.9 nmol/L, Bmax = 0.36 pmol/mg protein). The IC50s for insulinlike growth factor I and insulinlike growth factor II were 3 nmol/L and 90 nmol/L, respectively; whereas insulin at 1-3 mumol/L displaced 50% of specific binding. Autoradiography of insulinlike growth factor I binding demonstrated significant differences in receptor density in gastrointestinal smooth muscle, epithelium of the esophagus, stomach, small intestine, and colon. These results indicate that a single class of specific, high-affinity insulinlike growth factor I receptors were distributed in muscular and mucosal layers of the entire rabbit gastrointestinal tract. Insulinlike growth factor I is likely to be an important local mediator of intestinal growth and metabolism.

Insulin-like growth factor I (IGF-I) is a polypeptide hormone structurally related to insulin with insulin-like metabolic effects. It is a potent mitogen, eliciting cell multiplication in tissue culture by increasing deoxyribonucleic acid and protein synthesis. IGF-I was found to promote the growth of cultured arterial smooth muscle cells. We studied the in situ distribution of IGF-I receptors in different arteries of the rabbit by autoradiography and examined their binding characteristics in the wall of the thoracic aorta. The thoracic and abdominal aortas and carotid, superior mesenteric, renal, and iliac arteries of three adult New Zealand rabbits were harvested and stored at -70 degrees C. Autoradiographic analysis of 125I-labeled IGF-I binding to frozen arterial sections showed that silver-grain density was consistently located in the arterial wall. Binding studies in the thoracic aorta demonstrated high-affinity IGF-I receptors with a dissociation constant of 2 nmol/L and maximum IGF-I binding capacity of 4.17 pmol/mg protein. Inhibition studies with insulin, IGF-I, and IGF-II showed that these binding sites were more specific for IGF-I than for IGF-II or insulin, with a concentration of peptide that inhibits 50% of maximum binding of 1.75 nmol/L, 5 nmol/L, and greater than 100 mumol/L, respectively. The presence of high-affinity, specific IGF-I receptor binding in rabbit arteries suggests that IGF-I plays an important role in regulating the multiplication of arterial smooth muscle cells; a role that may prove important in different pathologic processes.