HospiMedica International September 2018

V I S I T

WORLD’S

CLINICAL NEWS

Vol.36 No.4 • 8-9/2018

LEADER DAILY CLINICAL NEWS

ISSN 0898-7270

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QR Bracelet Improves Patient Treatment racelets imprinted with a quick response (QR) code may allow patients with rare diseases to receive improved treatment through immediate access to management protocols, claims a new study.

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Antigen Matching Breakthrough Could Transform Transfusion Medicine y way of the application of advanced whole-genome sequencing techniques, antigen typing can enable more precise antigen matching of patients with blood donors, thus preventing complications of sensitization to antigens and materially improving

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transfusion outcomes.

There are more than 300 known red blood cell (RBC) antigens and 33 platelet antigens that differ between individuals. Sensitization to antigens is a serious complication that can occur in prenatal medicine and after blood

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Automated System Identifies Ventilated Patients at Risk

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Radio Emissions Helmet Rapidly Detects Stroke novel cerebral scanner detects asymmetry of intracranial fluids in patients undergoing a neurological assessment. The Cerebrotech Medical Visor consists of a headband device with multiple integrated antennas that rapidly detect changes and distribution of cerebral fluids by broadcasting and receiving each other’s signals.

The technology, which is based on volumetric impedance phase-shift

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RT System Personalizes Cancer Treatment n innovative magnetic resonance imaging/radiation therapy (MRI/RT) system allows clinicians to adapt the patient’s RT treatment plan to current anatomical information.

The Elekta (Stockholm, Sweden; www.elekta.com) Unity system integrates MRI, linear accelerator (LINAC) technologies, and advanced treatment planning into a single platform, allowing clinicians

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n automated system for detecting mechanically ventilated patients at risk of ventilator-associated events was developed by a consortium of three prominent US research institutes. According to a latest study, the system surpasses traditional surveillance methods.

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LED Light Delivers High-Quality Operating Room Illumination

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new surgical lamp uses light emitting diode (LED) technology to provide optimal performance, reliability, and visual comfort. The distribution of the 43 LEDs generates a shadowless, homogeneous light to

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Industry News . . . . . . . . . 25 International Calendar . . 26

News Update . . . . . . . . . . 6 Product News . . . . . . .6-10

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GE to Spin Off Healthcare Business

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n line with a sweeping strategic reorganization, General Electric Company has announced the decision to spin off its Healthcare business segment as an independent company. The move comes on the

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heels of a lengthy managerial review conducted

by GE management under newly-appointed CEO John Flannery, and is expected to be fully implemented in the course of the coming 12 to 18 months.

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News Update . . . . . . . . . 16 Product News . . . . . .16-20

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GLOBETECH >>> MEDIA <<<

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LED Light Delivers High-Quality Operating Room Illumination cont’d from cover

assure visual comfort. The ACEM Medical (Bologna, Italy; www.acem.it) STARLED5 NX is made up of five reflector groups (each with 7 LEDs), and another eights LEDs placed radially around the handle. The superior optical quality of the next generation LEDs produces an illumination level of 130,000 lux (or an optional 160,000 lux). A microprocessor-controlled feature called ACRIS ensures that power consumption curves remain unaltered over the time, helping maintain a steady life cycle of about 50,000 hours.

To achieve heatless infra-red (IR)-free illumination, STARLED5 NX produces both focused and ambient light via a light field focusing system that adjusts light-spot diameter so as to accent sharpness of details

RT System Personalizes Cancer Treatment cont’d from cover

to see and track difficult-to-visualize soft tissue anatomies as radiation dose is being delivered. The new technology addresses an unmet need in cancer therapy by enabling clinicians to confidently track the target during treatment and respond accordingly. The core of the system is the combination of three key aspects: A digital LINAC equipped with multileaf collimator technology and positioned on a gantry capable of continuous rotation around the MRI scanner, with the treatment beam passing through the inner MRI ring; A high-field 1.5Tesla MRI imaging system made by Royal Philips (Philips; Amsterdam, The Netherlands; www. philips.com) that allows clear, high resolution soft tissue visualization simultaneous to treatment delivery; Intelligent software that allows INTERACTIVE treatment plans to be adapted while DIGITAL EDITION the patient is on the table in response to changes in tumor position, shape, biology and the relationship to sensitive organs over time.

“Our MR-LINAC system is truly groundbreaking because it overcomes the technical barriers that have hindered the integration of radiation therapy with real-time high-field imaging,” said Richard Hausmann, CEO of Elekta. “It is the first system that provides the ability to ‘see what you treat’ with diagnostic image quality during treatment and respond based on what is being seen, offering the potential to personalize therapy for each patient.”

A LINAC uses microwave technology to accelerate electrons, forming high energy x-rays that can be shaped to conform to the shape of the patient’s tumor in a customized beam. The beam may be shaped either by blocks or a multileaf collimator incorporated into the head of the machine. RT can be delivered to the tumor from any angle by rotating the gantry and moving the treatment couch.

in the operating area. Ambient adjustable illumination is managed by the ENDO system, situated on the upper part of the lamp, which is particularly useful during minimal invasive surgery (MIS), visualizing the microscopic operating field as well as the surrounding environment to provide staff with visual comfort during patient monitoring.

All functions are managed via the digital and easy-to-read I–SENSE control panel positioned on the cardanic shaft structure. The panel controls power, light intensity, light spot diameter dimension (focusing), the ENDO light for endoscopy, and depth of field (DOF) for a full visualization of the operating field and deep cavities. An optional SYNC mode synchronizes controls among different lamps combined into different configurations, such as a STARLED5 NX twin dome configuration, or a STARLED5 NX with STARLED7 NX or STARLED 3 NX. The STARLED5 NX is also practical for the medical team, since it can be moved using lateral handles that assure stability and constant illumination. It’s ergonomic and practical design also considers sanitary requirements essential for the operating room. The lamp is therefore manufactured from smooth, resistant material that facilitates cleaning, and the removable central handle can be detached for sterilization.

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Automated System Identifies Ventilated Patients at Risk n automated system for detecting mechanically ventilated patients at risk of ventilator-associated events surpasses traditional surveillance methods, according to a new study.

Developed at Massachusetts General Hospital (MGH; Boston, USA; www.massgeneral. org), the Georgia Institute of Technology (Atlanta, USA; www.gatech.edu), and Harvard Medical School (HMS; Boston, MA, USA; https://hms.harvard.edu), the automated process uses an algorithm that analyses physiologic data to detect increases in positive endexpiratory pressure (PEEP) and fraction of inspired oxygen (FiO2); queries the electronic health record (EHR) for leukopenia or leukocytosis and antibiotic initiation data; and retrieves and interprets microbiology reports.

Based on the data, the algorithm can determine whether criteria were met for a ventilator-associated event and, if so, which level of event: A ventilator-associated condition (VAC), an increase in a patient’s need for oxygen without evidence of infection; an infection-related ventilator-associated complication (IVAC), with increased oxygen need accompanied by signs of infection, such as fever, elevated white blood cell count or an antibiotic prescription; and possible ventilator-associated pneumonia (VAP), with evidence of bacterial growth in the respiratory system, along with the factors listed above.

A validation study to test the algorithm followed 1,234 patients admitted to the intensive care unit (ICU), 431 of who received

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ventilator support. During that period, manual surveillance produced accuracies of 71%, 98% and 87%, respectively, while results for the automated system were 85%, 99% and 100% accuracy. The drop-off in accuracy of the automated system during the validation period was the result a temporary interruption of data availability while software was being upgraded. The study was published on May 17, 2018, in Infection Control & Hospital Epidemiology.

“Manual surveillance made many more errors than automated surveillance, including false positives, reporting cases that on review, did not meet criteria for what are called ventilator-associated events; misclassifications, reporting an event as more or less serious than it really was; and failure to detect and report cases that, on closer inspection, actually met criteria,” said lead author Erica Shenoy, MD, PhD, of the MGH division of infectious diseases. “In contrast, so long as the necessary electronic data were available, the automated method performed perfectly.”

Traditional surveillance of patients receiving mechanical ventilation involves manual recording of ventilator settings every 12 hours and adjusted throughout the day to accommodate the patient’s needs. The settings, which reflect the pressure required to keep a patient’s lungs open at the end of a breath and the percentage of oxygen being delivered to the patient, are reviewed by an infection control practitioner for signs that indicate possible VAP.

Antigen Matching Breakthrough Could Transform Transfusion Medicine cont’d from cover

transfusion, particularly for patients who require multiple transfusions. Although pretransfusion compatibility testing largely relies on serological methods, reagents are not available for many antigens. Methods based on single-nucleotide polymorphism (SNP) arrays have been used, but typing for ABO and Rhesus, the most important blood groups, cannot be done with SNP typing alone.

Scientists at Brigham and Women’s Hospital (Boston, MA, USA; www.brighamand womens.org) and their colleagues created a database of molecular changes in red blood cell (RBC) and platelet antigens and developed an automated antigen-typing algorithm based on whole-genome sequencing (bloodTyper).

This algorithm was iteratively improved to address cis–trans haplotype ambiguities and homologous gene alignments. Whole-genome sequencing data from 110 MedSeq participants (30 × depth) were used to initially validate bloodTyper through comparison with conventional serology and SNP methods for typing of 38 RBC antigens in 12 blood-group systems and 22 human platelet antigens. The blood-

Typer was further validated with wholegenome sequencing data from 200 INTERVAL trial participants (15 × depth) with serological comparisons.

The scientists iteratively improved bloodTyper by comparing its typing results with conventional serological and SNP typing in three rounds of testing. The initial whole-genome sequencing typing algorithm was 99.5% concordant across the first 20 MedSeq genomes. Addressing discordances led to development of an improved algorithm that was 99.8% concordant for the remaining 90 MedSeq genomes.

Additional modifications led to the final algorithm, which was 99.2% concordant across 200 INTERVAL genomes or 99.9% after adjustment for the lower depth of coverage.

The authors concluded that by enabling more precise antigen-matching of patients with blood donors, antigen typing based on whole-genome sequencing provides a novel approach to improve transfusion outcomes with the potential to transform the practice of transfusion medicine. The study was published on May 17, 2018, in the journal The Lancet Haematology.

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ISSN 0898-7270 Vol.36 No.4 • Published, under license, by Globetech Media LLC Copyright © 2018. All rights reserved. Reproduction in any form is forbidden without express permission.

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QR Bracelet Improves Patient Treatment cont’d from cover

Newcastle University (United Kingdom; www.newcastle.ac.uk) and Queen Elizabeth Hospital (Gateshead, United Kingdom; www. qegateshead.nhs.uk) for people suffering from Addison’s disease, the QR code, which is printed both on bracelets and on plastic cards carried by the patient, links to the Addison’s Disease Information System (ADIS), which provides comprehensive clinical management advice specific to each patient, including emergency treatment that may be required, a letter from a medical consultant, and advice about preparation for surgery.

The study included a survey of 54 healthcare professionals, including doctors, nurses, paramedics, and dentists, who were asked about their experience in managing an adrenal crisis in Addison’s disease patients and their professional views of the ADIS. The results revealed that 37% of the healthcare professionals had never seen, and 59% had never managed such an adrenal crisis. Survey participants expressed a preference for QR code-linked information, and as many as 96% thought that ADIS would be helpful in an acute setting. The study was published on April 9, 2018, in BMJ Innovations.

“Rare medical conditions are prone to poor management in non-specialist units as, by definition, their presentation is uncommon. Some healthcare professionals do not feel they have the appropriate knowledge or confidence to manage these cases, and they may need more support from information systems such as ADIS,” said lead author Jolanta Weaver, PhD, of Newcastle University. “Our ADIS uses a web app run-

New MRI Technologies Advance Image-Guided Radiotherapy ew magnetic resonance imaging (MRI) pulse sequences and imaging enhancements further improve the precision by which radiotherapy (RT) is delivered to treat cancer.

Designed for the ViewRay (Oakwood Village, OH, USA; www.viewray.com) MRIdian SmartVISION system and the MRIdian Linac RT system, the new T1w and T2w pulse sequences can deliver diagnostic-quality MRI during RT treatments by providing refined highdefinition visualization and enhancing diagnostic contrast between cancerous and healthy tissues. Newly introduced diffusion weighted imaging (DWI) can also be used to distinguish between tumor and normal tissues, as well as to potentially assess and predict tumor response to RT. Other enhancements to the SmartVISION system include a doubling of MRI speed (from four frames to eight frames per second), and twice the image resolution and signal-to-noise ratio (SNR), helping to providing brighter, more detailed anatomical images. The system also continuously detects the shape and location of tumors and organs-at-risk (OAR) in real-time, automatically turning RT beams on and off when positional changes occur.

The MRIdian Linac system integrates real-time SmartVISION data and RT delivery via a rotating gantry assembly that a houses a compact inline S-band 6 MV standing wave linear accelerator (linac), with sidecoupled cavities and double focused multi-leaf collimator technology; magnetic and radiofrequency (RF) shielding technology to isolate linac and MRI systems from each other; and a 0.35 T split magnet for unrestricted beam path, volumetric, and multi-planar soft tissue imaging.

The system also includes a patient couch with three degrees of freedom, two in-room couch control panels, and a laser positioning system to facilitate initial patient setup.

A control console, located just outside the treatment room, is paired to an operator console for MRI acquisition, patient positioning, dose prediction, re-optimization, and real-time tumor tracking. An additional planning station helps define structures and constraints for planning and re-optimizing treatments, with support for plan reviews via a database server that contains patient and machine data, as well as software for creating treatment plans and managing the treatment delivery process.

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ning on a smart device, linked to a QR code. It is accessible at all times and shareable with healthcare professionals, patients, their carers, or when required in an emergency by bystanders.”

Addison’s disease is a rare chronic disorder of the adrenal glands resulting in inadequate production of cortisol, which is essential for blood pressure regulation, maintaining glucose levels, and the body’s response to stress. It is treated by daily tablets of prednisolone, a synthetic analogue of cortisol, and fludrocortisone, a synthetic analogue of aldosterone. But concurrent illness, surgery, missed, stopped, or malabsorbed medication can cause an adrenal crisis, a medical emergency that can be fatal if left untreated. Treatment involves intramuscular or intravenous hydrocortisone and further resuscitation with a saline infusion and hydrocortisone.

Image: A new study claims quick response coded bracelets protect Addison's disease patients (Photo courtesy of Newcastle University).

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CAPNOGRAPHY ADAPTER

EMERGENCY VENTILATOR

Hans Rudolph

Mercury Medical

Spencer Italia

The mask is made from Thermo Plastic Elastomer (TPE) that is extremely soft and ensures a comfortable fit and seal. Masks feature low dead space, four optional swivels, and they can be used from crash sites to acute/sub-acute hospital care.

The CarboTrack is designed primarily to adapt to oropharyngeal airways and facemasks, when administering deep sedation anesthesia. It enhances end-tidal CO2 monitoring and provides monitoring using equipment clinicians already have.

The Spencer 190 NXT offers special protections against accidental activation of the AIR MIX selection lever. It operates with a constant I/E ratio and is equipped with alarms for ventilation monitoring and device management.

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AF Patients with Carotid Artery Disease Face Increased Dementia Risk new study suggests that patients with atrial fibrillation (AF) diagnosed with carotid artery disease (CAD) face higher risks for developing dementia. Researchers at the University of Utah (Salt Lake City, USA; www.utah.edu) and Intermountain Medical Center (IMC; Salt Lake City, UT, USA; https://intermountainhealthcare. org) conducted a study that examined 6,786 patients (average age 71.6 years, 55.6% male, 21% with AF) with CAD and without prior history of dementia to determine if the presence of AF is associated with an increased risk of dementia and stroke or transient ischemic attack (TIA).

Subsequent analysis was based upon treatment (stent or endarterectomy), with outcomes including dementia and stroke or TIA. The results revealed that AF increased the risk of dementia, stroke/TIA, and the combination of both, but the associations were attenuated after adjustment by risk factors, comorbidities, and medication use. In patients that received a carotid stent (5,685 patients) dementia rates were 9.4% in the non-AF group versus 9.9% in the AF group. In the group that received an endarterectomy, dementia rates were 8.4% in the non-AF group and 13% in the AF group. The study was presented at the Heart Rhythm Society 39th annual scientific sessions, held during May 2018 in Boston (MA, USA).

“Atrial fibrillation and carotid artery disease are treatable. Neither disease should be accepted passively, and treatment is especially impor-

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tant, given the benefit of helping to prevent or postpone dementia,” said lead author Victoria Jacobs, PhD, of IMC. “Physicians should be discussing the treatment options with patients who are at risk to help educate them about what they can do to live the healthiest life possible.

Patients should be engaged in their own healthcare, knowledgeable about their risks, and active in maintaining healthy lifestyles.”

Prior research has shown that the abnormal heart rhythms of AF produce inconsistent blood flow to the brain, which contributes to the onset of dementia or a decrease in cognitive function. Risk factors are similar for AF and CAD and include age, weight, hypertension, high cholesterol, and diabetes. Smoking can also increase risk.

Image: A new study shows atrial fibrillation in people with CAD can elevate dementia risk (Photo courtesy of Shutterstock).

Enhanced Stent Retriever Treats Ischemic Stroke next-generation stent retriever captures and removes lifethreatening blood clots from the brain following an ischemic stroke. The Cerenovus (Irvine, CA, USA; www.cerenovus. com) EmboTrap II revascularization device is intended to restore blood flow in the neurovasculature by removing thrombii in patients experiencing ischemic stroke within eight hours of symptom onset. The 0.021”, microcatheter compatible clot retriever is designed to trap blood clots with minimum compression, rapidly deliver thrombolysis in cerebral infarction (TICI) 2b-3 reperfusion therapy, and retain the clots during removal to protect the patient from distal embolisms.

The EmboTrap II, which is available in both 5×33 and 5×21 sizes, features an inner channel that allows bypass while open, and five chambers to improve the clot-device interaction. The device also has a distal section with an extensive mesh designed to keep the clot in place, so that it does not fragment. The analysis of revascularisation in ischemic

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stroke with EmboTrap (ARISE II) study showed a final procedural reperfusion rate of 92.5% among acute ischemic stroke patients with large vessel occlusion within three passes of the EmboTrap II. “Embotrap II is the product of deep collaboration between engineers and clinicians to better understand the science of blood clot, what causes them to form and how a mechanical thrombectomy device can interact with them to help improve outcomes,” said Daniella Cramp, worldwide president of Cerenovus. “Cerenovus is committed to advancing treatment with evidence-based solutions so that fewer and fewer people are affected by the ravages of stroke.”

Stent retrievers are deployed in an occluded vessel and are temporarily expanded into the body of a thrombus in order to recanalize the vessel, allowing for reperfusion of ischemic sites and causing the thrombus to be partially entangled within the stent. Thrombectomy is then performed by retracting the stent.

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Mobile Stroke Unit Delivers Care Thirty Minutes Sooner

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specialized ambulance equipped with a 16-slice computed tomography (CT) scanner can provide life-saving tissue plasminogen activator (tPA) 30 minutes faster than traditional ambu-

lances.

The Northwestern Medicine (NM; Winfield, IL, USA; www.nm.org) Mobile Stroke Unit (MSU) is a 14 ton ambulance fitted with a specialized CT scanner that takes detailed pictures of the brain, and a direct telemedicine connection to NM neurologists positioned in Central DuPage Hospital (Winfield, IL, USA). If the neurologist determines that the patient is experiencing an ischemic stroke, he can advise the MSU team to administer tPA while still en route to the hospital. The goal is to diagnose and treat stroke within the “Golden Hour”, the first 60 minutes following onset of symptoms.

In addition to the neurologist, the dedicated MSU Stroke Care Team is comprised of a critical care nurse, a CT technician, an emergency medical technician (EMT) driver, and a critical care paramedic. The early intervention can lead to better outcomes, as stroke patients are typically not administered tPA until their arrival at the hospital. A recent data analysis of the MSU’s first year of operation found that on average, tPA was delivered to stroke patients 52 minutes after dispatch, compared to an average of 82 minutes for patients transported to hospital before receiving treatment.

“Treatment can be initiated within minutes of responding to a call.

This is crucial because when it comes to stroke, time is a factor in treatment. By treating stroke patients faster, we are greatly improving the odds patients will suffer minimal to no long term deficits,” said Harish Shownkeen, MD, medical director of the Stroke and Neurointerventional Surgery Programs at NM Central DuPage Hospital. “For every minute you delay in getting treated for a stroke, you lose 1.9 million neurons;

every minute the brain goes without oxygen, there is a 3.1 week acceleration of the natural aging process.”

Natural tPA is a serine protease found on endothelial cells. As an enzyme, it catalyzes the conversion of plasminogen to plasmin, the major enzyme responsible for clot breakdown. When manufactured using recombinant biotechnology techniques, it is referred to as recombinant tissue plasminogen activator (rtPA), which is used to treat embolic or thrombotic stroke. It is contraindicated in hemorrhagic stroke and head trauma.

Image: The specialized MSU is equipped with a 16-slice CT scanner (Photo courtesy of Northwestern Medicine).

Physician-Provided Life Support May Improve Heart Attack Outcomes new study suggests that patients with traumatic out-of-hospital cardiac arrest (OHCA) who receive pre-hospital advanced life support (ALS) from a physician have increased survival rates. Researchers at the University of the Ryukyus (Okinawa, Japan; www.u-ryukyu.ac.jp), Harvard Medical School (HMS; Boston, MA, USA; https://hms.harvard.edu), the University of Tokyo (Japan; www.u-tokyo.ac.jp), and other institutions conducted a Japanese nation-wide study involving 4,382 patients who suffered out-of-hospital cardiac arrest (OHCA) and major trauma following a traffic accident. The researchers compared outcomes in patients provided prehospital ALS by a physician to patients provided ALS by emergency medical service (EMS) personnel, and those who received only basic life support (BLS). The primary outcome was one-month survival.

The results showed that 2.2% of all patients survived one month after OHCA. Analysis revealed that survivors included 3.1% of those who received ALS by physician, 1.6% of those that received ALS by EMS personnel, and 2.3% of those who received BLS. After adjustment for potential confounders, ALS by a physician was associated with significantly higher odds of one-month survival; there was no significant difference between ALS by EMS personnel and BLS. The researchers considered several reasons that could explain the advantages of ALS by physicians, compared with that provided by EMS personnel.

First, physicians can perform ALS based on their own judgment, but EMS personnel need permission or instruction from a medical director in order to perform ALS, which may prevent timely treatments. Second, differences in the proficiency in ALS procedures between physician and EMS personnel may exist, for example in endotracheal intubation. Lower ability to perform advanced interventions could lead to longer interruption of cardiopulmonary resuscitation (CPR). Third, there are other advanced interventions that EMS personnel are not allowed to perform, such as surgical airway, chest drain, pericardial drain, or thoracotomy.

The study was published on April 25, 2018, in JAMA Surgery.

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PATIENT MONITOR / ECG

SEDATION SYSTEM

Stephan

Teknova Medical Systems

Medcaptain

The EVE NEO comes with a docking station featuring power supply, cylinder bracket, PDMS and call button. It offers invasive/NIV, pressure/volume-controlled ventilation forms, while basic modes can be combined with additional options.

The TE120 features a 12-inch color TFT screen for multi-angle observation along with a handwriting pen for easier operation and quicker information input. It offers multi-language and multi-size recording paper selection and paperless reports.

The MIRUS system consists of the MIRUSController (MC) and the MIRUS-Exchanger (ME). Both are connected via an interfaceline, helping the system achieve auto-control sedation with electronic vaporizer and target sedation level.

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Innovative Guard Helps Prevent Needlestick Injuries ntuitive ergonomic design and patented safety features increase staff security following retraction of arteriovenous fistula (AVF) dialysis needles.

The NxStage Medical (Lawrence, MA, USA; www.nxstage.com) MasterGuard Plus needles are designed with a patented FingerShield anchor that provides a barrier between the pressure-holding fingers and the sharp tip of the needle. During needle retraction, flexible wings with interlocking grips are drawn backwards into the jaw; the small jaw and rigid base of the MasterGuard plus align the needle into the center of the guard.

Once the needle is fully retracted, an audible click is heard, signifying that the needle is locked in a steep rear angle that prevents accessibility.

The MasterGuard plus needles themselves also offer several new features that allow for easier insertion, including ultra-thin walls; precisely ground bevels and a siliconized tip for smooth cannulation; a short hub designed to minimize leverage; and a rotatable bevel indicator that reduces the risk of potential tissue damage associated with unwarranted rotation of fixed wing needles.

“Early customer feedback has been very positive, validating many of the benefits we expected,” said Joseph Turk, president of NxStage Medical. “We are very excited to bring these enhanced features to dialysis staff and patients, while maintaining the ease of use that they have come to expect from Medisystems products.”

An AVF is the most recommended access for kidney disease patients undergoing dialysis, created by connecting a patient’s vein and artery to

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form a long-lasting site through which blood can be removed and returned. After the creation of an AVF, blood flow increases immediately, reaching 700–1,000 mL/min within one month. Both the artery and the vein dilate and elongate in response to the greater blood flow and shear stress, but the vein dilates more; when large enough to allow cannulation, the AVF is defined as mature.

Image: The MasterGuard Plus with FingerShield anchor (Photo courtesy of NxStage Medical).

Radio Emissions Helmet Rapidly Detects Stroke cont’d from cover

spectroscopy (VIPS), measures the ratio of bioimpedance between the brain’s right and left hemispheres, and especially changes in that ratio.

During severe stroke, a fluid asymmetry between hemispheres is formed; the greater the asymmetry, the more severe the stroke.

The small changes in intracranial fluids are reflected in the electrical properties of tissue, which can be calculated using several proprietary machine learning algorithms that can differentiate between the bioimpedance profiles of distinct brain pathologies, such as stroke, trauma, swelling, and others. In a study of 248 subjects across three cohorts, the Visor device differentiated between severe stroke and minor strokes with a sensitivity of 93%. The study was published on March 6, 2018, in the Journal of Neurointerventional Surgery.

“The thing that I like about this technology and this device is that it’s really easy to use. Instead of going through a checklist of stroke

diagnosis and trying to analyze symptoms in the field, first responders can pop the visor on a patient’s head and secure a reading after 10 to 15 seconds,” said study co-author Raymond Turner, MD, a neurosurgeon at the Medical University of South Carolina (MUSC; Charleston, USA). “This is really taking the guessing game out of it.

This is going to completely change how we triage stroke patients in the field.”

“We understand the challenges facing medical professionals who need to quickly assess patients with neurologic symptoms. The Cerebrotech Visor is designed to be portable, fast and accurate,” said Mitch Levinson, CEO of Cerebrotech Medical. “Utilizing the vast amount of data captured by our proprietary Cerebrotech Visor, our mission is to develop unique algorithms that can help physicians to better detect and diagnose a wide range of neurological conditions, improving outcomes for patients while reducing overall healthcare costs.”

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Critical Care

Excessive Oxygen Increases Mortality in Severely Ill Patients new review suggests that supplemental oxygen, when given too liberally to acutely ill adult patients, increases the risk of death without providing added benefit.

Researchers at McMaster University (Hamilton, ON, Canada; www.mcmaster.ca) and St. Joseph’s Healthcare (St. Joe’s; Hamilton, Canada; www.stjoes.ca) searched electronic academic databases from inception through October 2017 for randomized controlled trials that compared liberal and conservative oxygen therapy protocols and death rates, as well as their impact on disability, infection, and hospital length of stay.

A total of 25 studies encompassing 16,037 adult patients with sepsis, stoke, trauma, emergency surgery, heart attack, or cardiac arrest were identified.

The results revealed that compared to a conservative oxygen strategy, a liberal oxygen strategy – defined as a median baseline peripheral oxygen saturation (SpO2) of 96% – increased mortality by an average of 21%, signifying an additional death for every 71 patients treated with a liberal oxygen strategy. Further analyses suggested that the more supplemental oxygen patients were given, the higher their risk was for death, but the incidence of other conditions, such as infections or length of hospital stay, were similar between the two groups. The study was published on April 28, 2018, in The Lancet.

“Patients are frequently given supplemental oxygen and at excessive levels. Our results provide much-needed clarification by showing, with high-quality evidence, that administering too much supplemental oxygen increases mortality among a broad range of acute illnesses,” said lead author Derek Chu, MD, of McMaster University. “A simple

Image: New research asserts that too much oxygen is detrimental to acutely ill patients (Photo courtesy of iStock).

Hemoglobin A1c Unrelated to Diabetic Foot Ulcer Healing

ED May Indicate Subclinical Cardiovascular Disease

new study concludes that there is no clinically meaningful association between hemoglobin A1c (HbA1c) levels and wound healing in patients with diabetic foot ulcers (DFUs).

Researchers at Johns Hopkins University (JHU; Baltimore, MD, USA; www.jhu.edu) conducted a retrospective study involving 270 patients with a total of 584 DFUs treated at JHU during a 4.7-year period. The analysis assessed incidence of wound healing at any follow-up time, in relation to categories of baseline HbA1c and the incidence of long-term (over 90 days) wound healing. Tertiles of nadir HbA1c change and mean HbA1c change from baseline were measured, adjusting for potential confounders.

The results revealed that baseline HbA1c was not associated with wound healing. While a nadir change of 0.09 to 2.4 (third tertile) was positively associated with long-term wound healing in study participants with baseline HbA1c lower than 7.5%, no such association was seen with mean HbA1c change. Neither nadir HbA1c change nor mean HbA1c change were associated with long-term wound healing in participants with a baseline HbA1c higher than 7.5%. The study was published on April 16, 2018, in Diabetes Care.

“There does not appear to be a clinically meaningful association between baseline or prospective A1c and wound healing in patients with DFUs,” concluded lead author Betiel Fesseha, MD, of the JHU division of endocrinology, diabetes and metabolism, and colleagues. “The paradoxical finding of accelerated wound healing and increase in hemoglobin A1c in participants with better baseline glycemic control requires confirmation in further studies.”

HbA1c refers to glycated hemoglobin, and is used to identify the average plasma glucose concentration over prolonged periods of time. For people without diabetes, the normal HbA1c range is 4-5.6%. HbA1c levels between 5.7% and 6.4% indicate increased risk of diabetes, and levels of 6.5% or higher indicate diabetes. The goal for diabetics is HbA1c levels lower than 7%, which should be retested every three months to determine target level control.

new study suggests a novel risk factor for cardiovascular disease (CVD), erectile dysfunction (ED), which may share shared mechanisms. Researchers at Florida International University (FIU; Miami, USA; www.fiu.edu), Baptist Health South Florida (Miami, FL, USA; www.baptisthealth.net), and other institutions, searched multiple databases for studies examining the association of ED and known measures of subclinical CVD, such as endothelial dysfunction, indicated by flow-mediated dilation (FMD); carotid intima media thickness (cIMT); coronary artery calcification (CAC); and other measures of vascular function, such as the ankle–brachial index, toe–brachial index, and pulse wave velocity.

Following a systematic review and meta-analysis of 28 studies, the researchers found ED was associated with a 2.64% reduction in brachial FMD (as measured by ultrasound), and a 0.09 mm higher cIMT (an early manifestation of atherosclerosis), than those without ED. In subgroup analyses, mean age, study quality, and ED assessment questionnaire did not significantly affect the relationship between ED and cIMT, or between ED and FMD. The association between ED and CAC was also inconclusive. The study was published on December 15, 2017, in Vascular Medicine.

“The presence of erectile dysfunction portends a higher risk of future cardiovascular events, particularly in intermediate risk men, and may serve as an opportunity for intensification of cardiovascular risk prevention strategies,” wrote Naomi Hamburg, MD, and Matt Kluge, MD, of Boston University (MA, USA), in an accompanying editorial. “The findings add to the growing evidence supporting additional trials to determine the clinical impact of erectile dysfunction screening.”

ED, also known as impotence, is characterized by the inability to develop or maintain an erection during sexual activity. The most important organic causes of ED are CVD and diabetes, neurological problems such as trauma from prostatectomy surgery, hormonal insufficiencies (such as hypogonadism) and drug side effects.

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HospiMedica International August-September/2018

change to current practice, being more moderate and cautious with how much oxygen is administered to acutely unwell patients, could save lives.”

The use of oxygen in medicine became common around 1917, and is believed to be the most common treatment given in hospitals in the developed world. It can be delivered by a nasal cannula, facemask, or inside a hyperbaric chamber. In most conditions a SpO2 saturation of 94–98% is recommended, while those at risk of carbon dioxide (Co2) retention saturations of 88–92% are preferred, and in those with carbon monoxide (CO) toxicity or cardiac arrest they should be as high as possible. Air is typically 21% oxygen by volume, while oxygen therapy increases this by some amount up to 100%.

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PRODUCT NEWS SUCTION UNIT

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DEFIBRILLATOR

COLD THERAPY SYSTEM

Weinmann

Zoll Medical

Cincinnati Sub-Zero

The ACCUVAC Pro is designed for suctioning a patient's mouth / throat or endotracheal / bronchial areas and offers four pre-defined suction levels. Its simple operation enables users to provide effective treatment to patients.

The M Series family is the smallest and lightest in its class, enabling easy handling and optimal viewing. The models offer straightforward controls and intuitive menus to minimize errors, along with event documentation and easy data transfer.

The Electri-Cool II does not require ice to operate, allowing the user to add distilled water and select the desired temperature range.

The compact unit can be attached to the patient’s bed or may be mounted on a stand for easy mobility.

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Mobile Robot Helps Rescue Units in Critical Conditions n innovative robotic assistant collects data in emergency situations with extremely limited visibility, effectively improving the safety of rescue operations. The SmokeBot, developed at Örebro University (ORU; Sweden; www.oru.se), the Fire Department of Dortmund (FDDO; Germany; www.fp7-emergent.eu/team/fddo), the Fraunhofer Institute for High Frequency Physics and Radar Techniques (FHR; Wachtberg, Germany; www.fhr.fraunhofer.de), and other institutions, is a mobile robotic rescue unit equipped with a range of environmental sensors to help responders inspect disaster sites with heavily billowing smoke and similar visibility-diminishing factors.

The robot is remote-controlled by rescue personnel, but can also navigate itself if necessary. It can plot situation maps of smoke or dust filled areas, providing valuable data in areas where humans cannot see.

SmokeBot is also equipped with gas sensors, which not only detect different gases, but also provide data on the amount and concentration of such gases. According to the researchers, another potential area where the robot could be of benefit is in agriculture, as it can see through dust.

The gas sensors can be used for measuring different kinds of emissions.

“This robot is completely unique; it is equipped with gas sensors, radar, a laser scanner, and thermal camera. At present, there is no robot with this combination of features,” said SmokeBot project leader Professor Achim Lilienthal, PhD, of ORU. “It compiles information from different sensors and can assess, depending on temperature and occurrence of a particular gas, if there is a risk of a gas explosion. Should it lose contact with rescue

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personnel, which can happen, the robot remembers where it last had an Internet connection and can navigate back to that location.”

“Restricted visibility is particularly critical for our rescue units and affects our perception capacity. In such ‘blind situations’, SmokeBot can function as our eyes and lead us in search and rescue operations,” said Sylvia Pratzler-Wanczura, PhD, of the FDDO institute of fire service and rescue technology. “It is a considerable advantage in situations where it is too risky to send in rescue personnel or when we need to search through large areas as is the case with floods and forest fires.”

Image: Professor Achim Lilienthal and the SmokeBot (Photo courtesy of ORU).

Colonoscopy and OGD Infection Risk Higher Than Expected olonoscopies and osophagogastroduodenoscopies (OGDs) performed at outpatient specialty centers result in far more infections than previously believed, according to a new study.

Researchers at Johns Hopkins University (JHU; Baltimore, MD, USA; www.jhu.edu) conducted a study to estimate the rates of infections following colonoscopy and OGD procedures performed during 2014 in ambulatory surgery centers (ASCs) in the states of California, Florida, Georgia, Nebraska, New York, and Vermont. The researchers identified infection-related emergency department (ED) visits and in-patient admissions within 7 and 30 days of the screening procedure, noted infection sites and organisms, and analyzed predictors of infections. Screening mammography, prostate cancer screening, bronchoscopy, and cystoscopy procedures were comparators.

The results revealed post-endoscopic infection rates of 1.1 per 1,000 for screening colonoscopy, 1.6 for non-screening colonoscopy, and 3 for

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OGD procedures; all higher than screening mammography (0.6), but lower than bronchoscopy (15.6) and cystoscopy (4.4). The rates of 7-day post-endoscopic infections varied widely by ASC, ranging from 0-115 per 1,000 procedures for screening colonoscopy, 0-132 for non-screening colonoscopy and 0-62 for OGD. Predictors included recent history of hospitalization or endoscopic procedure; low procedure volume or nonfreestanding ASC; younger or older age; black or Native American race, and male sex. The study was published in the May 2018 issue of Gut. More than 15 million colonoscopies and seven million EGDs are performed annually in the United States alone; both procedures are performed with reusable endoscopes. Inadequate reprocessing between patients can result in retention of blood, tissue, and other biological debris, which can allow microbes to survive the disinfection or sterilization process. Inadequate reprocessing can also result in other adverse patient outcomes, such as tissue irritation from residual chemical disinfectants.

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Critical Care

Novel Sedative Quickly Tames Violent EMS Patients new sedative can help reduce the escalating violence against paramedics and emergency medical services (EMS), mostly by patients fueled by alcohol and drugs.

Researchers at the University of Queensland (Brisbane, Australia; www.uq.edu.au), the Queensland Ambulance Service (QAS; Brisbane, Australia; www.ambulance.qld.gov.au), and other institutions conducted a prospective study of the sedative droperidol for the treatment of prehospital acute behavioral disturbance, compared to the internationally accepted standard, midazolam. In all, 141 patients were administered midazolam and 149 patients were administered droperidol during the study period. The primary outcome was the proportion of adverse effects, with secondary outcomes including time to sedation, requirement for additional sedation, staff and patient injuries, and prehospital time.

The results revealed fewer patient adverse events with droperidol (7%) than with midazolam (23%). The median time to sedation was

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Neuromodulation Technology Effective for Diabetic Neuropathy Treatment novel device treats peripheral diabetic neuropathy (PDN) by subjecting damaged nerves to pulsed radiofrequency (PRF) electromagnetic waves.

The therapeutic effect of the Xavant Technology (Pretoria, South Africa; www.stimpodnms460.com) Stimpod NMS460 is based on cellular metabolic activity induced by the electromagnetic energy beamed to a neuropathic nerve, which seems to change its characteristics, and in many cases causing the nerve to recover its normal function. There are typically four phases associated with such a PRF procedure: a stunning phase that provides immediate relief; a phase of post-procedural discomfort; a phase of beneficial clinical effect; and lastly, a possible phase that involves pain recurrence or paralysis.

To locate the affected sensory nerve, a monophasic square wave is delivered transcutaneously by a pen-shaped mapping probe. Once near the adjacent motor nerve, the stimulation causes fasciculation of the relevant muscle; the closer the probe, the stronger the fasciculation. When pure sensory nerves need to be located, patient feedback is used. The closer the mapping pen gets to the sensory nerve, the stronger the sensation will be. The Stimpod NMS460 then delivers the PRF waveform, which creates discomfort in a healthy sensory nerve; however, the sensation to a neuropathic nerve is usually very comfortable.

Recovery of sensory nerves can be measured by the comfort experienced at different levels of stimulus intensity. For example, treating a neuropathic nerve at 30 mA at the first treatment may be comforting.

But as the nerve recovers, current intensity would need to be reduced in order to maintain a comfort level for the patient in subsequent treatments; this provides a quantifiable measure of progress. The same goes for motor nerves, but rather than the sensation, a progress judgment can be made on the intensity level of the fasciculation.

“We are thrilled to see that our technology continues to prove that it can impact positively on the population of diabetic patients to whom there are otherwise limited options of treatment, often plagued with exorbitant cost and severe side effects,” said Corlius Birkill, CEO of Xavant Technology, speaking at the 11th Diabetologists Conference, held during May 2018 in New York (NY, USA). “We attend conferences like these to spread awareness of a disruptive treatment option that truly embodies the vision of Xavant Technology, which is, to contribute to a healthy, vibrant and compassionate world.”

Diabetic neuropathies are thought to result from a diabetic microvascular injury involving small blood vessels that supply the nerves, in addition to macrovascular conditions that can accumulate in diabetic neuropathy. Conditions associated with diabetic neuropathy include third, fourth, or sixth cranial nerve palsy; mononeuropathy; mononeuropathy multiplex; diabetic amyotrophy; a painful polyneuropathy; autonomic neuropathy; and thoracoabdominal neuropathy.

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22 minutes for droperidol compared to 30 minutes for midazolam, and additional prehospital sedation was required in 4% of the droperidol patients, compared to 14% of the midazolam patients. In addition, 7% of droperidol and 42% of midazolam patients required further sedation in the emergency department (ED). There were no differences in patient or staff injuries, or prehospital time. The study was published in the March 2018 issue of The Journal of Prehospital Emergency Care.

“Our paramedics and emergency department staff welcome the impact droperidol is having and there are some amazing stories of how it quickly it works to calm really aggressive and violent patients,” said Lachlan Parker, ASM, executive manager of clinical policy development at the QAS. “It’s also simple to administer, there are much fewer sideeffects, it rarely over-sedates and patients wake up much nicer. We’re so happy to finally have a safe drug to use.”

“The days of repeated doses of midazolam being given by paramedics are over, it just takes too long to sedate patients using this drug, and it is more dangerous. We’re now pushing for paramedics and clinicians to administer the droperidol intramuscularly, and to stop mixing different sedatives,” said lead author toxicologist Colin Page, PhD, of the University of Queensland. “Based on our extensive research, the standard protocol for violent patients should be 10 mg droperidol (65-75% effective) followed by second dose of 10 mg (which is 95% effective), and then ketamine.”

Sedation is the reduction of irritability or agitation by administration of sedative drugs, and is typically used in procedures such as endoscopy, rapid sequence intubation (RSI), minor surgery, and in dentistry for high-anxiety patients. Sedation is also used extensively in the intensive care unit (ICU) so that patients who are being ventilated tolerate having an endotracheal tube in their trachea. Drugs that can be used for sedation include propofol, etomidate, ketamine, fentanyl, midazolam, and droperidol.

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PRODUCT NEWS FLAT PANEL DETECTOR

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ULTRASOUND LOTION

MR INJECTOR

Konica Minolta Medical Imaging

Parker Laboratories

Antmed

The AeroDR 2 1417S uses an ideal combination of components, grip materials and cover design. Featuring the AeroSync function for added convenience, it is the ideal wireless cassette-type DR and is easy to carry and hold.

The POLYSONIC lotion offers superior coupling efficiency and has a rich, moisturizing formula. Acoustically correct for the broad range of frequencies used, it is recommended for all ultrasound procedures when a lotion is preferred.

The MR Injector allows independent filling and air expelling along with independent injections of Side A and Side B respectively. It features a color touch screen with a simple and intuitive user interface that highlights key information.

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CT System Digitally Reconstructs Breast Specimens computerized tomography (CT) specimen imaging system provides detailed margin assessment by reconstructing a navigable three-dimensional (3D) render in real time. The Faxitron (Tucson, AZ, USA; www.faxitron.com) VisionCT system is a fully automated 3D specimen cabinet system equipped with a motorized, 360-degree rotating platform that can capture up to six highresolution images per second. The system reconstructs breast specimens in up to 1,024 slices at a standard slice thickness of 100 micron, allowing for complete and detailed radiographic assessment of margin status, in addition to immediate traditional orthogonal images. Users can review orthogonal images as the specimen is being scanned and reconstructed in real time, with automated magnification allowing for optimal resolution of any specimen size up to 11 cm in diameter.

The system is turn-key and fully automated, with no additional x-ray shielding, specialized knowledge, or manual specimen repositioning required; the specimen is simply positioned in disposable holder, placed in a container in the chamber, and scanned. Fast, versatile imaging allows for presentation of both

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2D and orthogonal images in less than 30 seconds, with full 3D reconstruction of the whole specimen in less than four minutes, including automatic metal artifact correction to minimize interference. DICOM images are automatically stored to PACS and saved to local or network drive, with images instantaneously displayed on the 24” high-resolution monitor.

“As imaging innovations in breast screening continue to drive earlier detection of abnormalities in breast tissue, there is a parallel need for ongoing improvements in methods for assessing and confirming specimen margin status during surgery,” said Donogh O’Driscoll, CFO and COO of Faxitron. “VisionCT gives providers a clearer, more detailed view of breast specimen margin status than ever before. We’ve spent decades pioneering new technologies that contribute to a higher standard of care for patients and are proud that legacy continues as we introduce VisionCT to the market.”

Planar specimen radiography is the current standard of care in intraoperative margin assessment. This requires the surgeon and radiologist to attempt to visualize microcalcifications or lesion in 3D space by viewing images

individually, but in relation to one another.

The challenge is that both collecting and visualizing the images are manual processes, and therefore may not always be standard practice.

Image: The VisionCT system scans 360-degree images of excised lesions (Photo courtesy of Faxitron).

PET Imaging Technique Pinpoints Colitis Inflammation new positron emission tomography (PET) method can detect inflammation sites in people with inflammatory bowel disease (IBD), according to a new study.

Researchers at the University of California, Los Angeles (UCLA; USA; www.ucla.edu) and Regeneron Pharmaceuticals (Tarrytown, NY, USA; www.regeneron.com) conducted a mouse model study of colitis that used PET imaging with antibody fragment probes (immunoPET) based on GK1.5 cys-diabody (cDb) that target CD4+ T cells, a subset of immune cells characteristic of IBD. A zirconium-89 (89Zr)-labeled anti-CD4 engineered cDb probe was used for noninvasive imaging of the distribution of CD4+ T cells in mice with induced colitis.

The results revealed an increased number of CD4+ T cells in the colons of colitic mice, as confirmed by immunohistochemistry. Increased uptake of 89Zr-malDFO-GK1.5 cDb was detected in the distal colon, ce-

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ca, and mesenteric lymph nodes (MLNs) in in-vivo PET scans. Ex-vivo scans and biodistribution also confirmed the higher uptake in dextran sulfate sodium (DSS)-treated colons, ceca, and MLN. The researchers suggest that CD4 immunoPET has the potential to guide development of antibody-based imaging in humans with IBD. The study was published in the June 2018 issue of The Journal of Nuclear Medicine.

CD4+ T helper cells are white blood cells that are an essential part of the human immune system. They are called helper cells because one of their main roles is to send signals to other types of immune cells, including CD8 killer cells, which then destroy the infectious particle. If CD4 cells become depleted, for example in untreated HIV infection, or following immune suppression prior to a transplant, the body is left vulnerable to a wide range of infections that it would otherwise have been able to fight.

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Innovative PET/CT System Improves Patient Comfort new positron emission tomography/computed tomography (PET/CT) system reduces scan time by a factor of 3.9, reducing patient radiation exposure and tracer cost. The Siemens Healthineers (Erlangen, Germany; www.healthcare.siemens.com) Biograph Vision PET/CT system features Optiso ultra dynamic range (UDR) detectors, which uses silicon photomultipliers (SiPMs) rather than the standard photomultiplier tubes. Consequently, the detector’s lutetium oxyorthosilicate (LSO) crystal elements can be reduced from 4x4 mm to 3.2x3.2 mm, delivering higher spatial resolution. By utilizing the extremely small LSO crystals and covering 100% of the scintillator array area with SiPMs, the Biograph Vision can deliver extremely fast time-offlight (ToF), with a temporal resolution of just 249 picoseconds, as well as a high effective sensitivity of 84 cps/kBq. Features include QualityGuard, designed to self-calibrate the detector without an external radioactive source by tapping natural background radiation from the LSO detectors; FlowMotion Multiparametric Suite, a fully automated solution that delivers whole-body PET images of tracer uptake rate, metabolic glucose rate, and distribution volume, in addition to standard uptake volume (SUV) images; OncoFreeze, designed to provide images that are virtually free of respiratory motion; and CardioFreeze, which is designed to correct for respiratory and cardiac motion.

“The Biograph Vision represents a major leap in performance beyond any PET/CT system previously manufactured,” said Jim Williams, PhD, head of the Siemens Healthineers Molecular Imaging. “With this system, we extend the boundaries of PET imaging and help our customers explore a new frontier in precision medicine.”

PET is a nuclear medicine imaging technique that produces a three dimensional (3D) image of functional processes in the body. The system detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide tracer. Tracer concentrations within the body are then constructed in 3D by computer analysis. In modern PET-CT scanners, 3D imaging is often accomplished with the aid of a CT X-ray scan performed on the patient during the same session, in the same machine.

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Image: The Biograph Vision PET/CT (Photo courtesy of Siemens Healthineers).

Ultra-High Resolution CT Doubles Image Sharpness he world’s first ultra-high resolution computerized tomography system (UHR CT) can resolve anatomy as small as 150 microns.

The Canon Medical Systems ( tawara, Japan; https:// global.medical.canon) Aquilion Precision UHR CT features a resolution never before seen in CT imaging, with a small focal spot tube at 0.4 x 0.5 mm, and a routine 1024 x 1024 reconstruction matrix. The ultrahigh resolution capabilities are combined with 1,792 efficient detector channels in 160 rows that are only 0.25 mm thick, major improvements in scintillator quantum efficiency, new digital acquisition system (DAS) and detector circuitry components, and improved tube, gantry, and reconstruction technologies.

New UHR CT applications include novel data sets that take advantage of artificial intelligence (AI) and computational learning techniques and image texture analysis algorithms in order to improve staging, treatment, and earlier tumor detection. A model-based iterative reconstruction (MBIR) computational algorithm reduces noise while maintaining resolution. On the patient side, precision technology provides a two-step slide mechanism and an ultra-high rigid couch with a precision reinforced drive mechanism.

“In order to deliver Ultra-High Resolution CT into clinical practice, it required a complete re-engineering of the detector manufacturing process,” said Dominic Smith, senior director of the CT, PET/CT, and MR Business Units. “The Aquilion Precision represents not only a breakthrough in imaging technology, but a breakthrough for health care providers who can potentially use the increased amount of accurate data from this system to further research artificial intelligence and computational learning techniques.”

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CONTRAST INJECTION SYSTEM

CT SYSTEM

Siemens Healthineers

ACIST Medical Systems

Hitachi Aloka Medical

The Acuson Sequoia uses a new high-powered architecture and innovative updates for producing penetration up to 40cm. It enables high-resolution imaging that adapts to the patient’s size and personal characteristics.

The ACIST CVi simplifies contrast injection for all procedures from small injections to large volume injections. Its design helps improve image quality and procedural efficiency and minimize patient contrast dose and radiation exposure to staff.

The SCENARIA View features dose reduction function Intelli IPV that does not require a processing room or added hardware. It reduces exam time by segmenting the procedure flow, and shortens operational procedures to ease workload.

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Advanced Ultrasound System Expands Clinical Capabilities n advanced automated breast ultrasound device provides better interpretation of dense breast tissue than traditional mammography. The Siemens Healthineers (Erlangen, Germany; www.healthcare.siemens.com) ACUSON S2000 ultrasound system, HELX Evolution with Touch Control is a premium ultrasound system that offers advanced technologies and diagnostic tools to provide sharp, clear images that increase diagnostic confidence. Powered by an intuitive, user-centric interface, the system boasts an intuitive 12.1” highresolution touch display with instant response technology, a laser-optical trackball, and a simplified home-base control structure that help to optimize exam workflows and reduce training time.

Workflow innovations include context-sensitive body markers, intuitive pictograms, transducer markers, and supportive protocols. Smartswap annotations with color-coded guidance simplify annotations by suggesting logical replacement text specific to the exam being performed.

System features include HD transducer technology for sharper detail and contrast resolution; full-body coverage; automated breast volume scanning (ABVS) for three dimensional (3D) and hand-held imaging of the breast; tissue strain analytics that provide deeper insights into dense breast tissue; shear wave elastography to evaluate tissue stiffness; indepth anatomy visualization when using contrast enhanced ultrasound

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(CEUS); and visualization of lesions in organs using Cadence contrast harmonic imaging (CHI) and Cadence contrast pulse sequencing (CPS) for vascularity and microbubble visualization.

ABVS uses high-frequency sound waves to produce a 3D volumetric image of the entire breast, which allows radiologists to check the breast from multiple angles. Using traditional ultrasound, exams can take up to 30 minutes and are highly impacted by the operator’s skill level due to the device’s handheld transducer. ABVS solves both of these problems by automatically scanning the breast in as little as seven minutes.

Image: The ACUSON S2000 ultrasound system (Photo courtesy of Siemens Healthineers).

Anchored Beacon Transponder Guides Lung Cancer Radiotherapy novel beacon transponder detects even slight movements of a tumor, helping clinicians deliver lung stereotactic body radiotherapy (SBRT) more precisely.

The Varian Medical Systems (Varian; Palo Alto, CA, USA; www. varian.com) Calypso Anchored Beacon Transponder is designed for implantation in small airways within or near the tumor target. Anchoring is provides via five expandable nitinol legs that provide stable fixation, preventing the transponder from moving. Once in place, the transponder emits continuous, non-ionizing electromagnetic signals that are tracked in real-time and used to keep a SBRT beam on target. The Anchored Beacon transponder is intended for use with the Varian TrueBeam, Edge, and Clinac C-series medical linear accelerators.

The direct internal tracking eliminates the need for external surrogates to track tumor motion in real time, so that high-dose lung SBRT can be delivered with reduced margins between the clinical target volume (CTV) and the planning target volume (PTV). The implantation process itself is straightforward, similar to a lung biopsy, using a preloaded, single use delivery catheter designed for interventional pulmo-

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nologists and general pulmonologists with advanced bronchoscopy training. The Calypso Anchored Beacon Transponder has been approved by the U.S. Food and Drug Administration (FDA).

“The 510(k) clearance of the Anchored Beacon Transponder expands the application of the Calypso system platform,” said Ed Vertatschitsch, vice president of global portfolio solutions at Varian. “Using the Calypso system and Anchored Beacon transponder, clinicians can deliver dose to lung tumors with increased confidence and accuracy.”

SBRT is emerging as an attractive option for treating cancers in the lung, head and neck, prostate, liver and other disease sites, with the objective of increasing local control of the target lesion while limiting damage to nearby critical structures and normal tissue. Requirements include precise localization of the target lesion in the treatment planning process; accounting for tumor motion due to respiration or other changes in the body; highly conformal dose distribution to the target volume, including a steep dose gradient to minimize radiation to surrounding healthy tissue; and image-guidance at the time of dose delivery for verification and adjustment of the target localization.

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Medical Imaging

Wearable MRI Detector Captures Anatomical Motion new study describes how a magnetic resonance imaging (MRI) element woven into a glove-like detector could aid the diagnosis of repetitive strain injuries such as carpal tunnel syndrome.

Researchers at NYU Langone Medical Center (New York, NY, USA; www.med.nyu.edu) and New York University (NYU, USA; www.nyu.edu) have designed a wearable detector array for MRI of the hand that is based on high-impedance coils that can cloak themselves from electrodynamic interactions. The MRI signal is produced by hydrogen protons; since no electric current is created by the MRI signal, the new receiver coils no longer create magnetic fields that interfere with neighboring receivers, thus removing the need for rigid structures. The coils do not suffer from signalto-noise (SNR) degradation mechanisms typically observed with the use of traditional lowimpedance elements.

While MRI can efficiently image muscles, nerves, and even cartilage, which are difficult to study using other non-invasive methods,

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tendons and ligaments, which are made of dense proteins instead of fluid, remain difficult to see independently, because both appear as black bands running alongside bone. But with the new coils stitched into a cotton glove, they could generate images of freely moving muscles, tendons, and ligaments. The new coils revealed how the black bands moved in concert with the bones, which could help to catalogue differences that come with injury. The study was published on May 4, 2018, in Nature Biomedical Engineering.

“We wanted to try our new elements in an application that could never be done with traditional coils, and settled on an attempt to capture images with a glove,” said senior author Martijn Cloos, PhD, of the department of radiology at NYU Langone Health. “We hope that this result ushers in a new era of MRI design, perhaps including flexible sleeve arrays around injured knees, or comfy beanies to study the developing brains of newborns.”

The densely packed resonant structures used for MRI, such as nuclear magnetic reso-

nance phased array detectors, suffer from resonant inductive coupling, which restricts the coil design to fixed geometries, in which receiver coils are painstakingly arranged to cancel out magnetic fields in neighboring coils.

Once the best arrangement is set, the coils can no longer move relative to one another, constraining the ability of MRI to image complex, moving joints. But by using high-impedance detectors, the receiver coils no longer create magnetic fields that interfere with neighboring receivers, thus removing the need for rigid structures.

Image: The wearable MRI glove is designed to image moving joints and aid in diagnosing repetitive strain injuries (Photo courtesy of NYU Langone).

Optoacoustic Imaging Augments Breast Mass Assessment novel breast imaging system fuses optoacoustic (OA) and ultrasound (US) technologies to generate realtime functional and anatomical images of the breast.

The Seno Medical Instruments (San Antonio, TX, USA; https://senomedical.com) Imagio OA/US breast imaging system uses OA to provide a “blood map” around breast masses, while US provides a traditional anatomic image. Unlike current techniques that create images by transmitting and receiving energy in the same form, OA/US imaging transmits photonic energy, but detects acoustic energy; by transmitting multiple bandwidths of laser light, a much broader range of data can be captured, which makes the functional images possible.

The system can thus detect the appearance (or absence) of two of the hallmark indicators of cancer, angiogenesis and deoxygenation, by measuring hemoglobin concentration in the breast tissues. The resulting amalgamation of data helps radiologists confirm or rule out malignancy with more certainty than current diagnostic imaging modalities, and without exposing patients to potentially harmful ionizing X-ray radiation or contrast agents.

A study by researchers at the Northwestern University (NU; Chicago, IL, USA; www.northwestern.edu) and other institutions involving 2,105 women conducted to compare the diagnostic utility of the Imagio OA/US breast imaging system to grayscale US alone, found that OA/US downgraded 40.8% of benign mass reads, with a specificity of 43%, compared to 28.1% for grayscale

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US alone, resulting in a need for fewer subsequent needle biopsies. The study was published in the May 2018 issue of Radiology.

“Needle biopsies are expensive, very stressful to the patient, often require another appointment for the patient, and it can take days to get the results. Patients who are safely downgraded to not needing a biopsy would benefit,” said Stephen Grobmyer, MD, of the Cleveland Clinic (OH, USA) Comprehensive Breast Cancer Program.

“Safely reducing the number of breast biopsy procedures through advanced imaging would add a lot of value to the current system. It also may help identify lesions that re-

quire biopsy that were thought to be benign by traditional imaging.”

OA is a biomedical imaging modality based on the photoacoustic effect, which results of some of the delivered energy absorbed and converted into heat, leading to transient thermoelastic expansion and thus wideband US emission. As optical absorption is closely associated with physiological properties, such as hemoglobin concentration and oxygen saturation, the magnitude of the US emission reveals physiologically specific optical absorption contrast, allowing 2D or 3D images of the targeted areas to be formed.

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The DVMAXX HD is designed to record video and capture images in full HD, and offers live viewing and playback. It can simultaneously store data to the 500GB internal hard drive, network server, or through the front-loading USB ports to a USB or external drive.

The Heama T4 monitors blood coagulation and assists physicians in making a diagnosis of coagulation/fibrinolysis status. It can be applied in various surgical applications, as well as in prevention of post-operative bleeding and thrombosis.

The 1488 HD system provides clear, bright images and cross-specialty standardization enabled through nine surgical settings. Its light sensitivity allows the light source to run at lower power levels to reduce the risk of patient/drape burns.

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Lithotripsy Laser Systems Facilitate Stone Removal nnovative Holmium:YAG (Ho:YAG) lasers feature a full range of lithotripsy modes including dusting, stone stabilization, and soft tissue ablation.

The new Olympus Medical (Tokyo, Japan; www.olympus-global.com) EMPOWER Holmium:YAG laser portfolio offers 35W and 65W systems with a full range of laser fibers to meet diverse lithotripsy challenges. The systems offer a ball-tip fiber that allows the physician to insert it through a deflected scope, while maintaining visualization of the stone. Benefits include a high power platform that offers greater efficiency and higher hertz rates; an intuitive user interface; greater dusting capability; and a stabilization mode that produces a vapor tunnel bubble to clear a path through the water in order to reduce retropulsion and keep the stone in place while applying energy.

The H65 system offers a full 60-hertz of power in a 65 watt Holmium laser generator for lithotripsy (dusting, fragmenting, stabilization and popcorning), soft tissue procedures (incision, tumor ablation, and hemostasis) or benign prostatic hyperplasia (BPH) treatment (HoLEP, HoLAP, and hemostasis). The H35 system offers a smaller-footprint device with 30 hertz of frequency. A full line of fibers is available to complement physician technique, such as the ball-tip fiber and true 200-micron fiber designed to minimize scope deflection loss and increase irrigation during fiber use.

“Urologists demand the ability to customize their treatment of stones with laser lithotripsy and can now approach all stones with greater effi-

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ciency with this EMPOWER laser platform,” said Randy Clark, group vice president of Olympus America.

The HO:YAG laser emits light at 2100 nm, merging features of carbon dioxide (CO2) and neodymium:YAG lasers by providing both tissue cutting and coagulation in a single device. And since the holmium wavelength can be transmitted down optical fibers, it is especially suited for endoscopic surgery. Tissue ablation occurs superficially, providing for precise incision with a thermal injury zone ranging from 0.5-1 mm, providing a level of coagulation sufficient for adequate hemostasis.

Image: The Biograph Vision PET/CT (Photo courtesy of Siemens Healthineers).

Artificial Intelligence Algorithm Aids Detection of Wrist Fractures nnovative diagnostic software uses artificial intelligence (AI) to analyze two-dimensional wrist radiographs for signs of distal radius fracture. The Imagen Technologies (New York, NY, USA; https://imagen.ai) OsteoDetect software platform analyzes posterior-anterior and medial-lateral X-ray images of suspect adult wrists in order to identify and highlight regions of distal radius fracture. The machine learning software is intended to be used as an adjunct tool for clinicians in various settings, including primary care, emergency medicine, and urgent specialty care, such as orthopedics, and is not intended to replace human review of the radiograph and clinical judgment.

A retrospective study of 1,000 radiograph images that assessed the independent performance of the OsteoDetect image analysis algorithm for fracture detection and localization, which was paralleled to that of three board certified orthopedic hand surgeons, found that their performance in detecting wrist fractures was improved using the software, including increased sensitivity, specificity, and positive and negative pre-

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dictive values, when compared to unaided performance according to standard clinical practice.

“Artificial intelligence algorithms have tremendous potential to help health care providers diagnose and treat medical conditions. This software can help providers detect wrist fractures more quickly and aid in the diagnosis of fractures,” said Robert Ochs, PhD, acting deputy director for radiological health, in vitro diagnostics, and radiological health at the U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH).

Distal radius fractures occur when the section of the radius bone closest to the wrist is broken; the wrist may be deformed, and the ulna may also be broken. Diagnosis is generally based on patient symptoms and confirmed with X-rays. Treatment is with casting for six weeks or surgery, generally indicated if the joint surface does not line up, the radius is overly short, or the joint surface of the radius is tilted more than 10% backwards.

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Imageless Navigation System Guides Orthopedic Surgeons three-dimensional (3D) mini-optical navigation system provides accurate intraoperative information during surgery. The intellijoint Surgical (Waterloo, ON, Canada; www.intellijoint surgical.com) HIP is intended for use during total hip arthroplasty (THA) procedures, providing surgeons vital intraoperative measurements to help establish proper cup position, equalization of leg length, and restoration or maintenance of offset and joint center of rotation. The correct alignments are imperative to prevent complications such as dislocation, revision, leg length discrepancies, and readmissions. Intellijoint HIP is suitable for anterior, lateral, and posterior THA surgical approaches, and can be used with all major implant vendors.

The imageless guidance system is based on a miniature camera and tracker that do not interfere with surgical workflow. The measurements are not affected by patient movement and anatomical variations, and are designed to complement a surgeon’s expertise. Envelope parameters include cup position angles to within less than one degree for inclination and anteversion; leg length measurements within 0.3-0.9 mm; and offset measurements within 0.5 mm of set targets. The average added operating room (OR) time is only 2.9 minutes.

“Intellijoint HIP provides offset and leg length determination, in conjunction with acetabular positioning, and allows you to fine tune these rather than guessing and using different landmarks,” said orthopedic surgeon Professor Wayne Paprosky, MD, of Rush University Medical Center (Chicago, IL, USA). “I see this as a potential game changer, as you can use the information provided by intellijoint HIP to combine reducing leg length discrepancy as well as prevent dislocation.

You can have your cake and eat it too.”

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“A miniature camera provides 3D information to surgeons in real time. As the surgeon is orienting the implant that goes into the pelvis, they have a readout that tells them what their angles of orientation are.

They don’t have to guess or use their intuition,” said Armen Bakirtzian, CEO and co-founder of Intellijoint Surgical. “The device helps surgeons align the cup, which replaces the patient’s socket, and can also help them choose the appropriate implant. If the patient’s leg length is done the right way, it leads to fewer re-hospitalizations, fewer revisions, fewer issues of back pain, less physiotherapy, and less medication.”

Image: An innovative mini-optical system helps ensure accurate THA (Photo courtesy of intellijoint Surgical).

Supply Chain Malfunctions Can Lead to Cancelled Surgeries new survey concludes that the operating room (OR) needs better supply chain management systems and analytics to help reduce costs and support patient safety.

The Cardinal Health (Dublin, OH, USA; www.cardinalhealth.com) 3rd annual Hospital Supply Chain Survey, fielded by SERMO (New York, NY, USA; www.sermo.com), a private social media network for physicians in the United States and 149 other countries, provides comprehensive OR supply chain perceptions as seen by supply chain administrators, service line leaders, physicians, and nurses. The survey included 128 frontline clinicians, 100 OR supply chain decision-makers, and 77 supply chain administrators from health care organizations varying in size, specialty, and practice area.

The results revealed that 40% of respondents had actually canceled a case, and more than two-thirds (69%) had delayed a case because of missing supplies. Furthermore, 27% had seen or heard of an expired product being used on a patient, and 23% had seen or heard of a patient harmed due to a lack of supplies. OR surgeons and nurses were frustrated with their hospital’s manual inventory process, with more than half stating that inventory management is complicated or a necessary evil, and 64% admitting to hoarding supplies and citing wasting or overuse of supplies as significant problems within their organization.

The majority (83%) of organizations are manually counting in some part of their supply chain, with only 15% having automated radiofrequency identification (RFID) systems. But the respondents did recognize the benefits of automation; one in four said automated systems free up time to focus on patients and support better outcomes, and 39% agree that automation reduces costs. Nearly all frontline providers surveyed saw the need for an inventory management system designed for the specific volume and nature of supplies in the OR, and 77% would like to be more involved in supply chain decision-making.

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Image: A new survey shows supply chain shortages can result in postponed surgeries (Photo courtesy of Cardinal Health).

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OPERATING TABLE

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The TruLight 1000 is equipped with LED technology and multi-lens matrix to ensure evenly distributed light. The long life, low power consumption, and low heat production make it ideal for exam rooms and ICUs, as well as clinics and practices.

The OM-6N is designed for adjustments to achieve suitable positions for carrying out all surgical operations. Its telescopic body enables height adjustment at different levels to fulfill patient and user requirements and maximize efficiency.

The MegaPulse 70+ features details that enhance handling, increase safety and save time in the OR. It is ideal for stone and BPH treatment in urology, as well as other interventions across a range of specialties.

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Spinal Anesthesia Superior For Hip Fracture Surgery new study suggests a strong association between spinal anesthesia (SA) and reduced mortality in elderly patients undergoing hip fracture fixation surgery. Researchers at the University of Toronto (Canada; www.utoronto.ca) and Toronto Western Hospital (Canada; www.uhn.ca/corporate/AboutUHN/OurHospitals/TWH) conducted a study of all patients who underwent hip fracture fixation between 2003 and 2015. The researchers then matched 883 patient cohorts for 29 variables known to affect mortality and morbidity associated with hip fractures. They then matched the patients who received SA with those who received general anesthesia (GA). The main outcome was impact of SA on 90-day mortality.

The results revealed that patients who received SA were more likely to be male, elderly, have a higher ASA score, and receive earlier hip fracture fixation; and less likely to have metastatic cancer and take calcium channel blockers. Overall, 90-day mortality was significantly lower in patients who received SA (6.3%) than in GA patients (8.8%), a relative risk reduction of 26.1%. The SA patients also had fewer blood clots in the lungs, lower rates of major blood loss, and shorter hospital stays. The study was presented at the 2018 World Congress on Regional Anesthesia and Pain Medicine, held during April 2018 in New York (NY, USA).

“A strong association was identified between spinal anesthesia and lower 90-day mortality post hip fracture repair. Overall, patients who received spinal anesthesia were less likely to die from a cardiac event, but more likely to die from a respiratory cause or sepsis,” concluded lead author Sarah

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Tierney, MD, of the University of Toronto. “There was no between-group difference noted in hospital length of stay or major cardiac events.”

SA involves injection of a local anesthetic into the subarachnoid space, generally through a fine needle, in order to block the transmission of afferent nerve signals from peripheral nociceptors. The degree of neuronal blockade depends on the amount and concentration of anesthetic used, and the properties of the axon. As such, thin unmyelinated C-fibers associated with pain are blocked first, while thick, heavily myelinated A-alpha motor neurons are blocked moderately. SA is not to be confused with an epidural, whereby a local anesthetic drug is injected through a catheter placed into the epidural space.

Image: A new study asserts spinal anesthesia reduces mortality following surgery (Photo courtesy of Getty Images).

Gripping Mechanism Minimizes Knee Movement During Surgery redesigned knee positioner accommodates the increasing number of obese patients undergoing total knee replacement (TKR).

The Innovative Medical Products (IMP; Plainville, CT, USA; www.impmedical.com) De Mayo D2 Knee Positioner is designed to reduce surgeon fatigue and assist in the stabilization of a patient’s leg during TKR surgery. Features include a spring-loaded lever on the device’s carriage to allow precise control of flexion, extension, tilt and rotation.

Standard components include the positioner base, an aluminum boot with distractor block, and a single lever clamp.

The unique single locking lever allows for precise control, and its ease of use saves time. The same lever releases the boot for testing of ligament stability and range of movement (ROM). The positioner is easily set up in the sterile field, on top of the sterile drapes. The locking carriage mechanism can be used with any existing clamping system, with new spring-loaded, fold-down pins to improve ease of use, and a full line

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of components and accessories. An additional benefit of the new D2 carriage is easy removal and cleaning.

“We constantly listen to what the market is telling us. By responding to customer needs, we continue to produce innovations that aren’t just new for newness sake but are real, practical solutions based on customer feedback,” said Earl Cole, vice president of IMP. “In this way, we remain faithful to the ideals inherent in our original ‘gold standard’ solution produced more than a decade ago.”

Proper axial alignment is of paramount importance for the longevity of the TKR implant, and even minor deviations can lead to early loosening, increased polyethylene wear, and poor function. Misalignment of any of the components in any anatomical plane can cause major complications. For example, inaccurate rotation of either the femoral or tibial component will critically affect patellar tracking and can lead to patellar subluxation or dislocation. For TKR, the knee joint has to be placed in a 70- to 90-degree angle.

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Surgical Techniques

Augmented Reality Microscope Provides Flexible Viewing Options highly advanced neurosurgical microscope with integrated digital augmented reality (AR) supports critical intrasurgical decisions. The Leica Microsystems (Wetzlar, Germany; www. leica-microsystems.com) ARveo AR neurosurgical microscope features a built-in 31-inch, 4K three-dimensional (3D) monitor and a cart-mounted 55-inch monitor that enables the entire operating room team to follow the procedure in 3D. The highlight of the system is GLOW AR technology, a comprehensive visualization solution that provides flexible viewing options by combining a high contrast indocyanine green (ICG) fluorescence signal and the white light image to provide a single view of cerebral anatomy in natural color, augmented by real-time vascular flow.

The result is a single, real-time view that obviates the need to recall and reconcile black and white near infrared (NIR) blood flow video with the natural anatomical view. The full depth perception and lack of dark peripheries through image homogenization support clear spatial orientation. In addition, GLOW AR provides flexible viewing options, such as digital image injection and three dimensional (3D) displays, as well as wireless sharing beyond the operating room (OR), such as by live streaming and by HD recording. Images can also be transferred into the patient electronic medical record (EMR).

The ARveo microscope is also ergonomically designed to adapt to the surgeon’s preferred style of work and body frame by providing a choice of binoculars, all with 360° rotation and versatile positioning of the optics carrier, as well as optimal visualization for the rear assistant with independent fine focus. Lightweight handling and an extensive range of movement of the optics carrier limits potential strain from harsh movements, as does the flexible use of long instruments thanks to the large 600 mm working distance.

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Image: The ARveo AR microscope with integrated GLOW AR fluorescence (Photo courtesy of Leica Microsystems).

Interbody Fusion Device Provides Integrated Fixation minimally invasive anterior lumbar interbody fusion (ALIF) system uses autogenous bone grafts to stabilize patients with degenerative disc disease (DDD).

The Camber Spine (Wayne, PA, USA; www.cambermedtech.com) ENZA-A Titanium ALIF system consists of a three-dimensional (3D) printed titanium body with multiple openings to allow a large volume of autogenous bone graft to be easily packed into the implant, and roughened cranial and caudal surfaces that encourage bone growth onto the surface of the device. The surfaces are deliberately designed with pores that average 500 microns in diameter, the optimal environment for bone growth that fully incorporates the implant with the vertebral bodies.

The ENZA-A features two sharpened anchor plates housed within the 3D-printed body until they are deployed into the adjacent vertebrae for fixation. Surgery time is reduced thanks to the single, inline instrumentation used to insert the device, deploy the anchor plates, and lock it in place. Patient safety is increased by minimizing the size of the incision and retraction required for implantation. The ENZA-A has been approved by the U.S. Food and Drug Administration (FDA) for use at one or two contiguous levels from L2 to S1 using supplementary fixation systems.

Interbody devices are designed to replace the intervertebral disc of the spine, enhancing stability in the region while the spine fuses. Over time, the packed bone graft material is gradually replaced by natural bone forming a solid piece. Fusion procedures typically use a posterior fixation device to the associated level, since the surgeons will implant interbody devices from an anterior approach and flip the patient over to implant a posterior pedicle screw device. This combination increases fusion success.

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The Combiport helps remove foreign bodies, reduce pathogen numbers and moisten wound tissue. The Combiguard Irrigation Splash Guard with an egg-shaped cup covers the wound site to prevent irrigation splashback.

The INP-ME range features a radiotransparent tabletop divided into four sections and a base made of stainless steel. Other features include a structural profile with linear guides and chassis made of steel plates with structural reinforcement.

The MF-13 features facetted lenses to guarantee homogeneity and the lowest shadiness in the light field. Separate optical systems generate their own light field, which increases its contrast and allows light intensities of 100.000 Lux to be attained.

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Endobronchial Valves Improve Lung Function in Emphysema n endobronchial valve (EBV) improves lung function, exercise capacity and quality of life in patients with heterogeneous emphysema and hyperinflation, according to a new study.

Researchers at Temple University (Philadelphia, PA, USA; www. temple.edu), University Medical Center Groningen (UMCG, The Netherlands; www.umcg.nl), and other institutions conducted a study in 190 patients with severe heterogeneous emphysema and little to no collateral ventilation to evaluate the effectiveness and safety of the PulmonX (Redwood City, CA, USA; www.pulmonx.com) Zephyr EBV as compared to standard medical management of hyperinflation related to emphysema, which includes lung-volume-reduction surgery (LVRS), bullectomy, and lung transplantation.

In all, 128 patients were randomized to EBV, with a median of four valves placed, mostly in the left upper lung lobe. At 12-month follow-up, hyperinflation was reduced to a significantly greater extent in the EBV group, with 47.7% of EBV patients presenting a 15% or higher increase in post-bronchodilator forced expiratory volume (FEV1), versus 16.8% of those under standard medical care. They also had significant improvement in six-minute walk distance (6MWD) and respiratory questionnaire scores.

The study was published on May 22, 2018, in the American Journal of Respiratory and Critical Care Medicine.

“Zephyr Valves offer clinically meaningful improvements in three important areas for patients - the ability to breathe better, be more active, and enjoy an improved quality of life,” said lead author Professor Gerard Criner, MD, of Temple University. “All primary and secondary endpoints were met, with Zephyr Valve treatment showing significant improvement for pa-

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tients across multiple measures of breathing and quality of life. The Zephyr Valve also demonstrated an acceptable safety profile given the magnitude of benefit seen in this study.”

The Zephyr EBV is a one-way valve that blocks airflow to diseased regions of the lung, allowing healthy regions to expand and function more efficiently. The valves, which are either 4 or 5.5 millimeters in size, are implanted in a minimally invasive procedure using a bronchoscope equipped with a video camera. During the 60-minute procedure, 3-5 Zephyr valves are placed in airways leading to the diseased region of the lung. Once deployed, the self-expanding, one-way valve conforms to the bronchial wall and forms an airtight seal, blocking airflow to the diseased regions.

Image: The Zephyr endobronchial valve (Photo courtesy of PulmonX).

Stabilization Platform Assists Endolumenal Interventions novel accessory ensures complete positioning of an endoscope in the large intestine and assists with optical visualization, diagnosis, and treatment.

The Lumendi (High Wycombe, United Kingdom; https://lumendi. com) DiLumen C2 is an endolumenal interventional platform that consists of a soft flexible sheath that fits over standard and small diameter endoscopes. The device employs two balloons, one behind the bending section of the endoscope and the second in front of the tip. When both balloons are deployed and inflated, the area in between the two balloons is stabilized, creating a therapeutic zone that facilitates stabilization, insufflation, and manipulation of the tissue, thus allowing the clinician to more effectively treat the target area.

The platform also includes two six mm diameter tool channels,

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which accommodate two independent flexible articulating hand instruments, such as a flexible grasper called the DiLumen Ig, which can be used together with the DiLumen C2 to grasp and manipulate mucosal tissue. Several additional flexible articulating instruments are under development, and will be available for cutting and dissection of tissue.

Once the therapy is completed the balloons are simply deflated and removed, along with the colonoscope.

“We are continuing our commitment to develop innovative devices that facilitate endolumenal procedures for many gastrointestinal interventions in an effort to reduce costs and improve patient outcomes,” said Dr. Peter Johann, CEO of Lumendi. “To date, we have completed over 350 procedures with the commercially available DiLumen EIP, with no serious adverse events.”

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Surgical Techniques

Weight-Loss Surgery Negatively Impacts Skeletal Health new review of studies suggests that weight loss surgery can cause declines in bone mass and strength, and it is linked with an increased risk of bone fractures.

Researchers at Université Laval (Quebec City, Canada; www. ulaval.ca), the University of California, San Francisco (UCSF; USA; www.ucsf.edu), and other institutions conducted a review of six studies that examined the effects of various bariatric surgeries, and especially the Roux-en-Y gastric bypass (RYGB) procedure, which was the most commonly performed weight loss procedure worldwide until it was overtaken by sleeve gastrectomy (GS). But because sleeve gastrectomy is a newer procedure, its skeletal effects have not yet been well defined.

The results of the studies show an increased risk of fracture after RYGB and biliopancreatic diversion with duodenal switch, both of which include a malabsorptive component. Bariatric surgery also induces early and dramatic increases in biochemical markers of bone turnover, which may explain a heightened skeletal fragility. RYGB results in pronounced declines in bone mass at the axial skeleton – demonstrated by dual energy X ray absorptiometry (DXA) and quantitative computed tomography (QCT) – and at the appendicular skeleton – demonstrated by high resolution peripheral quantitative computed tomography (HR pQCT).

RYGB also has detrimental effects on trabecular and cortical microarchitecture and estimated bone strength. The review also shows that the skeletal changes after RYGB appear early on, and continue even after the weight loss plateaus and stabilizes. The researchers noted that nutritional factors, mechanical unloading, hormonal factors, and changes in body composition and bone marrow fat may contribute to poor bone health. The review was published on March 30, 2018, in JBMR Plus.

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Resorbable Scaffold Promotes Spinal Cord Injury Healing novel bioresorbable polymer scaffold placed within a spinal cord injury (SCI) site provides structural support to the spared spinal tissue, and a supportive matrix to facilitate endogenous repair processes.

The InVivo Therapeutics (Cambridge, MA, USA; www.invivo therapeutics.com) Neuro-Spinal scaffold is a highly porous device designed to mitigate tissue damage resulting from some of the critical patho-physiological events that occur during the acute phase of SCI, including increase in tissue pressure, hemorrhage, and edema. The scaffold is composed of two biocompatible, bioresorbable polymers, Polylactic-co-glycolic acid (PLGA) and Poly-L-Lysine (PLL), a positively charged polymer conducive to cellular attachment and neurite outgrowth.

The scaffold is trimmed and fitted in the epicenter of the SCI, where it modulates the healing process by providing biocompatible and cellular-adhesive appositional healing, similar to the function of sutures or a butterfly bandage in a skin laceration. It then degrades over several weeks. A study that examined the objective performance of the scaffold in 19 SCI patients showed conversion from complete paraplegia to incomplete injury within six months in 44% of the patients, exceeding the 25% conversion criterion. The study was presented at the American Association of Neurological Surgeons (AANS) annual meeting, held during May 2018 in New Orleans (LA, USA).

“At the time of stabilization surgery, a decompression laminectomy was done at the site of injury and the maximal damage was determined by ultrasonography,” said study presenter Stuart Lee, MD, of Vidant Health (Greenville, NC, USA).

Large, multinational natural history databases consistently indicate that only 12-16% of subjects with complete thoracic injury will convert to an improved American Spinal Injury Association Impairment Scale (AIS) grade by six months after injury.

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“Current clinical guidelines do address bone health, but most recommendations are based on low-quality evidence or expert opinion,” said study co-author Anne Schafer, MD, of UCSF and the San Francisco VA Health Care System (CA, USA). “The review’s findings indicate that clinical guidelines on weight loss surgery should address bone health as a priority. Future studies should address strategies to avoid long-term skeletal consequences of these otherwise beneficial procedures.”

The RYGB procedure was the gold standard for surgical weight loss intervention for many years. The procedure usually involves laparoscopic minimally invasive surgery to create a stomach pouch from the larger stomach body. A portion of the small intestine is then connected to the stomach pouch, leaving a small opening for food to travel. The result is a sensation of satiety or fullness after eating small meals.

Image: A new study suggests gastric banding for weight loss increases fracture risk (Photo courtesy of Getty Images).

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Dissatisfaction with Electronic Health Records Drives Physician Burnout egulatory requirements are likely to be an important aspect of physician dissatisfaction with electronic health records (EHRs), according to a new editorial.

An opinion piece by researchers at Stanford University School of Medicine (Stanford; CA, USA; med.stanford.edu), the University of California, San Diego (UCSD, USA; www.ucsd. edu), and other institutions discusses a growing sense within the medical community in the United States that the EHR is driving professional dissatisfaction, emotional fatigue, and burnout to crisis proportions. One of the reasons is that clinical notes are nearly four times longer in the United States than in other countries, even across the same EHR. As a result, U.S. physicians spend as much time interacting with a computer as they do face to face with patients.

In comparison, the EHR tends to be much briefer in other countries, containing only essential clinical information and omitting much of the compliance and reimbursement documentation. Physicians in the United States are required to document an increasing amount of low-value administrative data; these documentation requirements are the remnant of the fee-for-service system. However, meaningful use incentives have created even more requirements for low-value documentation, and value-based models have their own documentation requirements. The opin-

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ion piece was published on May 8, 2018, in Annals of Internal Medicine.

“One study suggested that more than half of physicians in some disciplines are burned out, and that this proportion is increasing. The number of clinicians leaving the workforce represents a major concern to health care professionals and to the health of the nation,” concluded lead author N. Lance Downing, MD, of Stanford. “We believe that platform improvements are essential, but will be insufficient to address a key cause of physician burnout: our outdated regulatory requirements. Simplifying the regulations around documentation and billing would likely benefit

the health care system and patients.”

The 2009 American Reinvestment & Recovery Act (ARRA) included many measures to modernize infrastructure, one of which is the Health Information Technology for Economic and Clinical Health (HITECH) Act. ARRA set aside nearly USD 20 billion in incentives for hospitals and physicians who adopt qualified, certified EHRs with the ability to exchange information with other sources, which is defined conceptually as meaningful use (MU).

Image: Studies show cumbersome EHRs are driving doctors to despair (Photo courtesy of 123rf.com).

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Software Platform Tracks Endoscope Usage and Reprocessing

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n innovative workflow and supply chain management solution provides optimum efficiency and safety in the management of endoscopes. The Olympus Medical Systems (Tokyo, Japan; www.olympus-global.com) Unifia reprocessing documentation, workflow, and asset management system is designed to provide supervisors, infection prevention staff, and hospital supply chain managers with greater visibility into the utilization, cleaning, reprocessing, and storage of flexible endoscopes. Unifia utilizes radiofrequency identification (RFID) technology to track and visualize an endoscope’s movement, from the front desk to storage room and all stops in between, in order to better understand trends, conduct analysis, and act accordingly.

The system uses wireless scanner technology to capture data from virtually all automated endoscope reprocessors, storage cabinets, leak testers, stating system-wide performance initiatives, Unifia provides value and bio burden test kits. A consolidated real time Daily Dashboard view through automated tracking and easy data navigation.” provides insight into critical operational, reprocessing, and storage steps, including procedure room turnover, delayed reprocessing requirements, Image: The Unifia inventory management solution is designed to simplify the endoscopic workflow (Photo courtesy of Olympus). manual cleaning times, and endoscope hang times. Onscreen alerts warn users when scanning steps are missed, allowing for a repeatable and compliant process, while making sure all reNE DES W quired data is collected.

IGN In the procedure room, Unifia can track the endoscope serial number, link the patient to the device, note which doctor is performing the procedure, and how much time has WORLD’S MEDICAL PRODUCT MARKETPLACE elapsed. When the procedure is over, the Unifia Daily Dashboard is updated, alerting users the procedure room needs to be turned over. In the soiled SIGN UP room, manual cleaning time is FOR FREE! tracked to reduce the need for delayed steps, while in the reprocessing room, users are able to easily log minimum recommended concentration (MRC) testing results.

Nurse Managers or Infection Prevention champions can use the Unifia Analysis module to audit staff workloads, endoscope reprocessing compliance, and reprocessing breach analysis in a simple interface. In addition, they can identify peak and low demand periods so as to optimize staffing demands, identify which staff members necessitate remedial competency training, and benchmark staff performance by looking at how long the endoscope is located in specific areas so as to streamline workflows.

“Unifia is an example of Olympus’ strategy of transformation to a solutions company, by which we make it Connecting Buyers with easy to bring our gastrointestinal cusSuppliers Worldwide tomers more than clinical data, but Reach new sources of supply now also operations data that will Identify latest products and technologies drive compliance, safety, and utilizaSend inquiries directly to suppliers tion initiatives,” said Kurt Heine, Receive latest product alerts group VP of the endoscopy division at Chat live with suppliers Olympus. “Whether we’re talking about a nurse manager gaining visibility into the entire department, a techTradeMed provides a sophisticated yet easy-to-use global B2B platform for sourcing medical nician improving his own performequipment. TradeMed connects buyers and sellers worldwide through a safe, secure and dyance, an administrator making decinamic network. Solely dedicated to medical products, TradeMed is the premier choice for medsions about acquisitions or a CEO inical suppliers, hospital decisionmakers and buyers worldwide, regardless of size or budget.

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Trade Show Update

Health IT

Social Media Infrastructure Helps Manage Medical Emergencies

new study describes an online platform that enables first responders to monitor emergency situations using tweets and Instagram posts.

Developed at Purdue University (Lafayette, IN, USA; www.purdue. edu), Arizona State University (ASU; Tempe, USA; www.asu.edu), and other institutions, the Social Media Analytics and Reporting Toolkit (SMART) browser-based platform filters social media content according to key words and geographic regions defined by the user. To help break down various interpretations of a situation, the researchers use a context-preserving, multi-scale spatial aggregate tool called TopoText, which visualize key words from user-defined themes.

Dominant crime, for example, may be theft and robbery in a city; or it may be liquor law violations and noise for a university campus. While conventional exploration requires users to navigate across multiple scales, it only presents information related to the current scale. TopoText, instead, renders multi-scale aggregates into a single visual display that combines text-based encoding and a layout that draw labels along the boundary or filled within the aggregates. Another feature is customizable email alerts.

The text itself not only summarizes the semantics at each individual scale, but also indicates the spatial coverage of the aggregates and their underlying hierarchical relationships. First responders are already using a beta version of the tool to analyze both live and historical data in order to gain insight on spatial phenomena. SMART and TopoText were presented at the Association for Computing Machinery CHI 2018 Conference on Human Factors in Computing Systems, held during April 2018 in Montreal (Canada).

“If, for example, a key word came up more than five times in ‘x’ amount of minutes, then the user will get an email alert. Users can also request a summary email of tweets or posts related to key words they input to SMART,” said study co-author Chittayong Surakitbanharn, PhD, of the Purdue department of electrical and computer engineering.

“The telephone was invented in the 1800s; by the time you have the 91-1 system, that’s the 1960s. Now if we dial 9-1-1, we definitely expect someone to help us. But on social media, there has been no pre-designed system.”

“People already provide information about situations using social media; organizing and filtering this information helps first responders attend to certain areas faster,” said senior author Professor David Ebert, PhD, of the Purdue department of electrical and computer engineering.

“The goal is for SMART to be an affordable social media analytics tool that anyone can download. We want this to be available at low cost for every first responder.”

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Image: A browser-based platform filters tweets and Instagram posts (Photo courtesy of Jiawei Zhang/ Purdue University).

The Health Industry Summit (tHIS) To Play Greater Role In Growing Chinese Health Industry

he Health Industry Summit (tHIS) 2018 held at the National Exhibition and Convention Center in Shanghai on April 11, 2018, was the largest gathering of healthcare industry professionals in the world with well over 200,000 attendees from more than 150 countries and regions and over 7,000 exhibitors. The fourth edition of tHIS covered an exhibition space of over 350,000 square meters with 160 individual events and conferences being held alongside the main expo. tHIS 2018 is fast becoming China's solution for promoting technology innovations and academic exchange in the medical healthcare arena. China is the second-largest healthcare market in the world and is one of the most attractive in the world for foreign investors. A recent report from McKinsey & Co. estimates China's healthcare market to grow at an unprecedented CAGR of about 12% from USD 357 billion in 2011 to reach USD 1 trillion by 2020. The growth of the Chinese healthcare market is expected to be driven mainly by the country’s ageing population, rise in incidences of lifestyle related diseases such as diabetes and cancer, and major steps taken by the government to improve the local healthcare infrastructure. Recent regulatory changes by the Chinese government are expected to speed up the approvals of medicines and medical devices, thus easing the process of introducing new treatments to the market.

Additionally, under its “Made in China 2025” plan, the Chinese government is focusing on the development of high-performance devices such as diagnostic imaging equipment, robotic surgery devices, high-end medical consumables, including fully degradable cardiovascular stents, wearable devices, and telemedicine. With local companies increasing their technological capabilities and producing high-end medical devices, China’s medical device market will continue to strengthen even as the competition between the players intensifies.

In line with the call by Chinese President Xi for greater promotion of the country’s health industry at the Boao Forum for Asia, tHIS 2018 covered the entire industry value chain, including the key segments such as medical devices, pharmaceutical production, drug distribution and natural health and nutrition. The key events at the four-day summit included China's top medical equipment and pharmaceutical exhibitions CMEF, PHARMCHINA and API China, which showcased cutting-edge technologies such as virtual reality, augmented reality, wearables and artificial intelligence as part of the new Intelligent Health exhibition. The show also highlighted traditional medicine as China's own solutions for treatment and prevention which runs parallel to modern medicine and drug development.

Various medical device giants such as GE, United Imaging, Siemens, Philips and Mindray as well as major pharmaceutical groups in China including Sinopharm, Shanghai Pharma and CR Pharmaceuticals used the show as a platform to launch more than 600 new products for the global or Asia Pacific markets. tHIS 218 was hosted by Reed Sinopharm (www.reedexpo.com.cn), a joint venture between the world's leading event organizer Reed Exhibitions and China's state-owned medical & pharmaceutical giant Sinopharm. The next edition of the event is scheduled to be held in May 2019 in Shanghai.

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Industry News

GE to Spin Off Healthcare Business

Philips Acquires Remote Diagnostic Technologies to Expand Therapeutic Capabilities

cont’d from cover

The once-sprawling industrial conglomerate is making the move in order to focus on aviation, power, and renewable energy sectors. The decision follows a similar healthcare business segment spin-off realized earlier in the year by arch-rival Siemens AG (Munich, Germany; www.siemens.com).

GE (Boston, MA, USA; www.ge.com) is betting that these sweeping changes will strengthen its balance sheet and allow it more financial flexibility by reducing corporate risk in the future. The turnaround plan was announced by GE on the same day of the company's removal from the Dow Jones Industrial Average.

GE Healthcare (Little Chalfont, UK; www.gehealthcare.com) recorded over $19 billion in revenues in 2017 and posted 5% revenue growth and 9% segment profit growth in the same year. The business provides medical imaging (including contrast agents), monitoring, biomanufacturing and cell therapy technology, leveraging deep digital, artificial intelligence and data analytics capabilities. Its products and services serve customers in some 140 countries around the world.

Kieran Murphy, president and CEO of GE Healthcare, will continue to lead GE Healthcare as a stand-alone company, maintaining the GE brand. "GE Healthcare's vision is to drive more individualized, precise and effective patient outcomes. As an independent global healthcare business, we will have greater flexibility to pursue future growth opportunities, react quickly to changes in the industry and invest in innovation. We will build on strong customer demand for integrated precision health solutions and great technology with digital and analytics capabilities as we enter our next chapter," he said. CEO Flannery added, "GE Healthcare is an industry leader with financial strength, global scale and cutting-edge technology. Our talented Healthcare team will continue delivering precision health solutions, building on our heritage of technology innovation that delivers patient outcomes."

According to GE, the changes are expected to generate at least $500 million in corporate savings by the end of 2020. The company plans to reduce its industrial net debt by about $25 billion before 2020 and maintain more than $15 billion of cash on its balance sheet.

GE expects to generate cash from the disposition of approximately 20% of its interest in the Healthcare business and to distribute the remaining 80% to GE shareholders through a tax-free distribution. The structure, sequence and timing of these transactions will be determined and announced at a later date, but are expected to be completed over the next 12 to 18 months. GE Healthcare will conduct business as usual throughout this process, continuing to serve its partners and customers.

Worldwide Surgical Tables and Lights Market to Exceed USD 1.8 Billion by 2026 he global surgical tables and lights market was valued at more than USD 1.3 billion in 2017 and is projected to grow at a CAGR of over 3.0% over 2018 to 2026 to surpass USD 1.8 billion by 2026. The demand for surgical tables and lights during the forecast period is likely to be driven by developing health care infrastructure in the emerging countries and the introduction of technologically-advanced surgical tables and lights by the market players. However, constant evolution in the surgical tables and lights segment, with the introduction of new features and designs has led to high prices of these products, thereby acting as a major restraint to the market growth. These are the latest findings of Transparency Market Research, (Albany, NY, USA; www.transparencymarketresearch.com), a global market intelligence company providing business information reports and services.

In terms of product type, the surgical tables segment held the largest market share in 2017 and is expected to continue dominating the market during the forecast period due to the increasing number of new and advanced surgery tables introduced in the global market and their comparatively higher prices. The gynecology examination tables segment is expected to lose market share during the forecast period and account for less than 18.0% by 2026.

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oyal Philips (Amsterdam, the Netherlands; www.philips.com) has acquired Remote Diagnostic Technologies {Hampshire, UK; www.rdtltd.com (RDT)}, which offers advanced solutions for the pre-hospital market providing monitoring, cardiac therapy and data management. RDT’s portfolio of connected emergency care solutions will complement Philips’ Therapeutic Care business and strengthen its leadership position in the resuscitation and emergency care market.

RDT’s acquisition will also strengthen Philips’ ability to innovate, drive digital transformation in healthcare, and enter new markets.

Philips focuses on the areas of diagnostic imaging, image-guided therapy, patient monitoring and health informatics, as well as consumer health and home care. The company offers a range of monitoring and therapeutic products and solutions to help emergency medical services, hospitals and lay responders accelerate the delivery of care at the scene. Its portfolio includes automated external defibrillators (AEDs), advanced life support monitors, and data management solutions. RDT will complement Philips’ portfolio with a product range for ambulance and emergency responders, which includes Tempus ALS, a modularized monitor and defibrillator that offers premium functionality in a smaller, lighter and more flexible package.

RDT also offers highly robust and lightweight monitors equipped with telecommunication capabilities for various emergency responders.

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Global Ambulatory Surgical Center Sector to Reach USD 97 Billion by 2024 he global ambulatory surgical centers (ASCs) market is estimated to have been valued at USD 77.1 billion in 2017 and is expected to grow at a CAGR of 3.5% to reach USD 97.3 billion by 2024, driven mainly by the growing number of surgeries performed in ASCs and increasing accidental cases. Some key advantages of using ASCs such as the personal attention received by patients and lack of exposure to a wide range of infections will also aid the market growth over the coming years. These are the latest findings of Energias Market Research Pvt. Ltd. (Buffalo, New York, USA; www.energiasmarketresearch.com), a market research and consulting company.

ASCs, which provide surgical and emergency care services on an outpatient basis, offer improved patient care quality at lower healthcare cost.

More patients are opting for ambulatory services due to the rising burden of treatment cost and better outcomes with higher patient satisfaction. Additionally, technological advancements in surgical techniques are allowing an increasing number of procedures to be performed in ASCs. The rising prevalence of acute and chronic diseases, growing incidence of accidental cases across the globe, lower rate of infections and cost effectiveness of ASCs will drive the market growth during the forecast period.

Based on specialty, the multi-specialty surgical centers segment held the largest market share in 2017, led by an increasing number of surgery procedures being performed in these centers and growing preference for such centers among patients due to the presence of highly skilled and qualified surgeons, nurse, and staff. On the basis of services, the surgical services segment accounted for the largest market share in 2017 and is expected to continue dominating the ASCs market during the forecast period.

Geographically, North America held the largest share of the global ASCs market in 2017 and is likely to maintain its dominance during the forecast period. The growth of the North American ASCs market can be attributed to the increasing investments by major private healthcare companies in ASCs and rising adoption of minimally invasive therapies by patients. Europe held the second-largest share of the global ASCs market due to a higher volume of orthopedic surgery, increased number of eyes disorders, and local governments promoting the adoption of ASCs in the region. The ASCs market in Asia Pacific is expected to grow at the fastest pace during the forecast period, driven by an increasing aging population, growing number of accidental cases, and rise in chronic conditions in the region.

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International Calendar For a free listing of your event, or a paid advertisement in this section, contact:

International Calendar, HospiMedica International P.O.Box 801932, Miami, FL 33280-2214, USA Fax: 1-954-893-0038 • E-mail: info@globetech.net

SEPTEMBER 2018 Building Healthcare Innovation & Design Show 2018. September; Dubai, United Arab Emirates; www.building healthcare-exhibition.com MedEXPO Kenya 2018. Sep 4-6; Nairobi, Kenya; www.expogr.com Euroson 2018 – Congress of the European Federation of Societies for Ultrasound. Sep 6-9; Poznan, Poland; www.euroson2018poznan.pl 37th Annual ESRA Congress. Sep 1215; Dublin, Ireland; http://esraeurope. org ERS 2018 – Annual Congress of European Respiratory Society. Sep 15-19; Paris, France; www.ersnet.org EACMFS 2018 – European Association for Cranio Maxillofacial Surgery Congress. Sep 18-21; Munich ,Germany; www.eacmfs.org

OCTOBER 2018 Medical World Americas 2018. Oct 23; Houston, TX, USA; www.medicalworld americas.com 12th Interventional MRI Symposium 2018. Oct 5-6; Boston, MA, USA; http://imri2018.org 11th World Stroke Congress. Oct 17-20; Montreal, QC, Canada; www. world-stroke.org 28th World Congress on Ultrasound in Obstetrics and Gynecology. Oct 2024; Singapore; www.isuog.org ESICM 2018 – Annual Congress of the Euro Society of Intensive Care Medicine. Oct 20-24; Paris, France; www.

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International Calendar FEBRUARY 2019

APRIL 2019

The Obs-Gyne Exhibition & Congress 2019. Feb 4-7; Dubai, UAE; Web: www.medlabme.com/obs-gyne CACVS 2019 – Controversies & Updates in Vascular Surgery. Feb 7-9; Paris, France; Web: cacvs.org HIMSS19 Global Conference & Exhibition - Healthcare Information and Management Systems Society. Feb 11-15; Orlando, FL, USA; Web: www. himssconference.org Critical Care Congress 2019 – 48th Annual Meeting of the Society of Critical SCCM 2019 – Care Medicine. Feb 17-20; San Francisco, CA, USA; Web: www.sccm.org MEDICAL JAPAN 2019. Feb 20-22; Osaka, Japan; Web: www.medical-jpn.jp Medical Fair India 2019. Feb 21-23; New Delhi, India; Web: www.medical fair-india.com

MARCH 2019 Acute Cardiovascular Care 2019. Mar 2-4; Malaga, Spain; Web: www.escardio.org KIMES 2019. Mar 14-17; Seoul, Korea; Web: www.kimes.kr EAU19 – European Association of Urology. Mar 15-19; Barcelona, Spain; Web: www.uroweb.org ISICEM 2019 – 39th International Symposium on Intensive Care and Emergency Medicine. Mar 19-22; Brussels, Belgium; Web: www.intensive.org Africa MedExpo 2019. Mar 21-23; Addis Ababa, Ethiopia; Web: http://expogr.com/ethiopia/medexpo/ Asia Health 2019. Mar 27-29; Singapore; Web: www.medlabasia.com ExpoMED Eurasia 2019. Mar 28-30; Istanbul, Turkey; Web: http://expomed istanbul.com

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MAY 2019 ECTES 2019 – 20th European Congress of Trauma & Emergency Surgery. May 5-7; Prague, Czech Republic; Web: www.estesonline.org 2019 ARRS Annual Meeting - American Roentgen Ray Society. May 5-10; Honolulu, HI, USA; Web: www.arrs.org Vietnam Medi-Pharm 2019. May 8-11; Hanoi, Vietnam; Web: http://vietnam medipharm.vn CMEF Spring 2019 – China International Medical Equipment Fair. May 14-17; Shanghai, China; Web: www.cmef.com.cn KIHE 2019 – Kazakhstan International Healthcare Exhibition. May 15-17; Almaty, Kazakhstan; Web: https://kihe.kz MedtecLIVE 2019. May 21-23; Nuremburg, Germany; Web: www.medteceurope.com Hospitalar 2019. May 21-24; Sao Paulo, Brazil; Web: www.hospitalar.com Heart Failure 2019. May 25-28; Athens, Greece; Web: www.escardio.org EURSON 2018 – Congress of the European Federation of Societies for Ultrasound. May 29-Jun-1; Granada, Spain; Web: www.efsumb.org

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