SOMATOM X.cite Dual Energy Workflow Online Training (VA30) - USA

Congratulations. You have now completed the SOMATOM X.cite Dual Energy Workflow (VA30) Online Training. Listed below are the key points that have been presented. Take time to review the material before you proceed to the final quiz. Select the link below to view and/or print your review material before proceeding to the final quiz. Download and print a copy of the Course Review. Introduction to Dual Energy Principle of Dual Energy Dual Energy CT is an imaging modality based on the acquisition of two CT datasets corresponding to two different X-ray spectra Different attenuation of materials at different energies enable material decomposition and characterization TwinSpiral DE scan mode  The TwinSpiral DE scan mode consists of two successive spiral scans at different kV and mA levels. The two spirals are automatically coupled Well suitable for material characterization TwinBeam DE scan mode With the TwinBeam DE scan mode, the high and low energy CT datasets are acquired simultaneously using a tin and a gold filter Well suitable for cases in which fast image acquisition is required and for examinations with contrast media    Perform the Dual Energy Scan Perform routine Dual Energy examinations successfully in a step-by-step approach Step 1: Position patient correctly on the patient table Step 2: Select a registered patient from the Scheduler of the Patient Browser Step 3: Select the body region-specific Dual Energy scan protocol  Step 4: Check and, if necessary, correctly adapt patient position on the Topogram taskflow card  Step 5: Check correctness of the planned scan range and perform the topogram scan  Step 6: Perform the tomogram scan and check the image quality Step 7: Start all configured reconstruction jobs Step 8: Close the current patient  Step 9: Unload the patient from the patient table myExam Compass myExam Compass collects information about the current patient to dynamically adapt the scan and recon parameters according to the patient's characteristics. Depending on the information that is needed, myExam Compass:     retrieves patient characteristics such as gender, age from the RIS/HIS retrieves patient information such as heart rate or patient diameter from the CT scanner asks predefined questions referring to the examination (e.g. "What is the breathhold capability of the patient?") myExam Compass then chooses the scan strategy. Depending on the scan strategy, scan and recon parameters are adapted.  Image Reconstruction Dual Energy Reconstructions Spectral Recon creates primary Dual Energy CT images with the image reconstruction system (IRS) and remains full freedom of recon parameters. It allows for example the planning of oblique Dual Energy series.  Inline DE results provide PACS ready series for all Dual Energy applications. Reconstructions are based on strictly axial planning.  Interactive Spectral Imaging (with SPP) allows you to switch between the most common Dual Energy application classes (VNC, Iodine Map, Monoenergetic Plus). This is enabled by the new SPP data format which reduces the amount of series in your PACS.  Reconstructing images for an evaluation with Liver VNC Step 1: Localize the recon job that you want to configure or repeat and modify an existing recon job Step 2: Double-click the recon icon of a recon job. The parameter panel opens Step 3: Click the Inline Options button Step 4: In the Inline Results column, select Multi Energy > DE Parallel Ranges  Step 5: In the Application Class column, select Liver VNC Step 6: For DE Parallel Ranges you can select the required data set(s) in the Data Set column:               VNC, Iodine, Fused, 3D Step 7: Set the remaining Inline Options parameters as appropriate:               Organ, Viewing Direction, High Resolution  Scan&GO workflow The Scan&GO workflow enables you to perform a complete diagnostic scan in the examination room. On the tablet, you can select a registered patient and a scan protocol, perform the topogram scan and the tomogram scan, and finalize the examination. You can also change the language of patient instructions. Some operations, such as connecting scan ranges or modifying parameters for image reconstruction, are only possible at the syngo Acquisition Workplace. Welcome to the SOMATOM X.cite Dual Energy Workflow Online Training.  In this training you will get basic information about spectral imaging with Dual Energy CT and you will learn more about the routine Dual Energy scanning workflow. Please note: This Online Training reflects software version VA30. Upon successful completion of this course, you will be able to:  Name the benefits of a Dual Energy (DE) scan Define the differences between TwinSpiral DE scan mode and TwinBeam DE scan mode Understand the basic principles of myExam Compass Perform a routine Dual Energy scanning workflow successfully Customize relevant reconstruction parameters for a Dual Energy CT Scan   On the following pages you will learn about Principle of Dual Energy image acquisition  Benefits and advantages of Dual Energy in the clinical routine TwinSpiral DE scan mode TwinBeam DE scan mode Courtesy of University Hospital Erlangen, Erlangen, Germany Dual Energy CT is an imaging modality based on the acquisition of two CT datasets corresponding to two different X-ray spectra (i. e., spectra with different effective energies). Different attenuation of materials at different energies enable material decomposition and characterization to create different image sets like Virtual Non Contrast (VNC), Iodine Maps or monoenergetic images with additional diagnostic information.  Select the link below to learn more about spectral imaging with Dual Energy CT:  Whitepaper Spectral Imaging with Dual Energy CT - Comparison of different technologies and workflows  Dual Energy CT is a solution that  allows you to quantify, highlight, characterize and differentiate materials moves your CT images from morphological to functional imaging supports decision-making through new insights and thereby impacts clinical pathways  Clinical benefits of Dual Energy CT include:  Evaluate vasculature by utilizing high-contrast dynamic applications Better characterize suspicious lesions in the course of standardized assessment thanks to increased image contrast Visualize and evaluate uric acid crystals and kidney stones Assess lung perfusion and vessel situation in pulmonary embolism Courtesy of Clinica Universidad de Navarra, Pamplona, Spain The TwinSpiral Dual Energy CT scan mode consists of two successive spiral scans at different kV and mA levels. The high kV spiral is acquired using a tin filter to enhance spectral separation. The two spirals are automatically coupled. Scan set-up and scan parameter selection are as easy as for any standard single energy spiral.  Because of the high spectral separation, TwinSpiral is particularly well suitable for material characterization.        The TwinBeam Dual Energy™ scan mode enables simultaneous acquisition of high- and low-kV datasets by splitting the X-ray beam using a tin and a gold filter.  Tin filter: high energy Gold filter: low energy Because the high- and low-kV data sets are acquired simultaneously, TwinBeam is particularly suitable for: Examinations with contrast media Cases in which fast image acquisition is essential   On the following pages you will learn how to perform a Dual Energy scan. You will learn about the SOMATOM X.cite Dual Energy scanning workflow using the example of an abdomen scan.  The examination is based on the Abdomen DE Virtual Non Contrast [factory] protocol and uses the TwinBeam DE scan mode. Let´s take a closer look at the steps to be taken during the examination and what to look for. Patient positioning is an important part of preparing for the patient examination. Correct positioning ensures reproducible image quality. Also, the patient should feel as comfortable as possible while lying on the table waiting for the scan. To properly position patients for abdominal exams, proceed as follows: Patient in supine position, head first, arms over the head, and relaxed on the head support. Support lower legs. Please note: For all studies, it is very important to position the patient in the isocenter of the scan field. Use the lateral laser beams to ensure. The Home screen is the access point for the main functions of the system. Select Examination to perform a CT examination.   If your system is connected to a RIS, all scheduled patients are listed in the Scheduler of the Patient Browser. With the selection of the patient, the patient data is displayed on the Patient Registration dialog on the right side of the Patient Browser.   If your system is not connected to a RIS, the patient data can be entered and saved here manually. Check the patient data and medical information. Select Exam to load the selected patient.   To start the examination of the abdomen, select a Dual Energy scan protocol with TwinBeam DE scan mode in the Protocol Selection. To do this, choose the abdomen as desired body region on the schematic body map. All available scan protocols are displayed. Select the Abdomen DE Virtual Non Contrast scan protocol with TwinBeam DE scan mode. Hint: Several scan modes are available for TwinBeam Dual Energy scans. These modes include TwinBeam as a keyword in the scan mode parameter entry. Select OK to apply the protocol. If a decision tree is linked to a scan protocol, the myExam Compass task is added to the taskflow control during the examination. The purpose of myExam Compass is to collect information about the current patient. Depending on the information that is needed: You may be prompted to answer questions referring to the examination. Specific values are retrieved from the patient registration or from medical equipment that is connected to the patient. Based on your answers and the collected values, myExam Compass dynamically adapts the scan and recon parameters to match the patient’s characteristics. In our example, myExam Compass would have changed the recommended scan mode to Single Energy if the patient was obese.  myExam Compass: Workflow and Decision Trees Learn more about myExam Compass and decision trees Tab TitleTextmyExam Compass workflow In our example, myExam Compass makes a Dual Energy recommendation. For this, it retrieves information about the patient characteristics from the topogram scan. If necessary, myExam Compass changes the scan mode to Single Energy – for example if a Dual Energy scan is not recommended because of patient obesity. Since this decision is made automatically by the system, you don´t have to answer a question. The tomogram scan procedure starts directly after the topogram has been scanned. myExam Compass will only be displayed with an info text if the scan mode has been switched to Single Energy. Please note:  You can manually change decisions made by myExam Compass by using the Edit icon. You can also skip the questions prompted by myExam Compass and proceed with the examination. In that case, the parameters are not dynamically adapted.  Decision Trees A clinical decision tree combines scan parameters into scan strategies. Let´s look on the scan strategies for the Abdomen TwinBeam DE decision tree, used by myExam Compass in our example.  This is a very simple decision tree with only two scan strategies TwinBeam DE and Single Energy. According to the characteristics of the current patient myExam Compass chooses the scan strategy. Depending on the scan strategy, scan and recon parameters are adapted.  In our example, there’s only one scan parameter: the scan mode. If myExam Compass decides to use the TwinBeam scan strategy, the TwinBeam scan mode is activated, otherwise a Routine scan mode would be configured. No recon parameter is adapted in this example. Check the patient position and select Confirm to continue. Select Go to activate the Topogram scan, then press the highlighted Start button on your control box next to you to start the Topogram scan. The Topogram is displayed in real time in the topo segment and can be suspended at any time if its length goes beyond the necessary anatomy. FAST Planning automatically places the correct recon range for you. If you wish to make additional adjustments to the recon range, grab any of the white dots and modify the recon range accordingly.   Checking the patient position Learn more about checking the patient position   Check the patient position and, if necessary, change it by selecting one of the eight orientation icons on the Topogram taskflow card. The patient graphic in the center of the screen indicates the selected patient position. The selected tube position and table direction are highlighted in white. If necessary, select the appropriate icons to change them. The correct patient position for an Abdomen DE Virtual Non Contrast scan should be as indicated here. The tube position set to Top, the patient position set to HF supine and the Topo length set to 512 mm.  Please note: A wrongly selected patient position will result in invalid orientation information in CT images. Select Go to activate and load the tomogram range. Press and hold the Move button on your control box next to you until the start position of the spiral is reached. Press the Start button on your control box to initiate the Abdomen Virtual Non Contrast DE scan. During scanning real time images will be displayed in the Tomo segment. When the scan is completed you are prompted to manually check the quality of the scan.   Image Quality Check Learn more about image quality check   Upon reception of the images the Check&GO algorithm is activated. The algorithm checks the anatomical coverage based on the images and the uniform and adequate distribution of contrast media if applied. The quality check stops all auto reconstructions until the quality is approved by you. You can view the coverage or image quality of the scan by right clicking, holding and moving the mouse up and down to scroll through the displayed images. Automatic Patient Instructions Learn more about patient instructions Automatic patient instructions ensure optimum image quality. They tell the patient how to behave during the scan to avoid movement artefacts.   In our Abdomen example, the patient instruction is Inspiration and sounds like this: (1) Start of scan range: Please breathe in and hold your breath.  (2) End of scan range:  Start breathing again. You can change the patient instruction in the scan parameter panel. To access the scan parameter panel, double-click a scan range in the timeline. After a scan is completed and the image quality is approved, you can proceed to the reconstruction task. The reconstruction parameters are preset in the scan protocol, but they can still be adapted: In the Recon Ranges section, double-click a Recon icon of a Recon job to open the Parameter panel and edit the presets. Select Recon all in the execution control area to start all reconstruction jobs previously configured with Recon&GO. Select Next to continue with the Close step.   Dual Energy Reconstructions Learn more about Dual Energy reconstructions TitleTextOverviewTab TitleTextReconstruction types Spectral Recon reconstructions and dedicated Inline Results reconstructions are available for Dual Energy CT scans. You can select the Dual Energy reconstruction types in the Recon&GO category of the parameter panel. Use cases The use cases are characterized as follows: Spectral Recon creates primary Dual Energy CT images with the image reconstruction system (IRS) and retains full freedom of recon parameters. It allows for example the planning of oblique Dual Energy series.  Inline DE results provide PACS ready series for all Dual Energy applications. Reconstructions are based on strictly axial planning.  Interactive Spectral Imaging allows you to switch between the most common Dual Energy application classes (VNC, Iodine Map, Monoenergetic Plus). This is enabled by the new SPP data format which reduces the amount of series in your PACS.  Multi Recons Multi Recons allow you to perform multiple reconstructions for the same anatomic coverage out of one recon job. These so-called sub recon jobs share most of the reconstruction parameters but provide different orientations or different image impressions. You can generate two or three standard reconstruction series for Orientation Multi Recons or Impression Multi recons in Dual Energy CT scans. To select Multi Recons, go to the Recon&GO category in the parameter panel. Spectral ReconTab TitleTextIntroduction Spectral Recon types can be combined with all reconstruction parameters that are available for single energy reconstructions. Primary Dual Energy CT images are created by the image reconstruction system (IRS).  Please note: Spectral Recon reconstruction jobs provide basic grey-scale reconstructions for Dual Energy images and are only available for Dual Energy protocols.  Reconstruction types The following reconstruction types are available: Parameter Description None A conventional CT reconstruction of Dual Energy scans generate images equivalent to 120 kV or 140 kV.  In case of a TwinSpiral scan, a mixed image of both energy spectra is generated.  In case of a TwinBeam scan, a composed image of both energy spectra is generated for which the projection data of the spectra is merged in raw data space.  Monoenergetic Plus Reconstructs images that are equivalent to images scanned with a single photon energy beam, depending on the energy (keV). Monoenergetic Plus images can be selected in a range from 40-190 keV.  VNC* Generates virtual non contrast (VNC) images by subtracting iodine.  Iodine* Generates images that visualize the iodine concentration or enhancement after a contrast media scan. It also performs motion correction.  L3D Performs a conventional CT reconstruction of the low energy image of a Dual Energy scan. H3D Performs a conventional CT reconstruction of the high energy image of a Dual Energy scan.   Inline DETab TitleTextIntroduction Dual Energy reconstructions with Inline DE functionality allow you to set up and activate image reconstruction and image post-processing within one step.  Inline DE produces PACS ready reconstructions for dedicated clinical applications (for example visualization of gout or kidney stones).  Ranges The Inline DE functionality is available for DE Parallel Ranges or DE Radial Ranges in the Recon&GO category or in the Inline Options category.   You can choose application classes depending on the range types: DE Parallel Ranges (DE Parallel Ranges application classes) DE Radial Ranges (DE Radial Ranges application classes) Application Classes The functionality of the Inline DE applications is as follows: Application Class Description Bone Removal/ Direct Angio Automatically removes bone or dense plastic from CT angiography (CTA) data sets. Liver VNC Visualizes the contrast agent concentration in the liver without an additional non-contrast scan.The application class generates virtual non-contrast (VNC) images by subtracting iodine from the Dual Energy data sets.  Monoenergetic Plus Simulates images that are equivalent to images scanned with a single photon energy beam, depending on the energy (keV). Monoenergetic Plus images can be selected in a range from 40-190 keV. You can increase contrast by lowering the keV for evaluating suspicious lesions, or you can increase the keV for reducing metal artifacts.  Virtual Unenhanced Visualizes the contrast agent concentration in soft body tissue without the need of an additional non-contrast scan.Virtual Unenhanced can produce Virtual Non Contrast and Iodine Maps. Iodine Maps visualize the contrast agent concentration in soft body tissue. Virtual Unenhanced generates virtual non-contrast (VNC) images by subtracting iodine.  Lung Analysis* Visualizes the iodine enhancement in pulmonary vessels and visualizes and quantifies the iodine uptake in the lung parenchyma. Gout Distinguishes between urate, bone, bone marrow, and contrast agent. Kidney Stones Visualizes the chemical differences between kidney stones. Bone Marrow The bone marrow reconstruction allows for the segmentation and visualization of the bone marrow based on a material decomposition into bone marrow and calcium.  Brain Hemorrhage** Distinguishes contrast agent from a hemorrhage in the brain. Rho/Z Measures electron density as well as effective atomic number and thus performs a basic characterization of the material of interest. Liver Fat Map Evaluates the fat distribution of the liver based on contrast enhanced CT scans as well as for non-contrast scans. * in TwinBeam Dual Energy scan modes only ** in TwinSpiral Dual Energy scan modes only Interactive Spectral Imaging (with SPP)Tab TitleTextImage types You can select Dual Energy reconstructions for postprocessing with CT View&GO or the syngo.CT Dual Energy workflow. The following reconstruction types are available: SPP (Spectral Post Processing images for postprocessing) L&H (high energy and low energy images for postprocessing) SPP With SPP you no longer have to send separate L&H image series to the PACS. You get all the information you need for further post-processing in one object. The object contains the information of the L&H image series. By maintaining this information the Interactive Spectral Imaging capabilities are enabled. As a result, SPP offers a solution for data overload in PACS due to too many series. SPP data sets contain the following: conventional CT images or Monoenergetic Plus images (main representation) additional Dual Energy information for Interactive Spectral Imaging in MM Reading or CT View&Go If you open a SPP data set with MM Reading or CT View&GO, you can interact with different Dual Energy information: Monoenergetic Plus (40-190 keV), VNC, Iodine Map, Mixed. Please note: For further information on Interactive Spectral Imaging, please view pages 21 to 25 of the syngo.via VB40 Delta - Computed Tomography Online Training in the syngo.via training area of PEPconnect. Image Reconstruction Learn more about reconstructing images for an evaluation with Liver VNC Checklist TitleChecklist TypeChecklist ContentSelect recon jobHTML Localize the recon job that you want to configure or repeat and modify an existing recon job. For example, in the Abdomen DE Virtual Non Contrast protocol, three recon jobs are preconfigured in the Recon Ranges area: Conventional CT reconstruction of Dual Energy images with Orientation Multi Recon (coronal/axial) Dual Energy Parallel Range with Orientation Multi Recon (coronal/axial) Dual Energy SPP Open parameter panelHTML Double-click the recon icon of the Dual Energy recon job.   The parameter panel opens. Go to Inline OptionsHTML Click the Inline Options button. The Inline Options parameters are displayed. Select RangeHTML In the Inline Results column, select Multi Energy > DE Parallel Ranges    Hint: If you modify any parameters, the background color of the modified parameters changes to green. The icon identifies categories that include modified parameter settings. Select Application ClassHTML In the Application Class column, select Liver VNC. The Liver VNC (Virtual Non-Contrast & Contrast Image) application calls allows you to visualize the contrast agent concentration in the liver without an additional non-contrast scan, even if there are irregular fatty infiltrations or necrotic areas.  The application class generates virtual non-contrast (VNC) images by subtracting iodine from the Dual Energy data sets. The VNC images can be used for baseline density measurements.  The basis for this approach is the decomposition of the liver into its component parts: iodine contrast agent, fat, and liver tissue.  Select required data set(s)HTML For DE Parallel Ranges you can select the required data set(s) in the Data Set column. Multi-selection is possible and allows multiple reconstructions to be created simultaneously. Parameter Description VNC Provides VNC images Iodine Provides iodine overlay images Fused Provides fused images of both image volumes 3D Provides thin slice results for 3D postprocessing Set remaining Inline OptionsHTML Set the remaining Inline Options parameters as appropriate. Parameter Description Organ Specifies the organ for which the organ detection is to be run for anatomical ranges. Organ detection can be turned off if it is not needed or if the reconstruction fails because the organ is not found. Viewing Direction Specifies the viewing direction per image for anatomical ranges. High Resolution Turns on or off high resolution for anatomical and radial vascular ranges. You can finalize an examination at any time even if some tasks are not yet completed.   The Job Status tab opens. It provides an overview of all recon jobs, their status and auto tasking settings like Auto View&GO or Auto Printing.   If applicable, check the Auto Tasking parameters.   In the execution control, click the Close button. The patient is closed. All pending recon jobs are processed in the background.   After closing the patient the Scheduler will open automatically. Now you can select the next patient to continue with the next examination.   Once the required scans are completed, you can unload the patient from the patient table.   On the Remote Scan Control or control box, press the Unload key or step on the Unload pedal of the table foot switch.   The table is moved out of the gantry.   If required, assist the patient in getting off the patient table. The Scan&GO workflow enables you to perform a complete diagnostic scan in the examination room without using the syngo Acquisition Workplace in the control room. The following workflow steps are available on the tablet: Selecting a registered patient and a scan protocol Performing the topogram scan and the tomogram scan Finalizing the examination However, some operations are only possible at the syngo Acquisition Workplace, for example connecting scan ranges or modifying parameters for image reconstruction.   Scan&GO workflow Learn more about the Scan&GO workflow for an evaluation of the abdomen Checklist TitleChecklist TypeChecklist ContentStartHTML The No patient registered screen is the first screen that is displayed after launching the Scan&GO examination workflow.   Tap GO.   Select PatientHTML The Patient Selection screen lists all patients that are registered for that day.   The patient scheduled next is highlighted.   To load the patient, tap GO or tap the corresponding row. Select DE Scan ProtocolHTML On the patient model, tap on the abdomen as the desired body region to be scanned.   The matched protocols are displayed. Tap the Abdomen DE protocol.   Tap GO. The protocol is assigned to the patient.   Hint: Scan&GO Approved workflow: This icon identifies scan protocols for complete scans with the tablet.   myExam CompassHTML The Breathing Instruction Practice display enables you to practice the breathing instructions with the patient prior to the examination. In the Audio Control, you can enable or disable the visual and audible patient instructions and change their language. The Patient Characteristics display belongs to myExam Compass and shows attributes automatically entered by the system, in our example the Dual Energy Recommendation. Tap GO.  Confirm Patient PositionHTML The CT system automatically selects the position that is defined in the scan protocol. Make sure that the patient position is correct.   To change the selected position, tap the arrows around the patient model or use the swipe gestures.   Tap GO. The patient position is confirmed. Perform the Topogram scanHTML On the Ready to load Topogram screen, you can change the topogram length by tapping the Topogram Length button.   Tap GO to load the topogram range.   Then press the Start key on the control box or on the Remote Scan Control to perform the Topogram Scan. Perform the Tomogram scan (1/2)HTML Once the topogram is acquired, the Tomogram Planning screen is displayed.   FAST planning automatically positions the recon range for you. To edit the recon range, tap and drag a handle on the borders.   Tap GO to load the tomogram range. Perform the Tomogram scan (2/2)HTML After you have loaded the tomogram range, you can start the scan. If the planned examination is performed with the injection of contrast medium, check and enable the injector.   Press and hold the Move key on the control box or on the Remote Scan Control to move the table to the range start position.   Then press the Start key on the control box or on the Remote Scan Control to perform the Tomogram Scan. Check Image quality and start ReconstructionHTML As soon as the scan is finished, the acquired tomogram images are displayed on the screen. Check the quality of the images by dragging the slider on the right to scroll through the acquired images. You can also move two fingers away from each other to zoom in and move them towards each other to zoom out. The Check&GO feature checks coverage and contrast media injection. In this example, only the coverage check is configured. Tap the timeline entry to access the Check&GO interface and to be able to Repeat the Scan, if necessary or Start Auto Tasking.    If you are satisfied with the overall quality of the images, tap Recon All to start the reconstruction. Finalize the ExaminationHTML Tap Close to close the patient. The patient closes and the examination data is distributed as specified.   The No patient registered screen is displayed to examine the next patient. After reading the disclaimer, please proceed to the final quiz to complete the online training.  Please note that the learning material is for training purposes only! For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Note: Some functions shown in this material are optional and might not be part of your system. The information in this material contains general technical descriptions of specifications and options as well as standard and optional features that do not always have to be present in individual cases. Certain products, product related claims or functionalities described in the material (hereinafter collectively “Functionality”) may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. All names and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Copyright © Siemens Healthcare GmbH, 2019