HospiMedica International March 2017

V I S I T

WORLD’S

CLINICAL NEWS

Vol.35 No.1 • 2-3/2017

LEADER DAILY CLINICAL NEWS

ISSN 0898-7270

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Fungus Key Factor In Crohn’s Disease

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3D Technology Maps The Brain During Surgery

esearchers have for the first time identified a fungus, Candida tropicalis, as a key factor in the development of Crohn’s disease in humans.

They have also linked a new bacterium to the bacteria previously associated with Crohn’s. The groundbreaking findings could facilitate development of new treatments and ultimately

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novel multidisciplinary approach to patient care merges informatics, advanced imaging, and robotics to bring state-of-the-art visualization to the operating room (OR).

The Synaptive Medical (Toronto; Canada; www.synaptivemedical.com) Servo system is an advanced OR solution based on BrightMatter Guide tac-

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tographic capabilities. When BrightMatter Guide is interfaced with BrightMatter Vision optics and the BrightMatter Drive robotic arm, the Servo system can address the complexities of the OR and transform the surgical workflow. A camera mounted on a robotic arm automatically follows the surgeon’s instruments, with

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Pathogen Transmission Rife in Hospital Settings

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Nanochannel Implant Could Revolutionize Drug Delivery new study describes a tiny implantable drug delivery system that uses thousands of nanochannels to regulate the release of various medications. Developed by researchers at the University of Texas San Antonio (UTSA; USA; www.utsa.edu), and Houston Methodist Research Institute (TX, USA; www.houstonmethodist. org/research) the capsule system combines a biomedical nanoelectromechanical systems (BioNEMS)

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3D Printed Implants Help Shoulder Reconstruction

ccording to a new study conducted by researchers at Duke University, hospital rooms, and not just the patients occupying them, can spread germs by way of healthcare personnel. The study points to the need for utmost caution whenever healthcare providers enter a patient room, regardless of the task they’re undertaking.

A Image: Courtesy of the Children’s National Health System

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novel patient-matched glenoid implant is designed to treat rotator cuff injuries and extensive bone loss in primary, fracture, or revision total shoulder replacement.

The Zimmer-Biomet (Warsaw, IN, USA; www.zimmerbiomet.com) comprehensive vault reconstruction system (VRS) is indicated for use in patients whose shoulder joint has a grossly deficient rotator cuff with severe arthropathy and/or a previously

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Wireless Ultrasound Devices Guide Bedside Procedures ew wireless ultrasound devices for medical professionals are compatible with the latest iOS and Android smartphones and tablets.

The Clarius C3 and L7 wireless handheld ultrasound scanners are designed to be carried

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Light Therapy Could Revolutionize Early Prostate Cancer Care

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new photodynamic laser therapy for low-risk prostate cancer can effectively kill cancer cells while preserving healthy tissue, according to a new study.

Researchers at University College London (UCL, United Kingdom; www. ucl.ac.uk), Skäne University Hospital (Malmö, Sweden; vard.skane.se), and

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45 other European institutions conducted a study to examine the effectiveness of vascular-targeted photodynamic therapy (VTP) for treating lowrisk prostate cancer. The treatment involves injecting padeliporfin, a lightsensitive compound that releases free radicals when activated by light.

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3D Technology Maps the Brain During Surgery cont’d from cover

a customizable field of view projected onto a monitor and viewable by the entire operating team. Using three-dimensional (3D) visuals overlaid on an anatomical scan derived from preoperative imaging and volumetric anatomical and diffusion tensor imaging (DTI) renderings, the system can help visualize tractographic tool intersection and continuous tracking of multiple tools throughout a procedure, for real-time location updates within the surgical cavity. Until now, neurosurgeons have relied largely on conventional magnetic resonance imaging (MRI) scans that provide flat, two-dimensional renderings of the brain.

The three technologies – Guide, Vision, and Drive – are designed to work in concert in order to allow greater flexibility in both the navigation and execution of complex surgery, allowing surgeons to spend less time in manipulating cumbersome op-

tics, as well as permitting them to work in a comfortable, upright position while actively communicating with their staff during the procedure.

BrightMatter Guide, Vision, and Drive are approved by the U.S. Food and drug Administration (FDA).

“This technology allows for us to more safely enter the brain without disturbing the important pathways connecting the brain’s critical areas of operation,” said Keith Black, MD, chair of the Cedars-Sinai Medical Center (Los Angeles, CA, USA; www. cedars-sinai.edu) department of neurosurgery, the first medical center in California to employ Servo.

“An estimated 62,000 primary brain tumors and 150,000 metastatic brain tumors are diagnosed annually in the United States. This new tool offers us

a tremendous amount of hope for better outcomes for many of our patients.”

Image: The Servo tactographic system (Photo courtesy of Synaptive Medical).

Wireless Ultrasound Devices Guide Bedside Procedures cont’d from cover

around for quick exams and point-of-care (POC) procedures, with secure point-to-point wireless networking used to connect to an app on the selected devices. The Clarius C3 is a multipurpose ultrasound scanner for imaging the abdomen and lungs; it also incorporates virtual phased array for scans of the heart. The Clarius L7, on the other hand, is intended for guiding interventional procedures, such as nerve blocks and targeted injections, and for imaging superficial structures.

The ultrasound scanners are encased in a hard magnesium shell that is water submersible for easy cleaning and disinfection and for use in unpredictable environments, with features that include an intuitive user interface, “point and shoot” simplicity, automated gain and frequency settings. The wireless devices are powered by a rechargeable battery, which is easily exchanged when running low. The Clarius handheld ultrasound scanners are products of Clarius Mobile Health (Burnaby, BC, Canada; www.clarius.me), and have been approved by the U.S. Food and drug Administration (FDA).

“Physicians have been asking for a portable ultrasound system that works with their iPhone for some time. The challenge has been to make an affordable device that is small enough to carry around and that also produces great images,” said Laurent Pelissier, chairman and CEO of Clarius Mobile Health. “We are delighted to bring a new class of affordable and easy to use ultrasound to the medical community in the United States.”

“Clarius is the future of patient care. The image quality is amazing for any scanner, much less one that fits in my pocket,” said Steven Steinhubl, MD, director of digital medicine at the Scripps Translational Science Institute (La Jolla, CA, USA). “The ability to wirelessly connect it to any Apple or Android device means that anyone on my team can use it with whatever they already carry around in their pocket.”

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3D Printed Implants Advance Personalized Shoulder Reconstruction cont’d from cover

failed shoulder joint replacement. The patient must also be anatomically and structurally suited for the implants, and a functional deltoid muscle is necessary. The system uses computerized tomography (CT) scans and advanced three-dimensional (3D) reconstruction techniques to allow surgeons to personalize each patient’s implant.

The glenoid baseplate components are intended for cementless application, with the addition of Image: The Zimmer-Biomet screw fixation in patients with comprehensive vault unusual anatomy and/or extenreconstruction system (Photo sive bone loss. The system incourtesy of Zimmer-Biomet). cludes a cobalt alloy glenosphere, with titanium glenospheres availfor patients with severe glenoid deformities.” able for patients with cobalt alloy material sensitivity.

“The treatment options for extensive glenoid deInterlok finish humeral stems are intended for ceficiencies were limited to bone grafting or hemimented use, with MacroBond coated humeral stems arthroplasties, both of which were unreliable and with porous coated surface coating available for had marginal success,” said orthopedic surgeon press-fit or cemented biological fixation applications.

David Dines, MD, of the Hospital for Special Sur“The Comprehensive Vault Reconstruction Sysgery (HSS, New York, NY, USA; www.hss.edu). tem is another example of our commitment to ad“Comprehensive VRS represents an important addressing the clinical and unmet needs of shoulder vance in shoulder reconstruction by streamlining specialists,” said Orsa Britton, vice president and and personalizing the implant procedure in hope of general manager of Zimmer Biomet’s global extremmore predictable outcomes and results that extend ities business. “This innovative, patient-specific imbeyond pain relief, to restoring function and implant, coupled with extensive pre-operative planproving overall quality of life.” ning software, will expand viable treatment options

Pathogen Transmission Rife in Hospital Settings ospital rooms, not just the patients in them, can spread germs through contact with health care personnel, according to a new study.

Researchers at Duke University (Durham NC, USA; www.duke.edu) conducted a study to examine how pathogens cross the healthcare “transmission triangle”: patients, the environment, and the health care provider. During the study, they took cultures from the sleeves, pockets, and midriffs of a new set of surgical scrubs of 40 intensive care unit (ICU) nurses, both at the start and end of each shift.

Cultures were also collected from the bodies of all patients the nurse cared for during each shift, as well as and the patients’ room contents (bed, bedrail, and supply cart).

In all, the researchers collected 2,185 cultures from the nurses’ clothing, 455 from 167 patients, and 2,919 from the patients’ rooms. Molecular analysis identified organisms on the nurses’ clothing that were not present at the beginning of an ICU shift, but were present at the end. The researchers then looked for those same organisms in the samples collected from patients and their rooms, specifically searching for five pathogens known to cause difficult-to-treat infections, including Methicillin-resistant Staphylococcus aureus (MRSA).

During the shifts considered, the researchers confirmed 12 instances when at least one of the five

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pathogens was transmitted from the patient or the room to the scrubs. Six incidents each involved transmission from patient to nurse and room to nurse, and ten transmissions were from the patient to the room.

The researchers did not document any nurse-to-patient or nurse-to-room transmission. The pockets and sleeves of the scrubs were most likely to be contaminated, as were the bed rails in the rooms. The study was presented at the annual IDWeek meeting, held during October 2016 in New Orleans (LA, USA).

“This study is a good wake-up call that health care personnel need to concentrate on the idea that the health care environment can be contaminated,” said lead author and study presenter Deverick Anderson, MD, of the Duke University School of Medicine. “Any type of patient care, or even just entry into a room where care is provided, truly should be considered a chance for interacting with organisms that can cause disease.”

“I think sometimes there’s the misconception that if, for instance, a nurse is just talking to patients and not actually touching them, that it might be okay to skip protocols that help reduce pathogen transmission, like washing hands or wearing gloves,” concluded Dr. Anderson. “The study’s results demonstrate the need for caution whenever health care providers enter a patient room, regardless of the task they’re completing.”

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ISSN 0898-7270 Vol.35 No.1 • Published, under license, by Globetech Media LLC Copyright © 2017. All rights reserved. Reproduction in any form is forbidden without express permission.

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Fungus Key Factor In Crohn’s Disease cont’d from cover

cures for the debilitating inflammatory bowel disease. The study was conducted by an international research team, co-led by Mahmoud A Ghannoum, PhD, professor at Case Western Reserve University School of Medicine, (Cleveland, OH, USA; http:// case.edu/medicine) at University Hospitals Cleveland Medical Center. “We already know that bacteria, in addition to genetic and dietary factors, play a major role in causing Crohn’s disease,” said Prof. Ghannoum, “Essentially, patients with Crohn’s have abnormal immune responses to these bacteria, which inhabit the intestines of all people.

While most researchers focus their investigations on these bacteria, few have examined the role of fungi, which are also present in everyone’s intestines. Our study adds significant new information to understanding why some people develop Crohn’s disease. Equally important, it can result in a new generation of treatments, including medications and probiotics, which hold the potential for making qualitative and quantitative differences in the lives of people suffering from Crohn’s.”

Bacteria as well as fungi are present throughout the body; Prof. Ghannoum’s lab previously found that people harbor 9-23 fungal species in their mouths. In the new study, by analyzing fecal samples, the researchers assessed the mycobiome and bacteriome of: (a) 20 Crohn’s disease patients and 28 Crohn’s-free individuals from among their firstdegree relatives in 9 families; and of (b) 21 Crohn’s-

free individuals from 4 Crohn’s-free families.

The results showed strong fungal-bacterial interactions in those with Crohn’s disease: two bacteria (Escherichia coli and Serratia marcescens) and one fungus (Candida tropicalis) moved in lock step. The presence of all three in the Crohn’s patients was significantly higher compared to their healthy relatives, suggesting that the bacteria and fungus interact in the intestines. In vitro experiments showed that the three work together to produce a biofilm – which can prompt intestinal inflammation that results in the symptoms of Crohn’s disease. The researchers observed that E. coli cells fused to the fungal cells and S. marcescens formed a connecting bridge.

This is first report linking a fungus to Crohn’s in humans; previously it was only found in model Crohn’s disease mice. The study is also the first to include S. marcescens in the Crohn’s-linked bacteriome. The researchers also found that the presence

of beneficial bacteria was significantly lower in the Crohn’s patients, corroborating previous findings.

“Among hundreds of bacterial and fungal species inhabiting the intestines, it is telling that the three we identified were so highly correlated in Crohn’s patients,” said Prof. Ghannoum, “Furthermore, we found strong similarities in what may be called the ‘gut profiles’ of the Crohn’s-affected families, which were strikingly different from the Crohn’s-free families. We have to be careful, though, and not solely attribute Crohn’s disease to the bacterial and fungal makeups of our intestines. For example, we know that family members also share diet and environment to significant degrees. Further research is needed to be even more specific in identifying precipitators and contributors of Crohn’s.” The study, by Hoarau G, Mukherjee PK, et al, was published September 20, 2016, in the journal mBio.

Bedside Monitor Analyses Blood Gases and Glucose n updated sensor monitors blood gases and blood glucose frequently and directly, enabling earlier interventions and closer patient management.

The next-generation Sphere Medical (Cambridge, United Kingdom; www.spheremedical.com) Proxima system includes an in-line disposable sensor that contains an array of electrochemical biosensors on a silicon chip, and a medical grade tablet device with an intuitive touch screen user interface.

The system is used for monitoring blood gases and electrolyte levels (including pH, pCO2, pO2, hematocrit, and K+), and blood glucose levels over a 72 hour period for as many times as required, with results displayed on the dedicated bedside tablet.

All results are seamlessly transferred directly into the hospital laboratory information systems and electronic medical records (EMRs). Since the disposable sensor remains connected to the patient via their arterial line, a significant reduction in time to results is provided, when compared to conventional benchtop analyzers. This makes it particularly useful in the management of influenza, acute respiratory distress (ARDS), severe sepsis, trauma, traumatic brain injury (TBI), and other vulnerable conditions that require isolation in order to prevent contact and droplet-spread.

Arterial blood gas analysis measures the blood gas tension values of arterial oxygen tension (PaO2), arterial carbon dioxide tension (PaCO2), acidity (pH), and arterial oxygen saturation (SaO2), among others.

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The FAST Sphyg cuff inflator and aneroid sphygmomanometer features a unique push button inflation method, which reduces hand a wrist strain.

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Study: Prostate Cancer Patients Usually Die of Other Diseases

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new study implies that regularly scheduled prostate specific antigen (PSA) screening has no effect on prostate cancer mortality

rates.

Researchers at the U.S. National Cancer Institute (NCI, Rockville, MD, USA; www.cancer.gov), the University of Colorado (Boulder, USA; www. colorado.edu), and other institutions presented the updated findings of the Prostate, Lung, Colorectal, and Ovarian (PLCO) trial, which screened 76,685 men and 78,216 women for prostate, lung, colorectal, and ovarian cancers between 1993 and 2001.

The Intervention-arm men received annual PSA tests for SIX years and digital rectal examinations for four AQ years, while the control arm underwent opportunistic screening.

The researchers linked results with the U.S. National Death Index to extend mortality follow-up to a maximum of 19 years. The results revealed 255 deaths from prostate cancer in the intervention arm and 244 deaths in the control arm, a rate ratio (RR) of 1.04. For comparison, the RR for all-cause mortality was 0.977. But according to researchers, the results don’t necessarily negate the value of PSA

screening, but rather imply that within the data are clues for personalized decisions for subsets of the prostate cancer population.

The study was published in the November 2016 issue of Cancer.

“I treated a guy who’d been diagnosed in his 40s; we did surgery, but then a year later he was diagnosed with melanoma. It turned out that at the same time, his sister was diagnosed with triple-negative breast cancer and died within the year,” said study co-author David Crawford, MD, of the University of Colorado Cancer Center. “Being diagnosed with prostate cancer in your 40s is a red flag that there might be a germline mutation to blame, predisposing these men and maybe family members who share the mutation to more aggressive cancers.”

The conventional PSA test for prostate cancer has been used for nearly 30 years and is not specific enough to delineate between malignancies and non-malignant diseases of the prostate, such as benign prostatic hyperplasia (BPH). In fact, the U.S.

Preventive Services Task Force (USPSTF, Rockville, MD, USA; www.uspreventiveservicestaskforce.org) claims that evidence suggests the potential harms caused by PSA screening of healthy men as a means of identifying prostate cancer outweigh its potential to save lives, and that routine annual screening should be eliminated in the healthy.

Image: A new study suggests PSA tests may hold no prostate cancer screening benefit (Photo courtesy of 123rf.com).

Nanochannel Implant Could Revolutionize Drug Delivery cont’d from cover

nanofluidic membrane with thousands of parallel nanochannels. Using a concentration-driven diffusive transport, the nanochannel membrane platform is capable of sustained delivery of chemotherapy drugs, radio-sensitization agents, immunomodulation therapy, and imaging contrast agents, among others.

A minimally invasive, percutaneous trocar delivery method assists serial implantation throughout a target tissue volume. The capsule can deliver medicinal doses for several days or a few weeks, making it especially suited to treating cancer. A larger version may provide constant delivery of

HIV-battling drugs for over a year. The system could also be used to deliver cortisone to damaged joints in order to avoid painful, frequent injections, and possibly even to pursue immunotherapy treatments for cancer patients. The study was published in the October 2016 issue of the Journal of Biomedical Nanotechnology.

“The idea behind immunotherapy is to deliver a cocktail of immune drugs to call attention to the cancer in a person’s body, so the immune system will be inspired to get rid of the cancer itself,” said lead author assistant professor of mechanical engineering Lyle Hood, PhD, of UTSA. “The problem with most drug-delivery systems is that you have a

specific minimum dosage of medicine that you need to take for it to be effective. There’s also a limit to how much of the drug can be present in your system so that it doesn’t make you sick.”

NEMS are a class of devices integrating electrical and mechanical functionality on the nanoscale, forming the logical next miniaturization step from so-called microelectromechanical systems (MEMS). The name derives from typical device dimensions in the nanometer range, leading to low mass, high mechanical resonance frequencies, potentially large quantum mechanical effects such as zero point motion, and a high surface-to-volume ratio.

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Medical Disaster Drone Demonstrates Lifesaving Capabilities ew ambulance drones can support victims and rescue personnel during mass shootings, bombings, or other terrorist attacks. Developed at the William Carey University College of Osteopathic Medicine (WCUCOM; Hattiesburg, MS, USA; www.wmcarey.edu), the new drones are part of the ongoing Health Integrated Rescue Operations (HiRO) telemedical drone project. The ambulance drones are designed to carry telemedical packages to operators in adverse conditions, providing immediate and secure access to a physician on the other end of the screen to provide guidance amidst the chaos and confusion of a disaster situation. The telemedical packages can treat up to 100 people with significant to minor injuries.

To do so, the critical care kit includes Google Glass, which allows the wearer to be hands free and to move away from the drone while still maintaining audio and visual contact with the physician, who can provide simple, direct, and user friendly guidance to empower the provider and bystanders to save lives.

The technology debuted in a simulated mass casualty scenario held during December 2016 at John Bell Airport (Bolton, MS, USA), before an audience that included Mississippi state governor Phil Bryant and representatives from the U.S. Department of Homeland Security, Federal law enforcement agencies, and the United Nations.

“Reaching the victims is the critical challenge in these situations. As an osteopathic physician, my goal was to find ways to help save lives. A medical drone is the bridge that delivers life-saving treatment directly to the victims, giving remote physicians eyes, ears, and voice to instruct anyone on site,” said drone co-developer Italo Subbarao, DO, senior associate dean at WCUCOM, an expert in disaster and emergency medicine.

“These drones have impressive lift and distance capability, and can be outfitted with a variety of sensors, such as infrared, to help locate victims,” said Dennis Lott, director of the unmanned aerial vehicle program at Hinds Community College (Raymond, MS, USA; www.hindscc.edu). “Working together, we’re

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able to develop, test, and bring this technology to the field. It is just a matter of time before the drones are universally adopted for emergency and disaster response toolkits.”

Image: An advanced ambulance drone can help treat victims in disaster situations (Photo courtesy of WCUCOM).

Biodegradable Capsule Aids Hemophilia Treatment new study describes how an innovative biodegradable capsule that uses hydrophilic carriers for oral delivery of hematological factor IX (hFIX) can treat hemophilia B. Developed by researchers at the University of Texas (UT; Austin, USA; www.utexas.edu), the oral delivery system is based on a pH-responsive polymer hydrogel microcarrier system that carries the prophylactic hFIX particles. The poly (methacrylic acid)-grafted-poly(ethylene glycol) [P(MAA-g-EG)] polymer, synthesized using ultraviolet (UV) polymerization, is subsequently joined with an enzymatically degradable peptide crosslinking agent that allows for sitespecific degradation (by trypsin) in the small intestine.

As it moves through the body, the particle-containing capsule resists the major gastric enzyme in order to remain intact while in the stomach, protecting the encapsulated drug.

When in the small intestine, the capsule begins to swell with the increase in pH, and is subsequently degraded by the minor intestinal enzyme, slowly releasing the drug over time. In study models, the system successfully

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transported hFIX, and was able to deliver adequate levels of the drug to the target site in the small intestine.

The study was published on November 15, 2016, in the International Journal of Pharmaceutics.

“While an oral delivery platform will be beneficial to all hemophilia B patients, patients in developing countries will benefit the most,” said lead author Sarena Horava, PhD, of the UT Cockrell School of Engineering.

“In many developing countries, the median life expectancy for hemophilia patients is 11 years due to the lack of access to treatment, but our new oral delivery of factor IX can now overcome these issues and improve the worldwide use of this therapy.”

Hemophilia B is a blood clotting disorder caused by a mutation of the factor IX gene, leading to a deficiency of factor IX. It is the second-most common form of hemophilia, and is sometimes called Christmas disease, after Stephen Christmas, the first patient described with the affliction. Presentation of hemophilia B is consistent with easy bruising, urinary tract bleed, and nosebleeds. Current protein replacement therapies rely on intravenous (IV) injections and infusions.

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Diagnostic Tool Helps Identify Familial Mediterranean Fever new study describes how immunological screening can help diagnose Familial Mediterranean Fever (FMF), which is particularly common among Mediterranean populations.

Researchers at Ghent University (Belgium; www.ugent.be) and the Flanders Interuniversity Institute for Biotechnology (VIB; Ghent, Belgium; www.vib.be) developed the new tool, which differentiates FMF patients from those suffering from other autoinflammatory diseases or healthy individuals. The immunological screening tool is based on inflammasome activation, by detecting changes in the body’s immune reaction to pyrin, a protein usually mutated in FMF. Pyrin inflammasome activation persists in the peripheral blood mononuclear cells (PBMCs) of FMF patients, but not in the cells of patients afflicted with other autoinflammatory diseases. The researchers used Clostridium difficile and its enterotoxin A (TcdA) as the Pyrin-activating agents, and showed that wild-type and FMF pyrin are differen-

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tially controlled by cell microtubules. Following successful tests on mice, it has been validated in 13 patients in collaboration with physicians from Belgium and Italy.

The study was published on October 28, 2016, in PNAS. “We are setting up clinical trials in Belgium for which we are actively seeking volunteers, both FMF patients and people suffering from related inflammatory disorders,” said lead author Professor Mohamed Lamkanfi, of VIB and Ghent University. “In addition, labs from the Netherlands and Italy have already expressed interest. We are also exploring possible collaborations with industrial partners in order to make our method available as a diagnostic kit.”

FMF is a hereditary disease caused by mutations in Mediterranean Fever gene, which encodes a amino acid protein called pyrin. While all ethnic groups are susceptible to FMF, it usually oc-

curs in the Mediterranean basin, including the Middle East and the Caucasus. It has a prevalence of 1-2 patients per 1,000 inhabitants. FMF is usually diagnosed during childhood, after which a daily, lifelong treatment is necessary. Wrong or late diagnosis often even leads to unnecessary surgery and, ultimately, kidney failure due to amyloid accumulation.

Image: A new screening technique can identify FMF (Photo courtesy of 123RF).

Duration of Resuscitation Impacts Favorable Outcomes horter resuscitation times of out-of-hospital cardiac arrest (OHCA) patients have a positive impact on favorable functional outcomes, according to a new study.

Researchers at Michigan State University (East Lansing, MI, USA; www.msu.edu), the University of Alabama (Birmingham, USA; www.uab.edu), and other institutions conducted an analysis of a large, multi-center, study involving 11,368 patients (median age 69, 62.6% male), who were resuscitated by emergency medical services (EMS) following OHCA. The primary exposure of the analysis was duration of resuscitation, defined by return of spontaneous circulation (ROSC) or termination of resuscitation. The primary outcome was survival to hospital discharge.

Patients were additionally classified into those who survived with unfavorable outcome, those

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who had ROSC but did not survive, and those without ROSC. Accrual was plotted as a function of resuscitation duration, and the dynamic probability of favorable outcome at discharge was estimated for the whole cohort and in subgroups. The results revealed that 35.4% of the patient’s achieved ROSC, 10.8% survived to hospital discharge, and 8% survived to hospital discharge with favorable outcome.

The distribution of cardiopulmonary resuscitation (CPR) duration differed by outcome; for CPR duration of up to 37 minutes, 99% of patients with eventual favorable outcome at discharge had achieved ROSC. The probability of favorable outcomes declined over longer resuscitation duration, but subjects with initial shockable cardiac rhythm, witnessed cardiac arrest, and bystander CPR were more likely to survive with favorable outcome after

prolonged efforts (30-40 minutes). The study was published on October 19, 2016, in Circulation.

“Adjusting for prehospital and inpatient covariates, resuscitation duration was associated with survival to discharge with eventual favorable outcome,” concluded lead author Joshua Reynolds, MD, of the MSU College of Human Medicine, and colleagues. “Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge. Subjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes.”

The 2010 American Heart Association (AHA) guidelines for hands-only CPR call for at least 100 chest compressions per minute for at least two minutes, at a depth of at least two inches in the center of the victim’s chest prior to using an AED machine.

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Critical Care

Oral Antibiotics Preferred For Pediatric Pneumonia hildren with complicated pneumonia should be discharged from the hospital with oral instead of intravenous (IV) antibiotics when possible, according to a new study.

Researchers at Cincinnati Children’s Hospital (OH, USA; www.cincinnatichildrens.org), the University of Pennsylvania (PA, USA; www.upenn. edu), and other institutions conducted a multicenter retrospective cohort study of data from the Pediatric Health Information System (PHIS) to compare effectiveness and treatment-related complications of post-discharge antibiotics administered via a peripherally inserted central venous catheter (PICC), or administered orally. The study included 2,123 children from 36 hospitals who received oral (1,842) and PICC (281) antibiotics that were discharged with

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complicated pneumonia between 2009 and 2012.

The results showed no significant differences in treatment failure rates between PICC and oral antibiotics. Conversely, children discharged with PICCs experienced a higher rate of infections, adverse drug reactions, and hospital readmissions, with PICC complications occurring in 7.1% of children who received intravenous antibiotics. In addition, 17.8% of the children who received IV antibiotics required unplanned or emergency care, compared with only 3.1% of children who received oral antibiotics. The study was published on November 17, 2016, in Pediatrics.

Image: Research shows oral antibiotics following pneumonia in children show good results (Photo courtesy of Masterfile).

Clostridium Difficile Infection Risk Higher in Subsequent Hospital Bed Patients ospital patients who followed a prior bed occupant that received antibiotics had an increased risk for contracting Clostridium difficile infection (CDI), according to a new study.

Researchers at New York-Presbyterian Hospital/Columbia University Medical Center (NYP; New York, NY, USA; www.nyp.org) and Columbia University Medical Center (CUMC, New York, NY, USA; www.cumc. columbia.edu) conducted a retrospective cohort study of 100,615 paired adult patients hospitalized between 2010 and 2015. Patients were excluded if they had recent CDI, developed CDI within 48 hours of admission, had inadequate follow-up time, or if their prior bed occupant was in the bed for less than 24 hours.

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The primary exposure was receipt of antibiotics by the prior bed occupant, and the primary outcome was incident CDI in the subsequent patient to occupy the same bed, defined as a positive result from a stool polymerase chain reaction (PCR) for the C difficile toxin B gene, followed by treatment for CDI. In all, 576 (0.57%) of the secondary patients developed CDI within 2 to 14 days, representing a 22% hazard ratio after adjustment for CDI risk factors, including receipt of antibiotics by the second patient. The study was published on October 10, 2016, in JAMA Internal Medicine.

“These data imply that patient-topatient transmission of C. difficile or other bacteria that mediate susceptibility to CDI takes place in the nonoutbreak setting and in the face of a

multifaceted effort seeking to prevent healthcare-associated CDI,” concluded lead author Daniel Freedberg, MD, MSc, of NYP, and colleagues.

CDI is a serious illness resulting from infection of the internal lining of the colon by C. difficile bacteria, and typically develops after the use of broad-spectrum antibiotics that disrupt

normal bowel flora. C. difficile exists in the environment as a dormant spore; to colonize the gut, the spores need to germinate and turn in active, toxin-producing bacteria. Antibiotics that alter gastrointestinal microbiota facilitate this germination, leading to CDI, the leading cause of nosocomial diarrhea in industrialized countries.

Multi-Purpose Label Identifies Equipment Hygiene new label addresses one of the many unique challenges healthcare facilities are tasked with daily – identifying whether medical equipment is clean or dirty.

The Healthmark Industries (Fraser, MI, USA; www.hmark.com) Multi-Purpose Equipment Label is designed to provide high visibility to healthcare professionals in order to correctly confirm the status of medical equipment. Two pull-off tabs are used to indicate the hygiene state of the equipment. A green “CLEAN” tab indicates that equipment is ready for use. Once it is functional, the green tab is pulled, revealing a yellow “IN USE” tab.

Once the medical equipment needs to be cleaned or disposed of, a

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blank white tab is pulled, revealing the red “DIRTY” label. Spaces are provided to indicate the date and location equipment use was initiated. The brightly colored, pull-tab style 5 x 7.5 cm label has an adhesive backing that does not leave residue behind. The Multi-Purpose Equipment Label is available for purchase in rolls of 250.

Infection control is one of the major challenges facing healthcare today, and demands a range of novel approaches to battle the issue, including strict monitoring of antibiotic use, regular revision of standard treatment guidelines, public educational campaigns, better implementation of basic hygienic routines, and re-assessment and improvement of infection control interventions, among others.

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Critical Care

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Innovative Sleep Apnea Masks Increase Treatment Efficacy ew-generation positive airway pressure (PAP) masks improve fit, comfort, and ease of use in the treatment of obstructive sleep apnea (OSA).

The ResMed (San Diego, CA, USA; www.resmed.com) AirFit N20 and AirFit F20 masks feature an innovative silicone cushion, the InfinitySeal, which adapts to the unique facial contours of each patient in order to increase comfort, improve fit, and reduce leakage. The non-invasive, vented N20 mask provides an air seal around the patient’s nose and upper lip, while the F20 covers the mouth as well. The masks are held in place with adjustable head straps, and connect to a continuous PAP (CPAP) device air delivery hose via a standard 22mm swivel.

The masks are comprised of four sub-assemblies: a plush headgear to assists in a more comfortable night’s therapy; flexible fabric-lined frame for added comfort, with built-in easy to use magnetic clips for quick fitting; the InfinitySeal silicone cushion; and an elbow/short tube assembly, which also incorporates the exhaust port.

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Tests demonstrated that the AirFit N20 fit an astonishing 99% of patients tested, and the AirFit F20 fit 97%, regardless of facial structure, gender, or age.

“These new masks address two of the biggest catalysts for effective sleep apnea treatment: fit and comfort,” said Mick Farrell, CEO of ResMed. “Patients rate mask comfort as the number one reason that can help them stay on therapy. Not only are the F20 and N20 our most comfortable Image: The AirFit N20 and AirFit F20 facemasks (Photo courtesy of Res-Med). masks ever, they’re easier and faster for clinisible, therefore reducing or preventing that prevents the apneas. This has the cians to fit on patients the first time, apneas and hypopneas. It is important additional benefit of reducing or elimhelping more people suffering from to understand that it is the air presinating the extremely loud snoring sleep apnea adhere to this life-changsure, and not the movement of the air, that sometimes accompanies OSA. ing therapy.”

CPAP devices deliver a stream of compressed air via a hose to a nose mask, keeping the airway open so that unobstructed breathing becomes pos-

Plasma Jets Facilitate Transdermal Drug Delivery

new study describes how atmospheric microplasma irradiation (AMI) can be used to decrease the barrier function of skin and adapt it for transdermal drug delivery.

Researchers at Shizuoka University (Japan; www.shizuoka.ac.jp) used a plasma jet and a microplasma discharge method in order to investigate the barrier function of the stratum corneum – the outermost skin layer – of Yucatan micropig skin, which was chosen because of its similarities to human skin. The physical changes following plasma jet administration in the pig skin were studied microscopically, with the researchers focusing specifically on changes in the outer skin layer using Attenuated Total Reflectance – Fourier Transform InfraRed (ATR-FTIR) spectroscopy.

The ATR-FTIR spectra provides precise information about water content, the lipid bilayer, and proteins in the stratum corneum, all related directly to the skin’s permeability. The researchers found that when using AMI, which conducts electricity, they could successfully decrease the skin’s barrier function for transdermal drug delivery. A tape-stripping test – an evaluation method for skinbarrier performance – was also conducted to compare with AMI, confirming the findings. The study was

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presented at the 63rd AVS International Symposium and Exhibition, held during November 2016 in Nashville (TN, USA).

“Our data suggested that dye pathways through skin samples could be related to the dynamic behavior of intercellular lipid bilayers, suggesting that AMI could enhance percutaneous absorption,” said lead author and study presenter electrical engineer Marius Blajan, MSc, of the Shizuoka University Innovation and Joint Research Center.

Delivering drugs through needles presents risks of infection to patients, not to mention causing pain and discomfort. Oral delivery of drugs, on the other hand, can prove toxic and can be less effective than more direct methods, unless higher does are administered.

Transdermal delivery, where the drug is absorbed into the blood stream through the skin, provides an ideal solution, but only a fraction of drugs currently on the market can be administered this way because skin, by its very nature, is difficult to permeate, a characteristic measured by its barrier function.

Plasma is one of the four fundamental states of matter, the others being solid, liquid, and gas. The plasma stream contains charged particles: positive ions and negative electrons or ions, accompanied by dissociation of molecular bonds.

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Critical Care

Fatty Acid Levels Could Help Predict Psychosis Risk novel probabilistic model that combines history, clinical assessment, and fatty-acid biomarkers could help predict transition to first-episode psychosis, claims a new study.

Researchers at the University of Adelaide (UA; Australia; www.adelaide.edu.au), the Medical University of Vienna (Austria; www.meduniwien. ac.at), and other institutions conducted a study in 40 patients in Austria to explore if a probabilistic model that combine medical historical, clinical risk factors, oxidative stress and cell membrane fatty acids biomarkers, and resting quantitative electroencephalography (qEEG), could improve the identification of patients with ultra-high risk (UHR) of psychosis.

The researchers then analyzed concurrent and baseline data of the study cohort, who overall exhibited a 28% one-year transition rate to psychosis.

They then clustered several significant variables into historical (history of drug use), clinical (Positive and Negative Symptoms Scale [PNSS] and Global

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Assessment of Function [GAF] scores), and biomarker (total omega-3, nervonic acid) groups, and calculated the post-test probability of transition for each group separately and for group combinations, using the odds ratio form of Bayes’ rule.

The results showed that the combination of all three variable groups vastly improved the specificity of prediction. The model identified over 70% of UHR patients who transitioned within one year, compared with 28% identified by standard UHR criteria. The model classified 77% of cases as very high or low risk based on history and clinical assessment, suggesting that a staged approach, which reserved fatty-acid markers for 23% of cases remaining at intermediate probability following bedside interview, could be the most efficient. The study was published on September 20, 2016, in the Translational Psychiatry.

“Currently, all patients in the ultra-high risk group are considered to have a similar chance of a future psychotic episode; however, we have been

able to identify high, intermediate and low-risk groups. The model may help clinicians to decide when a patient’s risk of psychosis outweighs any side effects of treatment,” said lead author psychiatrist Scott Clark, MD, of the University of Adelaide.

“Fatty acids such as omega-3 and nervonic acid are critical for the normal functioning of the brain, and low levels have been associated with the development of psychosis in high-risk groups.”

The concept of clinical UHR for psychosis was developed to facilitate early detection and intervention, and is defined by a cluster of subthreshold psychotic symptoms. These can include perceptions, such as hallucinations; thinking - for example, ideas of reference, odd beliefs, or magical thinking; and trait risk factors like a family history of psychosis. These are accompanied by impairment in day-to-day function. In recent meta-analysis, studies show that less than 30% of UHR patients will have transitioned to psychosis three years after identification.

Oxygen Holds Negligible Benefit for Mild COPD xygen therapy may not help chronic obstructive pulmonary disease (COPD) patients with moderate desaturation, according to a new study.

Researchers at Johns Hopkins University School of Medicine (Baltimore, MD, USA; www.hopkinsmedicine. org/com) conducted a randomized trial involving 738 patients with stable COPD and moderate exercise-induced desaturation. The patients were randomly assigned to receive long-term supplemental oxygen, or not. In the supplemental-oxygen group, patients with resting desaturation were prescribed 24-hour oxygen, while those with moderate desaturation – i.e., only during exercise – were prescribed oxygen during exercise and sleep.

The results, across 42 treatment centers and follow-up of 1-6 years, showed no significant difference between the supplemental-oxygen group and the group without added oxygen in time to death or first hospitalization, nor in total hospitalizations rates, COPD exacerbation rates, and COPD-related hospitalizations. There was no consistent between group differences in measures of quality of life, lung function, and the distance walked in six minutes.

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The study was published in the October 27, 2016, issue of the New England Journal of Medicine (NEJM).

“The consistency of the null findings strengthens the overall conclusion that long-term supplemental oxygen in patients with stable COPD and resting or exercise-induced moderate desaturation has no benefit with regard to the multiple outcomes measured,” concluded lead author Robert Wise, MD, and colleagues.

“Our data support the conclusions of earlier studies that among patients with COPD who have a resting SpO2 of more than 88%, long-term treatment with supplemental oxygen does not result in longer survival than no long-term supplemental oxygen therapy, regardless of whether the patients have exercise-induced desaturation.”

“Since a lack of evidence of effect is not evidence of a lack of any clinical effectiveness, a trial of oxygen use might still be appropriate in selected patients with moderate exertional hypoxemia and intractable breathlessness despite appropriate evidencebased treatment,” commented Magnus Ekström, MD, PhD, of Lund University (Sweden; www.lu.se), in an accompanying editorial. “I think that the oxygen treatment should be evaluated by means of blinded exercise tests while the patient is breathing ambient air or oxygen, and discontinued if the patient perceives no benefit during the test or within a day or two after it.”

Two trials that were conducted in the 1970s showed that long-term

treatment with supplemental oxygen reduced mortality among patients with chronic obstructive pulmonary disease (COPD) and severe resting hypoxemia. These results led to the recommendation that supplemental oxygen be administered to patients

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with a SpO2 of less than 89%. In the 1990s, two other trials evaluated the long-term treatment with supplemental oxygen in patients with COPD who had mild-to-moderate daytime hypoxemia; neither trial showed a mortality benefit.

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DESKTOP SPIROMETER

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The KMO-121 monitors vital signs such as ECG, SPO2, NIV BP, respiratory rate and temperature, with options for monitoring invasive blood pressure and ETCO2 (end Tidal CO2). It has a 12.1inch color LCD display, and records and displays 480 hours of trends in graphic and tabular form.

The Rad-97 features a color display with userfriendly multi-touch navigation, allowing clinicians to easily customize the device to best suit their needs. It allows users to rapidly configure the device for accommodating different patients, and provides built-in wireless connectivity.

The Spirolab offers a wide range of selectable parameters, along with a fast and silent built-in printer with customizable format. Its 7-inch touch screen allows each function to be easily activated, and it is capable of storing up to 10,000 spirometry tests or 900 hours of oximetry recordings.

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Next-Generation Stethoscope Upgrades Auscultation new digital stethoscope wirelessly pairs with Android or iOS devices, allowing clinicians to securely record, save, annotate, and share heart sounds with experts. The Eko Core digital stethoscope enables remote clinical examination in any location, from a patient in their own home, to a paramedic in an ambulance or a care worker in a residential setting. The Eko Core stethoscope can be switched between analogue and digital modes, and can be sold either as a complete digital setup or as a digital conversion attachment for upgrading traditional Littmann Cariology III-style analog stethoscopes.

Features include x40 sound amplification and noise reduction capabilities.

Using a Bluetooth-connected mobile app, clinicians can study a visual representation of the heart sound waveform, save the heart sounds directly to a patient’s electronic health record (EHR), and securely collaborate with a cardiologist for a second opinion. The Eko Core is a product of Eko Devices (Berkley, CA, USA; www.ekodevices.com), and has received both the European Community CE mark of approval and the approval of the U.S. Food and Drug Administration (FDA).

“As many as 80% of internal medicine residents misdiagnose common murmurs with their stethoscope, so the idea was to build a ‘smart stethoscope’ to assist clinicians in their decision-making process,” said Connor Landgraf, CEO and co-founder of Eko. “Given the million heart disease patients in the UK, this has tremendous potential to help clinicians who are less specialized in cardiovascular medicine to detect and manage heart problems, saving significant NHS resources.”

“I use the Eko stethoscope in my GP surgery daily, it switches seamlessly between analogue and digital, the amplification works well, and the ability to

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share information with patients is really interesting aspect,” said digital healthcare innovator Keith Grimes, MD. “I had a mother who was concerned her son had a heart murmur; using the digital stethoscope connected to my phone she was able to hear it and be reassured that it was normal.”

Image: The Eko Core digital stethoscope (Photo courtesy of Eko Devices).

Hospital-Administered Antibiotics Linked to Sepsis Risk xposure to antibiotics that disturb the healthy microbiome during a hospital stay can sharply increase the risk of sepsis or septic shock after discharge, according to a new study. Researchers at the U.S. Centers for Disease Control and Prevention (CDC; Atlanta, GA, USA; www.cdc.gov) conducted a retrospective cohort study of the Truven Health MarketScan hospital drug database, which includes demographic, treatment, and hospital admission and discharge data; the database also includes pharmacy data, making it possible to track antibiotic use. The researchers obtained data on 12.7 million hospital stays in 516 U.S. facilities between 2006 and 2010, including 18,307 stays that were associated with sepsis admission within 90 days of discharge.

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The researchers then defined a list of antibiotics with a high risk of disturbing the microbiome, including third- or fourth-generation cephalosporins, fluoroquinolones, lincosamides, beta-lactam/betalactamase inhibitor combinations, oral vancomycin, and carbapenems. Earlier cephalosporins, tetracycline, and sulfa drugs were regarded as low-risk, while control antibiotics, such as penicillin, were thought to have limited potential to disrupt the microbiome. The primary endpoint was the risk of sepsis following use of those drugs, compared with no antibiotic use.

The results showed that in 43% of the hospital stays, patients had not been given any antibiotics, while patients got high-, low-, and no-risk drugs in 28%, 24%, and 5% of the stays, respec-

tively. Upon analysis, the odds ratio for sepsis was 1.78 following high-risk drugs, 1.1 following low-risk drugs, and 1.22 after no-risk drugs. Duration of therapy also played a role; regardless of drug type, patients treated for more than 14 days had twice the risk of later sepsis as those given shorter therapy, with an odds ratio of 2.4. The study was presented at the annual IDWeek meeting, held during October 2016 in New Orleans (LA, USA).

IDWeek brings together four organizations that focus on infectious disease – the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), the HIV Medicine Association (HIVMA), and the Pediatric Infectious Diseases Society (PIDS).

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Critical Care

IV Drip Failure Reduced

By Skin Glue Application sing medical cyanoacrylate skin glue to hold intravenous (IV) drips in place significantly reduces the need to replace them, according to a new study.

Researchers at Caboolture Hospital (Australia; www.health.qld.gov.au/ caboolture), the University of Queensland (Brisbane, Australia; www.uq. edu.au), and other institutions conducted a randomized, controlled trial of 380 peripheral IV catheters inserted into 360 adult patients to examine if failure rates could be reduced by the addition of a cyanoacrylate skin glue to standard care. The primary outcome was peripheral IV catheter failure at 48 hours, regardless of cause, and secondary outcomes were rates of specific failure causes, including infection, phlebitis, occlusion, or dislodgement.

The results showed that peripheral IV catheter failure was 10% lower with skin glue (17%) than standard care (27%), and IV drip dislodgement was 7% lower. Phlebitis and occlusion were also lower with skin glue,

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but were not statistically significant, and there were no infections. Empirically, the researchers reported that they found that using medical-grade superglue made IV lines five times harder to pull out. The study was published in the August 2016 issue of Annals of Emergency Medicine.

“We found that by using medical skin glue, we could reduce the failure rate to below 17%. The glue made IV lines harder to unintentionally remove, and was also shown to kill the bacteria that most commonly cause infections,” said lead author Simon Bugden, MD, of the department of emergency medicine. “The other major benefit was patient comfort, with patients in the trial reporting that the glue caused less irritation and they were less worried about the lines falling out.”

“There has been no improvement to the current procedure of inserting and securing IV lines in several decades, despite the rate of failure,” commented Professor Sally McCarthy, of the Emergency Medicine

Virtual Reality Helps Diagnose Systemic Dizziness Episodes n innovative portable technology provides a convenient and inexpensive method for diagnosing vestibular system disorders.

Developed jointly by researchers at Kaunas University of Technology (KTU; Lithuania; www.ktu.edu) and the Lithuanian University of Health Sciences (LSMU; Kaunas; www. lsmuni.lt), the technology is based on the Myo armband, a gesture recognition device worn on the forearm manufactured by Thalmic Labs (Kitchener, Canada; www.thalmic. com), which enables the user to control technology wirelessly using various hand motions, interpreted using a set of electromyographic (EMG) sensors.

The EMG sensors identify electrical activity in the forearm muscles, which is then combined with a gyroscope, accelerometer, and magnetometer to recognize the gestures.

The researchers analyzed data from the Myo, combining it with additional input from Samsung (Seoul, Korea; www.samsung.com) virtual reality (VR) software, synchronizing between the different programming languages and environments in order to analyze vestibular conditions. The

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technology is currently being tested with healthy volunteers.

“Dizziness is a very common health disorder, experienced by both young and older people. Strong systemic dizziness, followed by imbalance, nausea, paleness, and perspiration interferes with human activities and can cause great anxiety,” said lead author Professor Ingrida Ulozien, PhD, of LSMU. “If the condition persists, the quality of life, mood and work efficiency suffers. Sometimes dizziness can be a symptom of more serious diseases. Unfortunately, the condition is relatively difficult to diagnose.”

The vestibular system includes the parts of the inner ear and brain that process the sensory information involved with controlling balance and eye movements. Commonly diagnosed vestibular disorders include benign paroxysmal positional vertigo (BPPV), labyrinthitis and vestibular neuritis, Ménière’s disease, secondary endolymphatic hydrops, and perilymph fistula. Other problems related to vestibular dysfunction include vestibular migraine and complications from autoimmune disorders and allergies.

Foundation of Australia (EMF; Brisbane, Australia; http://emergency foundation.org.au), who helped fund the study. “Dr. Bugden’s method could be simply and cost-effectively introduced in hospitals worldwide. EMF is committed to ensuring Australia continues to stay at the forefront of emergency medicine care by funding to dedicated research in this field.”

Cyanoacrylates are a family of strong fast-acting adhesives with industrial, medical, and household uses, and are known generically as in-

stant glues or superglues. The acrylic resin base rapidly polymerizes in the presence of water, forming long, strong chains that join the bonded surfaces together. The medical versions are based on n-butyl cyanoacrylate and 2-octyl cyanoacrylate, which was specifically developed to address toxicity concerns and to reduce skin irritation and allergic response.

Image: Cyanoacrylate skin glue helps keep IV drips in place (Photo courtesy of EMF Australia).

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The NuBOOM “IR” provides radiation protection, integrated visualization, and surgical site illumination. NuBOOM appliances are an economical and fast way to upgrade an OR into a provisional interventional radiology procedure lab when used in conjunction with a mobile c arm.

The XFM wireless unit features a flat panel detector, long-life batteries, and collision prevention system that stops the unit when an obstacle is detected. The digital x-ray system with motorization offers easy manoeuverability, a touch screen console, and perfect visibility during transportation.

The PaxScan DXV family offers the latest electronics with a new X-ray conversion layer for low dose performance. It consumes approximately half the power of previous generations, simplifies cooling requirements and reduces overall system costs, making it suitable for various applications.

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New Ceiling-Mounted C-Arm Angiography System Launched new ceiling-mounted double sliding C-arm X-Ray system is aimed at serving for 3D imaging applications.

The imaging system includes large 12-inch x 16inch flat panel that provides increased coverage, increased and easier patient access.

The Infinix-i Sky + angiography system was introduced by Toshiba America Medical Systems (Tustin, CA, USA; http://medical.toshiba.com) and is intended for use by interventional radiologists, and vascular surgeons.

The 3D system features 210 degrees of anatomical coverage on both the left and right sides of the patient, and a 3D rotation speed of 80 degrees per second. The C-arm can be used in a lateral position, both over and under the table providing more flexibility and safety for clinicians in a sterile Operating Room (OR) environment. This feature also enables the system to be used for complex procedures such as long needle biopsies,

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vertebroplasty, or aspirations. Another feature of the system is support for low contrast imaging from either side of the patient, or from the head-end. The 270degree C-arm rotation feature also ensures easy head-end access.

The Infinix-i Sky + uses automated XRay dose management tools that can be selected by the user to minimize radiation exposure. One of these tools, the Dose Tracking System, can estimate peak skin dose exposure in real-time.

Bill Newsom, director, X-ray Vascular Business Unit at Toshiba, said, “The truth is, Toshiba has always provided customers with a great angiography system, but this new double sliding Carm offers premium flexibility to support clinicians in performing a wide range of procedures. The Infinix-i Sky + allows clinicians to move the C-arm around the patient, rather than the other way

around, and the development of 3D imaging anywhere demonstrates Toshiba’s understanding of our customers’ clinical needs for high quality imaging that doesn’t sacrifice efficiency or safety.”

Image: The ceiling-mounted, double sliding C-arm Infinix-i Sky + angiography system (Photo courtesy of Toshiba Medical Systems).

CT Nodule Detection App Clears Lung Structure novel lung nodule detection application allows superior automatic nodule detection performance for all primary nodule types, including solid, sub-solid, and ground glass nodules.

The Riverain Technologies (Miamisburg, OH, USA; www.riveraintech.com) ClearRead CT nodule detection application, powered by acquisition normalization technology, is designed to seamlessly processes computerized tomography (CT) scans from a wide range of manufacturers and acquisition protocols, suppresses lung vessel without the need for new hardware or customized tuning to specific protocols. The app is comprised of two powerful tools, ClearRead CT | Vessel Suppress, and ClearRead CT | Detect.

The ClearRead CT | Vessel Suppress tool was built using hundreds of normal scans spanning many different acquisition protocols, using thousands of simulated nodules to capture the large va-

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riety of different morphologies, texture, and attenuation characteristics of real nodules. The tool works by predicting the local lung air value, except where there is nodule tissue, which is left unaltered. Vessel suppression also suppresses the bronchial tree and pulmonary fissures, thus essentially suppressing all normal structures.

ClearRead CT | Detect is built on top of ClearRead CT | Vessel Suppress; using the vessel suppressed CT series, candidate nodules are detected using nothing more than simple thresholding and morphological post-processing. Through vessel suppression, nodules can thus be robustly and consistently detected, segmented, and characterized. Detect attempts to limit the number of false positives – such as residual vascular structure, bronchial wall, or scarring – but the radiologist must remain diligent, as some nodules may be inadvertently removed in the process.

Concurrent reading and deep learning enable the

vessel suppression technology to assist both machine and humans in the detection and characterization of all primary nodule types, allowing for previously unattained detection performance. In a recent multireader, multi-case clinical trial, radiologists achieved a 29% reduction in missed actionable nodules, while reducing reading time by 26%. The ClearRead CT nodule detection application has been approved by the U.S. Food and Drug Administration (FDA).

“Achieving high reading efficiency while maintaining accuracy is increasingly important given the burden placed on today’s radiologists. With more patients and increased data volume due to thinner sections, ClearRead CT offers a critical advantage,” said Steve Worrell, CEO of Riverain. “The use of deep learning and other key technologies to suppress the vessels in CT scans proved to be essential in realizing a product capable of achieving the two competing objectives.”

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Platform Combines Imaging Scans and Clinical Information Systems for Decision Support new software platform brings together Electronic Health Record (EHR) and imaging information for analytics and clinical decision support for radiology and oncology specialties. The platform combines imaging data, and clinical information sources such as Electronic Medical Records (EMR) and Radio Therapy (RT) data into the primary reading workflow. The platform is designed to improve clinical productivity and has been cleared by the US FDA. The Quantitative Imaging Decision Support (QIDS) software platform was showcased at the annual Radiological Society of North America (RSNA2016) meeting by HealthMyne (Madison, WI, USA; www.healthmyne.com). The software provides curated medical content, evidence-based analysis, and reporting for clinical collaboration and improved patient management, as well as data mining for research purposes. The platform is built around an image analysis engine that generates lung cancer screening information such as tumor size, and Lung-RADS categories, amongst other advanced quantitative metrics. HealthMyne plans to expand the platform to other specialties in the future.

President and CEO of HealthMyne, Arvind Subramanian, said, “Radiologists who efficiently leverage existing clinical systems information and generate new quantitative metrics within the primary read will thrive in the Value-Based world. By automatically providing quantitative data not currently available in the routine clinical workflow, HealthMyne is significantly enhancing collaboration between radiologists and oncologists to deliver precise patient management.”

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Image: The Quantitative Imaging Decision Support (QIDS) software platform (Photo courtesy of Healthmyne).

High-Resolution Scans Combined with Analysis to Help Detect Concussions esearchers in the Canada have found that there is a better chance of detecting concussion in the brain when patients undergo high-resolution Magnetoncephalography (MEG) scans, than if they undergo standard MRI or CT imaging.

The study was published in the December 2016 issue of the journal PLOS Computational Biology, and showed that MEG, which maps interactions between different brain regions, can be used to detect neural changes better than standard imaging.

The researchers from the Simon Fraser University (SFU; Burnaby, BC, Canada; www.sfu.ca) took MEG imaging scans of 41 men between 20 and 44 years old, half of who had a diagnosis of concussion in the three months prior to the scan, and found observable changes in communication between different areas of the patient’s brains. MEG functional neuroimaging is an imaging technique used for mapping brain activity that currently uses extremely sensitive magnetometers called Superconducting Quantum Interference Devices (SQUIDs).

One of the researchers, Vasily Vakorin, from the Behavioral and Cognitive Neuroscience Institute at the SFU, said, “Changes in communication between brain areas, as detected by MEG, allowed us to detect concussion from individual scans, in situations where MRI or CT failed.”

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DR DETECTOR

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The DX-D 60 provides virtually instant image access, improving image acquisition speed and workflow. It allows migration of mobile and stationary X-ray systems, including Bucky tables, floor stands and neonatal incubator trays, to DR technology without the cost of room replacement.

The MRidium 3860+ non-magnetic pump offers the ability to infuse medications in the MRI room and has been cleared by the FDA for use with up to 3T MR scanners. It allows clinicians to safely and reliably run both volumetric and syringe dosed infusions by way of syringe, bags, and bottles.

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MRI Contrast Agents Not Associated with Parkinson’s new study found no connection between gadolinium exposure and Parkinson’s disease (PD), a degenerative disorder characterized by tremor and impaired muscular coordination.

Researchers at Researchers at Western University (WU; London, Canada; www.uwo.ca) reviewed multiple linked administrative databases from Ontario (Canada) that included 246,557 patients older than 66 years who underwent at least one magnetic resonance imaging (MRI) scan between April 2003 and March 2013. Patients who were exposed to gadolinium-enhanced MRIs were compared with patients who received non-gadolinium-enhanced MRIs. MRI scans of the brain or spine were excluded.

The study found that 40.5% of the study patients received at least one dose of a gadolinium-based contrast agent (GBCA), with 81.5% undergoing a single study, and 2.5% receiving four or more GBCA-enhanced studies. In all, incident Parkinsonism

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developed in 1.2% of unexposed patients, and an equal 1.2% developed in those exposed to gadolinium. The study was published on July 5, 2016, in JAMA. “Gadolinium-based contrast agents are used for enhancement during MRI; safety concerns have emerged over retained gadolinium in the globus pallidi,” concluded lead author Blayne Welk, MD, MSc, of Western University, and colleagues. “This result does not support the hypothesis that gadolinium deposits in the globus pallidi lead to neuronal damage manifesting as Parkinsonism. However, reports of other nonspecific symptoms) after gadolinium exposure require further study.”

Gadolinium – a rare earth heavy metal – is used for enhancement during MRI. Neurotoxic effects have been seen in animals, and when a GBCA is given intrathecally in humans. In July 2015, the U.S. Food and Drug Administration (FDA) stated that it was unknown whether gadolinium

deposits in the globus pallidi, a subcortical structure of the brain, were harmful. The globus pallidus is a major component of the basal ganglia core along with the striatum and its direct target, the substantia nigra, and also retains close functional ties with the subthalamus, all part of the extrapyramidal motor system.

Image: Gadovist, a gadolinium-based contrast agent (Photo courtesy of Bayer).

Updated Human Brain Map Reveals Uncharted Regions sharper, multilayered map of the brain will shed light on how our brains work, and could also prove a boon to neurosurgeons as they decide where to insert their scalpels.

Researchers at Washington University School of Medicine (WUSTL; St. Louis, MO, USA; www. medschool.wustl.edu) and Radboud University Medical Centre (Nijmegen, the Netherlands; www.umcn.nl) used multi-modal magnetic resonance imaging (MRI) and functional MRI scans from 210 healthy young adults in the Human Connectome Project (HCP), together with an objective, semi-automated neuroanatomical approach to delineate 360 distinct sections (180 on each hemisphere) in the human brain, which were bounded by sharp changes in cortical architecture, function, connectivity, and/or topography.

The researchers were thus able to characterize 97 new areas and 83 areas previously reported us-

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ing post-mortem microscopy or other specialized study-specific approaches. To enable the automated delineation and identification of these areas in new HCP subjects, as well as in future studies, they also trained a machine-learning classifier to recognize the multi-modal ‘fingerprint’ of each cortical area.

This classifier succeeded in detecting the presence of 96.6% of the cortical areas in new subjects, replicated the group parcellation, and could correctly locate areas in individuals with atypical parcellations.

The new brain map was published on July 20, 2016, in Nature.

“We ended up with 180 areas in each hemisphere, but we don’t expect that to be the final number,” said lead author Matthew Glasser, PhD, of WUSTL. “In some cases, we identified a patch of cortex that probably could be subdivided, but we couldn’t confidently draw borders with our current data and techniques. In the future, researchers with bet-

ter methods will subdivide that area. We focused on borders we are confident will stand the test of time.”

“Each discrete area on the map contains cells with similar structure, function, and connectivity.

But these areas differ from each other, just as different countries have well-defined borders and unique cultures,” said senior author neuroscientist David C. Van Essen, PhD, of WUSTL. “We think it will serve the scientific community best if they can dive down and get these maps onto their computer screens and explore as they see fit.”

In 1907, German neurologist Korbinian Brodmann drew some of the first diagrams of the human cortex by hand, based on differences in cellular architecture that he could see under a microscope.

For more than a century, scientists have continued using those maps, which depict 52 regions of the brain, as well as those of other neuroanatomists that followed in Brodmann’s footsteps.

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Medical Imaging

Ingestible X-Ray Capsule Supports Colorectal Cancer Screening n innovative ingestible capsule system utilizes ultra-low dose X-ray emission for preparation-free colorectal cancer screening. The Check-Cap capsule is designed to ingested and left to do its work as the patient goes about his or her normal day, with the only requirement being that patient takes regular small amounts of a standard contrast agent with meals. As the capsule moves through the gastrointestinal (GI) tract, it emits radiation equivalent to that of a standard chest X-ray in order to scan the inside of the colon.

The information gathered is transmitted to a device on the patient’s back via wireless communication technologies.

The low-dose X-ray radar scans are used to create standard and three-dimensional (3D) images of the colon, using 360-degree angular scans that “see” through intestinal content. The data is later analyzed by a physician. If nothing is detected, the patient does not require a standard colonoscopy; however, if the Check-Cap device does reveal polyps, a therapeutic colonoscopy would be prescribed. The Check-Cap capsule is under development by Check-Cap (Isfiya, Israel; www. check-cap.com), and is currently not cleared for marketing in any jurisdiction.

“Check-Cap’s prep-free, non-invasive technology meets the real need for colon cancer screening that’s easy for patients. Patients are often hesitant to undergo colonoscopy due to the preparation, seda-

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tion, general discomfort and potential risks,” said Professor Oscar Lebwohl, MD, of Columbia University (New York, NY, USA). “If further studies demonstrate that Check-Cap is an accurate screening modality for colon cancer and polyps, then the Check-Cap system will be a viable testing alternative, allowing the screening of patients in greater numbers and the use of fewer resources compared with CTC and Colonoscopy.”

Colorectal cancer is the second leading cause of cancer death in the United State, with an estimated 134,000 diagnoses and 49,000 deaths in

2016. Despite compelling evidence that screening can detect colorectal cancer and precancerous polyps, nearly one-third of the recommended adult population has never been screened. The Check-Cap system was designed to improve the patient experience by addressing many frequently cited barriers to test completion, including laxative bowel preparation, invasiveness, stool handling, and sedation.

Image: The Check-Cap capsule system passing through the colon (Photo courtesy of Check-Cap).

Radiology Studies Provide Insights on Zika Effects hree now studies use computerized tomography (CT), ultrasound, and magnetic resonance imaging (MRI) to assess the impacts of Zika virus.

The first study examines CT findings of the central nervous system (CNS) in 16 newborn babies with congenital Zika virus infection confirmed by tests in cerebral spinal fluid (CSF). The researchers, from Barão de Lucena Hospital (Recife, Brazil; http://portal.saude.pe.gov.br), identified a recognizable pattern of decreased brain volume, simplified gyral pattern, calcifications, ventricular dilatation, and prominent occipital bone in the CT images.

The second study, by researchers at Federal Fluminense University (Niterói, Brazil; www.uff.br) analyzed the imaging results of three target groups affected by Zika: adults who developed acute neurological syndrome, newborns with vertical infection with neurological disorders, and pregnant women with rash outbreaks suggestive of Zika. They found common MRI findings that included enhancement of certain spinal and facial nerves. In the newborns, MRI showed orbital injuries and anatomical changes in brain tissue.

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The third study, conducted at Clínica de Diagnóstico por Imagem (CDPI; Rio de Janeiro, Brazil; www.cdpi. com.br), used ultrasound and fetal MRI performed on pregnant patients with Zika virus at different gestational ages. Once the babies were born, they underwent ultrasound, CT and MRI. The researchers then created three-dimensional (3D) virtual and physical models of the skulls. They found that more than half the babies had microcephaly, brain calcifications, and loss of brain tissue volume, along with other structural changes. All studies were presented at the RSNA annual conference, held during November 2016 in Chicago (IL, USA).

Zika virus is a member of the Flaviviridae family, and is transmitted by the daytime-active Aedes mosquitoes; in humans, the virus causes a mild illness known as Zika fever. Zika outbreak was first reported in Brazil in May 2015, and since then local health authorities estimate that around a million suspected cases have occurred.

Brazilian health authorities also observed a significant increase in the number of detected cases of microcephaly and Guillain-Barré Syndrome affecting fetuses and newborns.

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Featuring an intuitive touch screen and weighing just 406 grams, it offers applications with a range of capabilities, such as assessing heart failure patients and measuring bladder volume.

The DR 600 combines direct image capture capabilities with versatile panel formats. Key features include MUSICA image processing, quicker preview on the MUSICA workstation and tube head, touch screen display and user interface, and seamless migration to direct radiography.

The AMULET Innovality offers both 2D and advanced applications, and delivers sharper, clearer images that allow the radiologist to see breast tissue detail. It automatically optimizes the X-ray dosage for each breast type, and offers an extremely fast image time of just 15 seconds.

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Lung Cancer CT Screening Shows Impact on Death Rates new trial has found that lung cancer screening and early detection of lung cancer can prolong the lives of 70% of patients by one year or more.

In addition, the researchers also studied the long-term psychosocial outcomes of Computed Tomography (CT) lung cancer screening and found that screening did not result in unnecessary anxiety. The researchers did find that participants may face barriers such as fear and stigma that prevent their participation in a screening program.

The results of the trial were published in the July 2016 issue of the journal Thorax. The UK Lung cancer Screening trial (UKLS) was led by researchers at Cardiff University (Cardiff, UK; www.cardiff.ac.uk), and included more than 4,000 women, and men, between 50 and 75 years old, who had a high risk of contracting lung cancer.

The results of the trial are intended to guide UK clinical and policy decisions for the implementation

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of potential future low-dose CT lung cancer screening for high-risk patients.

Dr. Kate Brain, Cardiff University, said, “With the UK’s five-year survival rate for lung cancer being lower than many other countries with comparable healthcare systems, it is important that we do more to introduce early detection strategies that help to ensure treatment is delivered before patients present at an advanced stage of the disease.

Sometimes, fear of medical procedures and the results they might bring can prevent people from seeking life-saving tests. However, what our trial shows is that CT lung cancer screening actually has no long-term negative psychosocial impact on patients, making it an excellent tool for catching lung cancer earlier when there is a better chance of survival.”

Image: The UK lung cancer screening trial included more than 4,000 subjects who had a high risk of contracting lung cancer (Photo courtesy of Shutterstock).

Portable Digital Radiography Systems to Improve Access to Images U.S. hospital will deploy 11 mobile digital radiography systems to speed-up access to images and improve patient care in emergency rooms, Intensive Care Units (ICU) and operating theaters.

The radiography systems will include advanced software features aimed at critical care, and will be used in the hospital’s emergency department, in two ICUs including one for neonatal care, and in operating rooms.

Huntington Hospital (Pasadena, CA, USA; www. huntingtonhospital.com) retrofitted DRX Plus 3543C detectors to two existing Carestream Health (Rochester, NY, USA; www.carestream.com) portable digital X-ray systems, and installed nine new Carestream DRX-Revolution mobile X-ray systems.

For neonatal patients, the hospital purchased the small DRX 2530C detector. The hospital carries out

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more than 150,000 imaging exams every year. The two existing DRX-Revolution systems provide in excess of 2,300 exams every month in the emergency department of the hospital.

The Carestream DRX Plus is faster, lighter, has a thinner profile than previous versions, and features higher productivity, improved image quality, and a reduced radiation dose. The detectors are rated to IPX Level 7 for liquid resistance, and IEC standard 60529. Other features of the new detectors include faster calibration, boot, and preview times, and improved time-to-full-resolution display. The detectors have calibration file storage for a faster setup time, and improved battery life. The batteries can be changed without rebooting the system.

Ranilo Blasco, manager of Radiology, Huntington Hospital, said, “The DRX-Revolution systems deliver high-resolution images that can help our

physicians quickly and accurately assess and treat acute care patients, as well as inpatients who require bedside exams. We standardized on these systems because of the platform’s innovative design and its ability to deliver excellent quality images as well as reliability and maneuverability. Physicians use these images to help position tubes and lines for seriously ill or injured patients and to detect pneumothorax. Because the companion image is created from the initial image, we do not need to capture multiple X-ray exams of these patients. Converting from CR to DR has not only improved image quality, it also has lowered the dose required to obtain an excellent image. This is especially important for our ICU and NICU patients, so we have installed cesium detectors in these areas to deliver the lowest dose possible while maintaining extremely highquality imaging.”

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Medical Imaging

Pushing the Boundaries with CEUS and US Elastography

By Becky McCall, Contributing Editor ltrasound elastography and contrast enhanced ultrasound (CEUS) are among the latest advances in ultrasound (US) technology that offer improved spatial and temporal resolution in the detection and characterisation of abnormal tissues. SonoScape is leading the field in developing this technology that is improving outcomes for patients.

Leader in the field, Andrej Lyshchik, M.D., Ph.D., Assistant Professor at the Department of Radiology at Thomas Jefferson University Hospital in Philadelphia, US, is enthusiastic for SonoScape’s US elastography. He welcomed the nature of US elastography as a noninvasive technique that allows detection and characterisation of tissues with abnormal biomechanical properties.

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US Elastography Currently, there are three main types of US elastography: transient elastography, compression elastography and Acoustic Radiation Force Impulse (ARFI) imaging. Transient elastography uses an external device that generates mechanical displacement of tissues and a built-in US transducer to register shear wave that propagates within the examined tissues. ARFI imaging uses acoustic radiation forces to generate tissue displacement and map its elastic properties based on the speed of sheer wave propagation.

To date, liver, kidney, breast and prostate are among the organs that show most benefit from these technologies. In particular, Dr Lyshchik explained that one of the most commonly used clinical applications of ARFI and transient elastography is for the evaluation of patients with chronic liver disease.

CEUS in the Evaluation Of Tumor Blood Flow Likewise, CEUS also promises improvements in patient management with its high resolution, real-time visualisation of new blood vessels within tumours that increases diagnostic accuracy. CEUS can be used on SonoScape’s scanners.

CEUS uses US contrast agents that are composed of a gas microbubbles, encapsulated by an outer protein or lipid shell. These microbubbles are of a diameter (1-8 μm) that enables passage through the pulmonary capillar-

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ies, but restricts the microbubbles to the vasculature, making them excellent intravascular blood pool agents.

Unlike contrast agents for MRI and CT, US contrast agents are not nephrotoxic and have no renal contraindications, making them an exceptionally safe to use.

Detecting such changes in tumour vascularity (including blood flow kinetics and microvascular density) is a recognised indicator of treatment response via visualisation of the perfusion of US contrast agents. Parameters such as the time required from injection to contrast arrival, rate of US contrast agent inflow, rate of US contrast agent washout, and cumulative US contrast agents signal over time (an indicator of net blood flow) have all been shown to be potentially useful indicators of treatment response. CEUS also provides the opportunity to create 3D parametric maps of tumour perfusion to illustrate the differences in intra-tumoural blood flow kinetics.

Dr Lyshchik explained that within oncology, CEUS can detect changes in tumour vascularity that provide an indicator of treatment response to certain therapies. He remarked that due to the real time nature of ultrasound and the blood pooling properties of US contrast agents, visualisation of UCA perfusion provides an indicator of the blood flow kinetics and microvascular density of the tumour.

CEUS of Liver Nodules and Hepatocellular Carcinoma Of note, CEUS is also a potentially safer, less expensive and more readily available technique for characterising focal liver nodules in patients at risk for hepatocellular carcinoma, compared to the current clinical standard. This significant cancer, rated as the fifth most common cancer worldwide with an annual incidence of over 550,000, predominantly affects patients with cirrhosis and chronic hepatitis.

But imaging to diagnose hepatocellular carcinoma can be challenging, especially in patients with advanced cirrhosis, in which structural and physiological alterations of the liver can impair detection of the cancer.

However, studies of CEUS, which is available on SonoScape’s scanners in this capacity, have demonstrated safety, high specificity and positive predic-

Figure: Compression elastogram of thyroid demonstrated a very hard nodule, highly concerning for thyrosis cancer.

Figure: Indeterminate liver lesion in patient with cirrhosis (arrow) demonstrating avid arterial phase hyper-enhancement, suspicious for HCC.

Figure: The American College of Radiology Contrast-Enhanced Ultrasound Liver Imaging Reporting and Data System (CEUS LI-RADS)

tive value for diagnosis of hepatocellular carcinoma compared to hepatobiliary agent gadoxetate-enhanced MRI. In an effort to facilitate the clinical use of CEUS, the American College of Radiology recently introduced the CEUS Liver Imaging Reporting and Data System (CEUS LI-RADS), which provides standardisation of CEUS examination and reporting, and allows liver nodule classification based on their like-

lihood to be hepatocellular carcinoma.

Finally, worth a mention is CEUSguided biopsy, which is another application of SonoScape’s technology that targets and biopsies lesions, normally invisible or hard to detect, for example, the small nodules of hepatocellular carcinoma on cirrhosis or adenocarcinoma’s areas in the prostate. It can also target viable areas of large, necrotic tumours.

Medical Imaging

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Portable Imaging System Offers Easy Upgrade to Digital Radiography compact, lightweight system enables small to mid-size hospitals and other healthcare providers to easily transition from computed radiography (CR) to digital radiography (DR) technology.

The Carestream Health (Rochester, NY, USA; www.carestream.com) Motion mobile X-ray system is an affordable mobile and economical bridge between analog, CR, and DR imaging. The integrated DR version includes a 19-inch touch screen monitor; an interface that automatically acquires DAP and technique information, which eliminates manual data entry; DirectView software that provides faster image display and delivery to a PACS or printers; and support for Carestream DRX Core, DRX Plus, and DRX 2530C detectors that allow detector sharing with other DRX imaging systems.

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CR features include a choice of manual or anatomical programmed radiography (APR) mode for quick selection of exam technique; an 8-inch touch screen; a choice of push button or hand switch exposure control; a manual light beam collimator; and a 30kW capacitor discharge generator.

An optional dose-area product (DAP) meters information needed for monitoring dose.

The CR system also has a storage bin for cassettes or detectors, a tube head and column that are designed to fold down for excellent visibility, and a tilt step designed to facilitate moving the system over small obstacles, such as access points to elevators. The system can initially be used with film or CR cassettes, and then converted to a DR system to streamline image capture, viewing, and wireless communication to picture archiving and communi-

cation systems (PACS). “We designed this new portable system to equip imaging facilities of all sizes with the ability to efficiently capture images using film, CR, or DR technology,” said Sarah Verna, worldwide marketing manager for X-ray Solutions at Carestream.

Image: The Motion mobile X-ray system (Photo courtesy of Carestream Health).

RT Intraoperative MRI Imaging Improves Stem Cell Therapy For Parkinson’s Disease esearchers have demonstrated that RealTime Intraoperative Magnetic Resonance Imaging (RT-IMRI) can be used for guiding and monitoring stem cell therapy for Parkinson’s disease.

The research subjects were primates modeled with Parkinson’s disease. The researchers used RTIMRI to guide the transplantation of iPSC (induced Pluripotent Stem Cell) derived neurons into the brains of the primates and found that the technique improved cell survival, and provided improved visualization and monitoring during the procedure.

The researchers from the Preclinical Parkinson’s Research Program Center, University of WisconsinMadison, (Madison, WI, USA; www.primate.wisc. edu) will publish the results of their study in the upcoming October 2016, issue of the journal Cell Transplantation.

The results showed that the RT-IMRI system could be used for intracerebral targeting and delivery of iPSC-derived neuroprogenitors. The technique enables clinicians to monitor cell uploading and infusion. The researchers also found that the cells that had been transplanted and grafted had survived well in the test animals.

Dr. Paul R. Sanberg, distinguished professor, University of South Florida (Tampa, FL, USA), said, “Cell therapy is the cornerstone of regenerative medicine for neurodegenerative disease. With the advent of iPSCs, the field has made significant advances. The current study expounds upon those advances by addressing logistical concerns regarding cell administration and tracking. This method has wide applicability and may be relevant for not only Parkinson’s disease, but other neurodegenerative conditions as well.”

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Medical Imaging

Innovative Transducer Expands Emergency Cardiac Ultrasound new portable transducer frees physicians in emergency care situations of time and mobility restrictions incurred by locating an available ultrasound cart.

The Royal Philips (Philips; Amsterdam, The Netherlands; www.philips. com) S4-1 is a pocket-sized and lightweight point-of-care (POC) cardiac transducer for the Lumify platform, the Philips smart-device portable diagnostic ultrasound solution. Smaller than a smartphone, the S4-1 transducer and cable together weigh just 152 grams. The introduction of the S4-1 expands Lumify into ambulatory use, with clinical applications expanded to include a full offering of in-demand cardiac, abdominal, thoracic, and OB/GYN imaging.

The S4-1 transducer offers Lumify advanced high-sensitivity and highresolution, two-dimensional (2D) image quality, along with new exam presets, which allow clinicians to triage and assess their patients for faster, informed decisions. And beyond integrating with everyday technology, such as off-the-shelf compatible smart devices, Lumify uses cloud-enabled technology to connect with picture archiving and communication systems (PACS), shared networks, and system directories. Data is accessible on the Philips HealthSuite Digital Platform, an open and secure, cloudbased IT infrastructure.

“Our vision for smart-device ultra-

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sounds is focused on putting highquality devices in the hands of more professionals to serve more patients in more locations,” said Randy Hamlin, POC business leader for Philips Ultrasound. “With the S4-1 transducer and clinical pre-sets, Lumify is further extending the reach of ultrasound by delivering exceptional image quality, now for routine cardiac exams, and creating better connections between clinicians and their patients.”

“Lumify is a game-changing innovation,” said emergency ultrasound physician John Bailitz, MD, of the American College of Emergency Physicians (ACEP; Irving, TX, USA; www.acep.org). “The affordability, flexibility, and versatility of Lumify make it appealing to those working in emergency settings, and now with the S4-1 cardiac probe and FAST exam pre-sets, we can conduct critical exams at the point-of-care, resulting in more efficient triage of patients.”

The Philips Lumify is a complete, portable ultrasound system intended for a range of specialties and settings.

The system is supplied with two transducers and a scanning app that controls several types of ultrasound scans under a monthly subscription plan that includes not only the device and app, but also an entire healthcare ecosystem dedicated to care delivery.

Real-time automatic app updates include rollout of new features as soon as they are developed.

Image: The S4-1 POC cardiac transducer and Lumify system (Photo courtesy of Philips Healthcare).

Novel Imaging and Spectroscopy Technique Unveiled esearchers have demonstrated a new imaging technique that combines nuclear imaging using gamma-ray cameras and Magnetic Resonance Imaging (MRI).

The research was published online on September 29, 2016, in the journal Nature. The combined imaging and spectroscopic modality uses the spatial information encoded into the spin orientations of very small quantities of a polarized radioactive tracer.

The Polarized Nuclear Imaging (PNI) modality uses both Radio Frequency (RF) and magnetic-field gradients and obtains imaging information by detecting gamma rays. The modality requires only a single gamma ray detector, instead of a gamma ray camera.

The researchers from the University of Virginia (UVA; Charlottesville, VA, USA; www.virginia.edu) pro-

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duced images and spectra from a glass cell containing only a tiny quantity of 131mXe, a metastable isomer. The researchers polarized the isomer using a laser technique called spin-exchange optical pumping. The glass cell contained approximately 4 × 1013 atoms (around 1 millicurie) of the isomer.

According to the researchers, if they had filled the cell with water and used conventional MRI imaging, then they would have needed 1024 water molecules, billions of molecules more than the radioactive tracer. This new highly sensitivity technique could lead to a new class of nuclear medicine tracers and expanded applications for magnetic resonance imaging. The tiny quantity of radioactive tracer needed for the new imaging technique means that it would result in a much smaller radiation dose for imaging subjects.

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The DVMAXX HD is designed to record video and capture images in full 1920x1080 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 ClearVue laryngoscopes are compact and lightweight, and offer quick installation and removal of blades. Key features include an anti-fog lens, 2MP camera, reinforced screen with antishatter protection, rechargeable battery, and blades that can be reused up to 1,000 times.

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The drug is injected into the bloodstream, and then activated via a fiberoptic laser to destroy tumor tissue in the prostate.

For the study, the researchers randomly assigned 206 patients to VTP and 207 patients to active surveillance. The VTP patients received 4 mg/kg of padeliporfin intravenously over 10 minutes, and optical fibers were inserted into the prostate to cover the desired treatment zone. Subsequent activation was by 753 nm laser light at a fixed power of 150 mW/cm for about 22 minutes. Co-primary endpoints were treatment failure (histological progression of cancer) and absence of definite cancer at 24 months.

At the end of the follow-up period, the researchers found that 49% of patients treated with VTP had entered complete remission, compared with only 13.5% of patients who received active surveillance. Additionally, only 6% of men treated with VTP required radical therapy, compared with 30% in the control group. VTP-treated patients were also three times less likely to have their cancer progress, and VTP was found to double the average time to progression from 14 months to 28 months. The study was published on December 19, 2016, in The Lancet Oncology.

“With such an approach we should be able to achieve a significantly higher remission rate than in

the trial, and send nearly all low-risk localized prostate cancers into remission,” said senior urologist author Professor Mark Emberton, MD, Dean of UCL Medical Science. “We also hope that VTP will be effective against other types of cancer - the treatment was developed for prostate cancer because of the urgent need for new therapies, but it should be translatable to other solid cancers including breast and liver cancer.”

Current standard of care for men with low-risk prostate cancer is active surveillance, which involves monitoring of prostate-specific antigen (PSA) levels, digital rectal exams, or prostate biopsies. As radical therapy, which involves surgically removing or irradiating the whole prostate, it has significant long-term side effects, including erectile dysfunction and incontinence; it is only used to treat high-risk cancers.

Image: A new study shows vasculartargeted photodynamic therapy could cure prostate cancer (Photo courtesy of iStockphoto).

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Pneumatic Tissue Expander Facilitates Breast Reconstruction n innovative wireless tissue expander system provides a needle-free alternative to saline breast expanders for women undergoing breast reconstruction. The AeroForm system includes a tissue expander placed underneath the chest muscle following a mastectomy, and a wireless controller. The device uses compressed carbon dioxide (CO ) gas within an internal reservoir to fill the expander using the hand-held, wireless dose controller.

Patients and physicians can release 10cc of CO2, up to three times per day to gradually inflate the expander, stretching the tissue to prepare for a breast implant. This can be done from any location, such as home or work, and only takes a few seconds.

Use of the system greatly reduces the time needed to reach a fully expanded state, when compared to expansion via saline injection administered by a doctor, and also offers a needle-free alternative to the multiple painful saline injections that could be a barrier to reconstructive surgery for some patients. The system also reduces the time patients need to spend traveling to and waiting at their surgeon’s office. The AeroForm system is a product of AirXpanders (Palo Alto, CA, USA; www.airxpanders.com), and has been approved by the U.S. Food and Drug Administration (FDA).

“While AeroForm doses are a small 10cc puff each, they add up over time and can get a patient fully expanded within 17 days. A saline device can take upward of three months to reach the same state,” said Scott Dodson, CEO of AirXpanders.

“As U.S. mastectomy rates continue to rise and growing numbers of women undergo breast reconstruction, we are confident AeroForm will positively redefine the reconstruction process for women in the U.S.” “Reconstruction is one of the last phases of a long and sometimes taxing journey INTERACTIVE for women who are treated for breast canDIGITAL EDITION cer,” said Professor Jeffrey Ascherman, MD, of Columbia University Medical Center (CUMC; New York, NY, USA; www. cumc.columbia.edu). “They have lost time and control, and are eager to get back to their lives. Needle-free, patient-guided expansion could be a suitable option for many women undergoing the reconstruction process.”

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Image: A pneumatic system uses compressed CO2 to expand breast tissue (Photo courtesy of AirXpanders).

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BOOM SYSTEM

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The Rusch Airtraq features an anatomical design that provides visualization from the tip of the blade, and helps guide intubation. Other benefits of the single-use device include an anti-fog system, guiding channel, and simultaneous streaming and recording on five devices using Wi-Fi.

The U-Series NuBOOM is an all-in-one management, visualization, and ergonomic boom designed for ORs. The boom design eliminates drift common with ceiling-suspended arms, while moveable shelves add flexibility and facilitate better patient access and staff movement.

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Using Mesh for Hernia Repair Shows Mixed Results lthough mesh reinforcement for hernia repair is associated with several benefits, these are offset by mesh-related complications, claims a new study.

Researchers at Hvidovre Hospital (Denmark; www.hvidovrehospital.dk) and Zealand University Hospital (Køge, Denmark; www.regionsjaelland.dk) conducted a study that included 3,242 patients (average age 59; 53% women), who underwent elective incisional hernia repairs in Denmark from January 2007 to December 2010. Among these, 35% underwent open mesh repair, 11% had open non-mesh repair, and 54% had laparoscopic mesh repair. Median follow-up for all procedures was about five years.

The results showed that the risk of subsequent recurrent hernia was lower for patients with open mesh repair (12%) and for patients with laparoscopic mesh repair (10.6%), than for those who had non-mesh repair (17.1%). A progressively increasing number of mesh-related complications, includ-

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ing bleeding, bowel obstruction, bowel perforation, and late abscess, were also noted. At five years of follow-up, the cumulative incidence of mesh-related complications was 5.6% for patients who underwent open mesh hernia repair and 3.7% for patients who underwent laparoscopic mesh repair.

Conversely, the long-term repair-related complication rate for patients with an initial non-mesh repair was 0.8%. The researchers commented, however, that larger, more complicated hernias are likely to be repaired with mesh, while small, simple hernias with little likelihood of longterm problems tend to be repaired without mesh.

The study was presented at the American College of Surgeons (ACS) clinical congress, held during October 2016 in Washington (DC, USA).

“Mesh implantation prevented the need for subsequent reoperation in relatively few patients, suggesting that the benefits associated with the use of

mesh are partially offset by long-term complications associated with its use,” concluded senior author Thue Bisgaard, MD, PhD, of Hvidovre Hospital, and colleagues. “The complete spectrum for the risks and benefits of mesh used to reinforce hernia repair is not known, because there are very few clinical trial data reporting hernia outcomes as they pertain to mesh utilization.”

Image: The hernia sac and contents are returned to place and the hernia repaired with mesh (Photo courtesy Dr. G. Tan).

High-Frequency SCS Provides Superior Clinical Outcomes atients with severe back and leg pain benefit more from high-frequency 10 kilohertz (HF10) spinal cord stimulation (SCS) than conventional low-frequency SCS, according to a new study.

Researchers at Carolinas Pain Institute (Winston-Salem, NC, USA; www.carolinaspaininstitute. com) conducted a pragmatic randomized, controlled, pivotal trial in 171 patients with moderate to severe back and leg pain that persisted despite other treatments, in order to compare long-term results of HF10 therapy and traditional low-frequency SCS. The primary end point of the study was responder rate, defined as 50% or more back pain reduction from baseline at three months, with secondary end points at 12 and 24 months.

The results showed that at three months, scores

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for back and leg pain decreased by at least half in more than 80% of patients receiving HF10, while conventional SCS achieved similar responses in back pain for 44% of patients and in leg pain for 55%. At two years’ follow-up, the HF10 group still had higher response rates: 76% versus 49% for back pain and 73% versus 49% for leg pain. About 60% of patients receiving HF10 were “very satisfied”, compared to 40% with conventional SCS. The study was published in the November 2016 issue of Neurosurgery.

“The pragmatic clinical trial supports the superiority of HF10 over conventional SCS for patients with chronic, severe back and leg pain. The results are particularly impressive given the patients’ long history of pain and lack of response to other treatments, including back surgery,” concluded lad au-

thor Leonardo Kapural, MD, PhD, and colleagues.

“The superior and durable results demonstrated in this study are anticipated to lead to improved longterm cost effectiveness and payer acceptance, making this therapy broadly available to patients suffering from chronic pain.”

HF10 SCS therapy is delivered at a rate up to 10,000 pulses per second (10 kHz), compared to traditional SCS, which utilizes low frequency stimulation, typically 40- 60Hz. HF10 therapy also differs from traditional SCS in that it provides pain relief without paresthesia, a constant tingling sensation that is the hallmark of traditional SCS therapy.

For some patients, the stimulation sensation can fluctuate and paresthesia may become uncomfortable. For others, traditional stimulation does not effectively relieve their pain.

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Surgical Techniques

Tissue Resector Helps Remove Uterine Polyps disposable hand-held and hand-driven device combines the benefits of basic manual devices and complex electromechanical systems in uterine polyp removal. The RESECTR is a manual surgical instrument with an innovative cutting tip, a novel tissue aspiration mechanism, and a unique blade oscillator. Starting right at the cutting tip, the aspiration pulls tissue samples into a serrated window, where the oscillating blades (controlled by the clinician’s index finger and hand), spin both clockwise and counterclockwise to cut the tissue. The clinician has the ability to increase or decrease oscillation and cutting, based on visual and tactile information during the procedure.

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Device control, positioning, tissue aspiration, and cutting are all done with one hand actuation; each time the physician squeezes the device handle, a new level of control and feel is induced. The RESECTR device, a product of Distal Access (Park City, UT, USA; www.RESECTR.com), has been approved by the U.S. Food and Drug Administration (FDA), and is compatible with available fluid management systems and hysteroscopic and endoscopic devices.

“The RESECTR is designed to improve safety, speed, and control during tissue resection,” said Chris Livingstone, vice president of sales and marketing at Distal Access. “Patients are the real win-

ners here as the RESECTR can help clinicians ‘seeand-treat’ lesions in the hospital, clinic, or physician office. We look forward to seeing this tool help patients during a variety of procedures.”

“The system was easy to use; it allowed me to access the lesion and completely remove the polyp with precision and speed,” said gynecology and reproductive endocrinology surgeon Keith Isaacson, MD, of Newton-Wellesley Hospital (Newton, MA, USA), who was the first to use the RESECTR. “It provides a benefit to patients in that the entire polyp can be removed under direct visualization in a very short period of time without the risk of bleeding or uterine perforation.”

New Cartilage Implant Treats Osteoarthritis of the Big Toe novel biomedical polymer implant mimics the physical characteristics of articular cartilage, relieving pain while maintaining joint function.

The Cartiva Synthetic Cartilage Implant (SCI) is intended for use in the treatment of patients with painful arthritis at the base of the great toe as an alternative to fusion, providing pain relief and improvement in both function and motion by replacing damaged cartilage. Made of an organic polymerbased biomaterial comprised of 40% polyvinyl alcohol (PVA) and saline, the cylindrical synthetic polymer provides cartilage-like compressible, low-friction, and a durable bearing surface.

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The SCI is placed in a single surgical procedure, addressing focal articular defects. Due to the similar osmotic, physical, and frictional properties of Cartiva SCI to native cartilage, joint-resurfacing repairs using this implant does not require replacement of the opposing articular surface. Consequently, the procedure does not require significant removal of healthy tissue, resulting in nominal surgical trauma and rapid recovery. The procedure takes about 35 minutes and, unlike fusion, allows the patient to immediately bear weight.

A randomized, multicenter, 236-patient clinical trial that compared outcomes from patients who received the SCI with patients who underwent fusion

showed that the SCI group posted a 93% reduction in median pain and a 168% improvement in median function in sporting activities, and a 65% improvement in daily living activities. SCI patients also had a 26% increased range of movement from baseline.

The Cartiva SCI is a product of Cartiva (Alpharetta, GA, USA; www.cartiva.net), and has been approved by the U.S. Food and Drug Administration (FDA).

“Before Cartiva SCI, the options we could provide to patients with osteoarthritis of the great toe were limited, as the fusion procedure often necessitates sacrificing range of motion to get pain relief,” said Mark Glazebrook, MD, of the Queen Elizabeth II Health Sciences Centre (Halifax, Canada).

Early Surgery for Endometrial Cancer Increases Risk of Death omen with uterine cancer who underwent surgery within the first two weeks after diagnosis suffered a significantly increased risk of death within five years, according to a new study.

Researchers at the University of Pennsylvania (Penn; Philadelphia, USA; www.upenn.edu) queried the U.S. National Cancer Database between 2003 and 2012 for incident endometrial cancers to determine the impact of time from diagnosis to surgical treatment on mortality, and to characterize women who may be at highest risk; cancers were classified as low or high risk, and were analyzed separately. Demographic, clinic-pathologic, and health system factors were also collected, and hazard ratios for mortality were calculated by interval between diagnosis and surgery.

The results showed that nearly twothirds of the cases (140,078) were considered low-risk cancers. Of these, patients who had surgery in the first or second week after diagnosis had a 14% increased risk of death within five years, compared to patients who had surgery in weeks three or four.

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The patients likelier to undergo earlier surgery were more likely to be black, have advanced stage disease, have no insurance or be on Medicaid, and receive care at low-volume hospitals. The researchers therefore suggest that the target interval between diagnosis and treatment of endometrial cancers be less than eight weeks, but that adequate preoperative optimization should be prioritized over expedited surgery. The study was published on December 8, 2016, in the American Journal of Obstetrics and Gynecology.

Endometrial cancer begins in endometrium, a layer of cells that form the lining of the uterus. It is often detected at an early stage since it frequently produces abnormal vaginal bleeding which prompts women to see their doctors. Risk factors include hormonal imbalance; irregular ovulation patterns; early menstruation; never having been pregnant; old age; obesity; tamoxifen hormone therapy for breast cancer; and hereditary nonpolyposis colorectal cancer (HNPCC), a syndrome that increases the risk of colon cancer and other cancers, including endometrial cancer.

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The Redfin R3800 offers high quality optics and multiple console output options for streaming live, full HD images. The video console is compatible with any standard video recorder for recording the live feed, and the system is designed to handle the demands of diagnostic and surgical applications.

The SmartSuction Harmony auto-regulating device acts as an independent suction source to replace wall suction during surgery. Its high airflow efficiently moves fluid at low suction levels, and it can adjust the suction to clear the field in order to help optimize surgical visualization.

The Q-Flow is designed to decrease the airflow circulation in the operating area, thus reducing the potential for contamination. It has excellent illumination properties and delivers consistent light for seeing images and reading monitors, making it the light of choice for any surgical team.

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Proactive Technology Helps Keep Chest Tubes Clear new system proactively clears chest tubes and prevents the retention of blood and fluids in the chest cavity of cardiothoracic surgery patients. The PleuraFlow Active Clearance Technology (ACT) system is used to maintain chest tube patency and reduce potential retained blood syndrome (RBS). The system is indicated for use during cardiothoracic surgical procedures and chest trauma. Comprised of a silicone chest tube and a clearance apparatus, the system uses ACT proactively to remove clots formed inside a chest tube to prevent or minimize chest tube occlusion, and to enable evacuation of blood and fluid from the operative site after closure of the surgical wound.

The clearance apparatus consists of a guide tube and a polytetrafluoroethylene (PTFE) -coated clearance wire with a loop set on its distal end, bent at a 105-degree angle. The clearance apparatus is advanced into the PleuraFlow Chest tube using a magnetic shuttle. When indicated, the clearance wire and loop is advanced and retracted within the

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chest tube to proactively prevent or break up and clear any tube obstructions or clogging, keeping the chest tube patent and allowing fluid flow to the drainage canister.

The PleuraFlow Chest Tube is available in four standard sizes. These include a 20 Fr System with four side holes, intended for infant, preadolescent, and adolescent patients undergoing congenital cardiac surgery; a 20 Fr with 6 side holes for a higher flow rate; and 24 Fr and 38 Fr tubes for larger pediatric patients. Each chest tube has a cut length of 48.3 cm, with graduated measurements in centimeters from the distal eyelet, and a barium stripe to facilitate radiographic visualization. The PleuraFlow System is a product of ClearFlow (Anaheim, CA, USA; www.clearflow.com), and has been approved by the U.S. Food and Drug Administration (FDA).

“We commonly hear from pediatric heart surgeons, pediatric intensive care specialists and ICU nurses that they encounter problems with chest tube clogging after heart surgery in children, and

sometimes this results in preventable major complications or even fatal consequences,” said Paul Molloy, CEO of ClearFlow. “The older makeshift bedside techniques of stripping or milking conventional chest tubes have been shown ineffective to prevent these problems, and can even be harmful, and thus are banned in many hospitals.”

RBS is a composite of drainage-related complications that are detrimental to outcomes following cardiothoracic surgery and that may require early or late intervention to remediate. These clinical complications have significant economic consequences, including higher costs of care for patients, hospitals, and society at large.

Image: The PleuraFlow system with Active Clearance Technology (ACT) (Photo courtesy of ClearFlow).

Robotic and Open Prostate Surgery Show Similar Results new study comparing robotic and open prostatectomy shows no difference in urinary or sexual function following surgery.

Researchers at Griffith University (Gold Coast, Australia; www.griffith.edu.au), Royal Brisbane and Women’s Hospital (RBWH; Australia; www.health. qld.gov.au/rbwh), and other institutions conducted a study involving 326 patients whom were randomly assigned by a computer to receive either robot-assisted laparoscopic prostatectomy or radical retropubic prostatectomy. One surgeon experienced in robotic prostatectomy performed all of the robotic-assisted procedures, and another surgeon with a history of 1,500 open prostatectomies performed all of the open procedures.

In all, 278 patients completed six weeks of follow-up, and 252 remained in follow-up for 12 weeks. The primary outcomes were urinary and

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sexual function assessed at 6 and 12 weeks, and again after 24 months of follow-up. The results showed no difference in urinary or sexual function; positive surgical margins and pain also did not differ between treatment groups. Robotic prostatectomy was associated with less blood loss, shorter operative duration, and a longer length of stay. The study was published on July 26, 2016, in The Lancet.

“In brief, both approaches have shown good early results, with minimally invasive benefits seen in the robot-assisted laparoscopic prostatectomy group,” concluded senior author Frank Gardiner, MD, of RBWH, and colleagues. “Urinary and sexual function are expected to continue to improve with time and, as such, significant differences in functional outcome between these surgical approaches might not become apparent until longer follow-up.”

“Trials that show equivalence for an innovation

are sometimes interpreted as supporting a return to existing practice, including rediverting the training of a generation of surgeons who might have followed the innovation’s evolution,” wrote Ara Darzi, MD, and Erik Mayer, MD, of Imperial College London (United Kingdom), in an accompanying editorial.

Radical prostatectomy uses a surgeon-controlled robot, mainly the Intuitive Surgical (Sunnyvale, CA, USA; www.intuitivesurgical.com) da Vinci minimally invasive surgery system. Advantages include improved cosmetic result, less blood loss, briefer and less intense post-operative convalescence, and reduced hospitalization costs. It is also the basis of a nerve-sparing procedure called the Veil of Aphrodite, developed to minimize the erectile dysfunction common in men after undergoing traditional radical prostatectomy.

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Surgical Techniques

Stochastic Resonance Enhances Surgeon’s Haptic Sensation novel device can be slipped onto any surgical tool to vibrate against a surgeon’s palm, improving the ability to sense the details of a patient’s internal tissues and organs.

The PZT Actuator, developed at Hiroshima University (Japan; www.hiroshima-u.ac.jp), is a vibration device that works via the stochastic resonance effect, a mathematical principle that describes how a constant and regular signal can boost the strength of another irregular signal. The device produces vibrations that are so subtle they cannot be sensed; but the constant, uniform vibration of the actuator enhances the surgeon’s sensitivity to other, irregular sensations. As a result, the touching of different tissues with a metal tool, which may normally be too subtle for the surgeon to detect, is boosted to a noticeable level.

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In a study to test the device, the lead-zirconate-titanate PZT actuator was placed on the grip of surgical forceps. Volunteers were blindfolded and asked to use the forceps to try and identify different textures of sandpaper, as well as find a small Styrofoam ball inside a cup filled with silicone. The results revealed that the vibration intensity significantly improves sensitivity. The device does not need to be fine-tuned to each user’s unique sense of touch, meaning the PZT Actuator should be robust and simple to use.

The study was published on July 14, 2016, in IEEE/ASME Transactions on Mechatronics.

“The PZT Actuator remains safe for patients because the device is only on the handles of the surgeon’s tools, not inside the patient’s body. The vibrations are so subtle that they do not shake the tool. The electrical power supply is also safe for doc-

tors and patients,” said lead author Yuichi Kurita, PhD. “Our next set of experiments will confirm the usefulness of the PZT Actuator in surgical situations. Before we can give this tool to surgeons, we must also develop a method to maintain good hygiene of the device so it is always safe for patients.”

Stochastic resonance boosts any signal by adding a white noise, which contains a wide spectrum of frequencies. The frequencies in the white noise corresponding to the original signal’s frequencies will resonate with each other, amplifying the original signal while not amplifying the rest of the white noise, thereby increasing the signal-to-noise ratio, which makes the original signal more prominent.

Further, the added white noise is detectable by the sensor, which can then filter it out to effectively detect the original, previously undetectable signal.

Zika Infection in Pregnancy Linked to Joint Deformities new study suggests that Zika virus infection during pregnancy may be related to a severe birth defect called arthrogryposis, wherein the joints are deformed.

Researchers at the Association for Assistance of Disabled Children (AACD; Recife, Brazil; https:// aacd.org.br), the University of Pernambuco (UPE; Recife, Brazil; www.upe.br), and other institutions in Brazil reported a retrospective case series study of seven children with arthrogryposis and a diagnosis of congenital infection (presumably caused

by Zika virus) during the Brazilian microcephaly epidemic. The researchers described the clinical, radiological, and electromyographic features in the children, and examined the likely correlation between clinical and primary neurological abnormalities.

The results showed that brain images of all seven children were characteristic of congenital infection and arthrogryposis, with two of the children testing positive for IgM to Zika virus in the cerebrospinal fluid (CSF).

Arthrogryposis was present in the arms and legs of six children (86%) and the legs of one child (14%). Hip radiographs showed bilateral dislocation in seven children, subluxation of the knee associated with genu valgus in three children (43%), which was bilateral in two (29%). All the children underwent high definition ultrasonography of the joints, and there

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was no evidence of abnormalities.

Five of the children also underwent brain computed tomography (CT) and magnetic resonance imaging (MRI), with the remaining two undergoing CT alone. All presented cortical development malformations and calcifications, predominantly in the cortex and subcortical white matter (especially in the junction between the cortex and white matter), reduction in brain volume, ventriculomegaly, and hypoplasia of the brainstem and cerebellum. MRI of the spine in four children showed apparent thinning of the cord and reduced ventral roots. The study was published on August 9, 2016, in BMJ. “Congenital Zika syndrome should be added to the differential diagnosis of congenital infections and arthrogryposis. The arthrogryposis was unrelated to the abnormalities of the joints themselves, but was possibly of neurogenic origin, with chronic involvement of central and peripheral motor neurons leading to deformities as a result of fixed postures in utero,” concluded lead author pediatric neurologist Vanessa van der Linden, MD, of AACD, and colleagues.

“Based on the neurophysiological observations, we suggest two possible mechanisms: tropism of neurons, with involvement of peripheral and central motor neurons, or a relation with vascular disorders.”

Arthrogryposis multiplex congenita is characterized by joint contractures at birth, which can be divided into isolated and multiple contractures. Isolated contractures affect only one area of the body, most commonly the foot. The term arthrogryposis is often used as short-

hand to describe multiple congenital contractures affecting two or more areas of the body. Thus, arthrogryposis might be considered more a sign than a specific disease, and it might be associated with several disorders.

Zika virus is a member of the Flaviviridae family, of the genus Flavivirus, and is transmitted by daytime-active Aedes mosquitoes; in hu-

mans, the virus causes a mild illness known as Zika fever. Zika was first reported in Brazil in May 2015, and since then local health authorities estimate that around a million suspected cases have occurred. Brazilian health authorities also observed a significant increase in the number of detected cases of microcephaly and Guillain-Barré Syndrome affecting fetuses and newborns.

PRODUCT NEWS MEDICAL DISPLAY MONITOR

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DR CONVERSION SYSTEM

IMAGE SHARING PLATFORM

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lifeIMAGE

The RadiForce RX660 allows an image to be displayed that is true to the original source data, even at high brightness levels. Its wide viewing angles allow the user to view the screen from the side with minimal color shift, as well as view a variety of medical images at the same time.

The AeroDR Portable Retrofit turns an existing portable X-ray unit into a digital wireless solution.

It has a very small footprint, which allows for installation and storage inside the cassette storage bin, and is completely self-contained and includes two long-life batteries.

The lifeIMAGE 5.0 platform allows clinicians to quickly gain access and compare data from a number of locations internal and external to the hospital. It allows physicians in multiple locations to simultaneously review and annotate diagnosticquality images.

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New 4D Flow Software Platform company developing cloud-based medical imaging software has received 510(k) clearance from US FDA for its 4D cardiac flow quantification software. The software was showcased at the annual Radiological Society of North America (RSNA 2016) meeting. The company also presented new information about clinical applications that use the 4-D flow software.

The Arterys 4D Flow software was developed by Arterys (San Francisco, CA, USA; www.arterys. com), a company that develops quantitative imaging tools for supporting treatment decisions. The Arterys 4D Flow platform uses cloud computing and advanced analytics techniques.

The 4D cardiac flow quantification technique uses phase-contrast Cardiac Magnetic Resonance (CMR) 3D data that is velocity-encoded in three spatial directions. The data is resolved relative to

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the 3 spatial dimensions, and time, for the duration of the cardiac cycle, and enables clinicians to visualize, and measure blood patterns in the 3D volume. The 4D Flow sequence is faster and simpler than conventional MRI scans.

CEO of Arterys, Fabien Beckers, said, “This year, RSNA is focusing a lot of attention on breakthrough technological developments that are moving medical imaging into a new era where it’s possible to analyze data to help diagnose conditions much quicker, align various stakeholders in the health ecosystem, and mobilize on personalized treatment paths. We believe the Arterys platform will transform clinical practice through powerful, quantitative imaging tools that rapidly generate and analyze unprecedented amounts of data and insights that can support treatment decisions and the delivery of patient care.”

Image: An image generated by the 4D Arterys cardiac flow quantification software (Photo courtesy of Arterys).

Medical Monitor Combines 4K and 3D Imaging wo advanced medical monitors combine 4K color and three-dimensional (3D) imaging technologies to deliver high brightness, enhanced resolution, and increased depth of field for a range of applications.

The new Sony (Tokyo, Japan; www.sony.com) 55-inch and 31-inch medical monitors are designed for use with surgical microscopes and 3D endoscopes in operating rooms (ORs), as well for medical facilities in training and education. The new monitors will display 2D and 3D content in 4K or high definition (HD). In addition to side-byside, line-by-line, and top and bottom imaging, the 3D transmission method allows SDI dual streaming, making it possible to connect with a wide range of equipment via SDI (3G), DVI, and HDMI terminals.

Features include 2D image display in picture-inpicture (PIP) mode, with the ability to display reference images; in addition, 3D images can be flipped or rotated in 180°. An Advanced Image Multiple Enhancer (AIME) feature allows operators to adjust the profiles and colors of 4K images from endo-

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scopes and surgical microscopes for more comfortable viewing. The monitors also will come equipped with compatible and disposable 3D eyeshields.

OptiContrast technology replaces the layer of air between the panel and the glass with a layer of resin specially formulated to match the refractive properties of glass, thus reducing glare and reflection and helping to eliminate internal condensation. The panel also helps establish dark backgrounds for highcontrast images, even in brightly lit rooms. In addition, edge-to-edge screen protection and corner-tocorner uniformity help to maintain the monitor scratch-free and water resistant for easy cleaning.

“Combining 3D’s exceptional depth of field with 4K’s incredible resolution and clarity can change the way medical teams approach their work,” said Julie Holodak, senior marketing manager for the Sony Medical Systems Division. “Building on the design and construction highlights of previous generations of Sony’s imaging technologies, these new medical monitors give surgeons greater precision and enhanced visualization to help them navigate through a procedure easily, and also provide more

immersive and detailed training and education.”

The 4K resolution is a generic term for display devices or content having horizontal resolution on the order of 4,000 pixels, the standard for ultrahigh definition (UHD). Using horizontal resolution to characterize the technology marks a switch from previous definitions, which categorized media according to vertical resolution (1080i, 720p, 480p).

4K UHD has twice the horizontal and vertical resolution of the 1080p, high-definition (HD) format, with four times as many pixels overall.

Image: The lmdx550mt 4K 3D medical monitor (Photo courtesy of Sony).

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New Functionality Announced for Advanced Visual Analysis Platform

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n advanced visual analysis and quantification platform has introduced new multi-modality functionality and expanded neurological tools.

The analysis platform can now be used for neurological diagnosis to track and compare brain images and disease progression in patients, and features machine learning to improve the clinician workflow, and improved 3D printing options.

Royal Philips (Amsterdam, the Netherlands; www.philips.com) announced the IntelliSpace Portal 9.0 at the annual Radiological Society of North America Annual Meeting (RSNA2016) meeting. IntelliSpace Portal 9.0 includes new machine learning capabilities and can help radiologists detect, diagnose and follow the progression of patients with brain injuries, stroke, dementia, Multiple Sclerosis (MS) and Amyotrophic Lateral Sclerosis (ALS).

The platform includes CT Brain Perfusion, and MR T2 Perfusion enhancements, the Longitudinal Brain Imaging (LoBI)1 application for neuro reading, and the CorTech Labs (San Diego, CA, USA; www. cortechslabs.com) NeuroQuant measurement application for the quantification of brain volume loss.

IntelliSpace Portal 9.0 applications can be WORLD’S MEDICAL accessed from anywhere in the hospital network, and can integrate with Picture Archive and Communications Systems (PACS), and Hospital Information Systems (HIS) for information sharing and collaboration.

Senior VP and GM of Philips Healthcare IT, Yair Briman, said, “Radiology has a unique ability to influence and improve outcomes, and intelligent tools enable us to empower radiologists with the right information. With advances in machine learning, IntelliSpace Portal 9.0 will now be able to continually learn the usage patterns of users to enhance the important daily functions of a radiologist such as pre-preprocessing of images, encouraging faster and more streamlined diagnosis.”

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Image: The IntelliSpace Portal 9.0 includes the NeuroQuant application for objective quantification of brain atrophy (Photo courtesy of Royal Philips).

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Connecting Buyers with Suppliers Worldwide Reach new sources of supply Identify latest products and technologies Send inquiries directly to suppliers Receive latest product alerts Chat live with suppliers TradeMed provides a sophisticated yet easy-to-use global B2B platform for sourcing medical equipment. TradeMed connects buyers and sellers worldwide through a safe, secure and dynamic network. Solely dedicated to medical products, TradeMed is the premier choice for medical suppliers, hospital decisionmakers and buyers worldwide, regardless of size or budget.

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The ChromaPaxx 17C2D4G160 HD integrates a 17-inch display and digital recorder to capture video/images via S-Video or Composite and record in three formats. It is suitable for recording/displaying videos and images for endoscopy, surgical applications, and X-ray procedures.

The Digital Room Upgrade Kit for is meant for upgrading existing rooms with compatible X-ray systems from CR to DR without having to upgrade the entire room. It offers a choice of wireless, tethered, or fixed Canon CXDI DR system to suit different budgets.

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Custom Displays Deliver 4K HD Image Quality new series of custom monitors deliver 4KX2K resolution (3,840 × 2,160 pixels), four times that of full high definition (HD). The Canvys (LaFox, IL, USA; www.canvys.com) 4K2K custom display series deliver sharp, precise, detailed images with enhanced depth and color representation. In addition to displaying high-quality HD images, the monitors are also capable of delivering multi-modality; depending on the screen size and inputs, up to eight windows from eight different sources can be displayed on one screen at the same time. In addition, only one calibration and gamma setting are needed when utilizing a single screen for multiple images.

Picture-in-picture (PIP) functionality is used to compare two images side-byside on a single screen in 2KX2K resolution without losing image quality, allowing users to view fine image details, a feature that is especially useful in applications such as minimally invasive surgery and endoscopy. Another innovative feature offered is optional projected capacitive touch (PCap), which allows the monitor to be operated by 10 fingers or latex gloves.

With the 4K2K series, Canvys also deliver a range of custom options and services, including needs assessment, custom engineering, and prototyping; touch and protective shield integration; various housing designs, including open frame, panel, chassis, or rack mount; rugged to slim and light weight designs; a wide range of controller solutions with inputs in many combinations; and single board controller and PC integration. The monitors are available in seven screen sizes: 23.8, 27, 31.5, 55, 58, 65, and 84 inches.

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4K resolution refers to a horizontal resolution of 4,096 pixels. The use of width to characterize the overall resolution marks a switch from previous video standards such as 480i and 1080p, which categorize media according to its vertical dimension. Using that same convention, 4K would be named 2160p. As 4K is becoming standard, manufacturers are working on the next step, 8K, which forms an image dimension of 7,680×4,320 pixels.

Image: The Canvys 58-inch 4K2K display (Photo courtesy of Canvys).

Smartphone App Helps Screen Populations for Atrial Fibrillation esearchers at Princess Margaret Hospital (PMH; Hong Kong; www.ha.org.hk) conducted a study involving 13,122 Hong Kong citizens who consented and voluntarily participated in a territory-wide AF screening program between May 1, 2014, and April 30, 2015. The purpose of the study was to assess the feasibility of community screening using a smartphone-based wireless single-lead ECG (SL-ECG) and to generate epidemiological data on the prevalence and risk factors of AF in Hong Kong.

The 30-second test showed that 8.5% of those tested had AF, 101 cases (or 0.8%) of which had not been previously diagnosed; results were uninterpretable in only 0.4% of those tested. The AF fraction points to a disease prevalence comparable to that of populations in other developed countries. In

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two thirds of the new cases, the condition was symptomless, but their combined risk scores suggest that they would have benefited from treatment. The study was published on October 12, 2016, in Heart.

“Community screening for AF with SL-ECG was feasible, and it identified a significant proportion of citizens with newly diagnosed AF,” concluded study authors Ngai-yin Chan, MD, and Chi-chung Choy, MD, of PMH. “Increasing age (60+), male sex, weight, and a history of heart disease/surgery and peripheral vascular disease were all predictive of the condition.”

“In order to relieve both patients and society from the consequences of untreated AF, we believe and hope that AF screening in risk groups will be a part of the standard healthcare in many countries in the near

future,” commented Emma Svennberg, MD, of the Karolinska Institute (Stockholm, Sweden), and Johan Engdahl, MD, of the Sahlgrenska Academy (Göteborg, Sweden), in an accompanying editorial. “Besides, isn’t it encouraging that we can use our smartphones to search for other things than Pokémons?”

AF is the most common heart rhythm disorder, affecting more than 30 million people worldwide, with five million new cases reported annually. Accurate diagnosis of AF is critical because antithrombotic treatment significantly reduces the risk of recurrent embolism and death. Treatment options include medications, which do not address the underlying problem, and minimally invasive, catheter-based ablation procedures, which are designed to disrupt the transmission of abnormal impulses in the heart.

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Health IT

Stretchy Circuits Foretell Future of Wearable Electronics new wave of wearable integrated circuits could drive the Internet of Things (IoT) and a much more connected, highspeed wireless world.

Developed by researchers at the University of Wisconsin (WISC; Madison, USA; www.wisc.edu) and the University of Electronic Science and Technology (UESTC; Chengdu, China; www.uestc.edu.cn), the powerful, stretchable, highly efficient integrated epidermal electronic circuits could allow health care staff in an intensive care unit (ICU) to monitor patients remotely and wirelessly. What makes the stretchable integrated circuits powerful is their unique structure, which contains, essentially, two ultra-tiny intertwining power transmission lines in repeating S-curves.

The serpentine shape, formed in

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two layers with segmented metal blocks, like a three dimensional (3D) puzzle, gives the transmission lines the ability to stretch without affecting their performance. It also helps shield the lines from outside interference while confining the electromagnetic waves flowing through them, resulting in an almost complete elimination of current loss. The advance could allow health care staff to monitor patients remotely and wirelessly, increasing patient comfort by decreasing the customary tangle of cables and wires.

Unlike other stretchable transmission lines, whose widths can approach 640 micrometers (0.64 mil-

Mobile Telemedicine System Speeds Stroke Care low-cost, tablet-based videoconferencing platform can help paramedics reliably perform prehospital neurologic assessments in both rural and urban settings.

Researchers at the University of Virginia Health System (UVHS, Charlottesville, USA; www.health system.virginia.edu), Stanford University (CA, USA; www.stanford. edu), and other institutions conducted a pilot clinical trial of a mobile telemedicine system that uses commercial cellular networks for videoconferencing transmission.

The system is based on a wallmounted tablet that allows the hospital doctor to confer with the paramedic and the stroke patient in the ambulance. For the study, standardized patients portrayed scripted stroke scenarios during ambulance transport. The scenarios were evaluated by independent raters that compared bedside to remote mobile telestroke assessments.

In all, 27 ambulance runs at two test sites were successfully completed for all prehospital assessments without any prohibitive technical interruption. The researchers found that the system had sufficient quality and connectivity to allow successful consultations in over 90% of local test runs. The mean correla-

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tion of National Institutes of Health Stroke Scale (NIHSS) scores between bedside and mobile telestroke assessments was 96%. The study was published on June 6, 2016, in Neurology.

“Acute stroke is a very time-dependent illness. Specifically, in acute ischemic stroke, if you can remove the vascular obstruction and re-vascularize the injured part of the brain in a timely way, you can potentially prevent disability and death,” said lead author assistant professor of neurology Andrew Southerland, MD, MSc. “The goal of our study is to advance the assessment of acute stroke to the pre-hospital setting – to the ambulance transporting the patients to the hospital.”

Telemedicine is the use of communication and information technologies to provide health care at a distance and improve access to medical services not consistently available in distant rural communities.

Although there are distant precursors to telemedicine, it is essentially a product of 20th century telecommunication and information technologies that permit communications between patient and medical staff with both convenience and fidelity, as well as the transmission of medical, imaging and health informatics data from one site to another.

limeters), the new stretchable integrated circuits are just 25 micrometers (0.025 millimeters) thick, and can operate at radio frequency levels up to 40 gigahertz, a microwave frequency range that falls directly in the 5G range, which is slated to accommodate a growing number of cellphone users that can provide notable increases in data speeds. The study was published on May 27, 2016, in Advanced Functional Materials.

“This is a platform; this opens the door to lots of new capabilities.

We’ve found a way to integrate highfrequency active transistors into a

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useful circuit that can be wireless,” said senior author Professor Zhenqiang “Jack” Ma, PhD, the University of Wisconsin. “These concepts form the basic elements used in the design of stretchable microwave components, circuits, and subsystems performing important radio frequency functionalities, which can apply to many types of stretchable bioelectronics for radio transmitters and receivers.”

Image: The new integrated circuits, fabricated in interlocking segments (Photo courtesy of Yei Hwan Jung, Juhwan Lee / WISC).

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New Canadian Hospital Complex Reaches Completion he new Providence Care Hospital (Kingston, Canada; www.providencecare.ca) is set to open with full operations and services to clients and patients in April 2017, integrating long-term mental health care with physical rehabilitation and complex care programs in the same facility.

The new hospital was designed to be welcoming, providing a homelike, patient-centered environment that allows individuals to meet friends and families in comfortable spaces throughout the building. The main lobby includes a reception area, where visitors can be greeted and will proceed to the nearby cafeteria, gift shops, or outpatient clinics. On the upper level, dedicated space for education, learning and research supports Providence Care’s role as an academic hospital and its partnerships with Queen’s University (Kingston, Canada; www.queensu.ca) and other post-secondary institutions.

The new facility, which replaces the exiting St Mary’s of the Lake Hospital and Mental Health Services buildings, includes 270 private inpa-

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tient rooms, which benefit from the therapeutic effects of daylight, fresh air and views. The modern design concept blends masonry, stone, metal, and wood exteriors to create a 57,000 sqm building that is integrated into the landscape and local architecture, providing individuals with a sense of place and drawing influence from nearby heritage buildings.

Interior courtyards allow for natural light in corridor and office spaces, as well as patient and client areas, providing staff with improved work environments. Departments, services, and units have been organized to support collaboration and inter-professional care, minimizing travel distances between units for care staff. To further enhance care and patient experience, the Providence Care Hospital will incorporate the latest technology throughout the building, with modern security, communication, and computer systems throughout the facility.

All inpatient rooms are single and adjoin to a private, accessible washroom, and shower. Patients can use a bedside touch screen to adjust envi-

ronmental and entertainment controls, such as lights, temperature, curtains, television, and Internet. Quiet rooms, family lounges, kitchenettes and dining areas provide spaces for a range of activities, and all units have direct access to outdoor terraces or gardens, making it easier and more accessible for those with mobility challenges.

“It has taken a long time, 15 years as a matter of fact, to get to this point.

If it was not for the ultimate financing

process we are going through today, this hospital simply would not be built for the next 20 or 30 years. That is the reality of the situation,” said Kingston and the Islands MPP John Gerretsen. “The hospital that will be there at the end of the day will be publicly owned, publicly financed, publicly controlled, publicly managed and publicly run in every way.”

Image: An aerial view of Providence Care Hospital (Photo courtesy of Providence Care).

London Hospital to Build Research Facility reat Ormond Street Hospital for Children (GOSH; London, United Kingdom; www. gosh.nhs.uk) and University College London (UCL; United Kingdom; www.ucl.ac.uk) are constructing a new, state-of-the-art research center.

The Zayed Centre for Research into Rare Diseases in Children will be built adjacent to GOSH and the UCL Institute of Child Health, and will provide cutting-edge technology, equipment, and office space for up to 400 world-leading scientists and clinicians. The center will contain a variety of research laboratories to study rare diseases and develop treatments.

A good manufacturing practice (GMP) facility on the fourth floor will aid laboratories to manufacture specialist products for new therapies, clinical trials, and patient treatments.

The six-story building will have a total floor space of more than 13,000m², with equipment rooms and workspaces to develop diagnostic

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procedures, manufacture gene and cell therapies, and to create personalized medical devices. Additional features will include a cardiology suite; a flow cytometry suite for the counting, storing, and analysis of cells with laser technology; a new outpatient clinic; and research write-up areas, meeting rooms, and spaces to allow scientists and medical teams to collaborate and progress with their work. Two large laboratories will be located on the lower ground floor.

“The really exciting thing about the new building is the possibility of creating a working environment that brings everyone together. As a clinician, I need to explore my options for treating a patient with experts who can help me develop them,” said Professor Andrew Taylor, MD, of GOSH and UCL. “A variety of different professionals under one roof will allow us to turn innovative thinking into practical solutions. The centre will also give us a manufacturing capacity

to develop these solutions at scale so we can help more and more patients.”

The new research center, named in the honor of Sheikh Zayed bin Sultan Al Nahyan, the Emir of Abu Dhabi and first president of the United Arab Emirates (UAE), will operate as a partnership between Great Ormond Street Hospital, UCL, and the

Great Ormond Street Hospital Children’s Charity (London, United Kingdom; www.gosh.org). Construction is scheduled to begin in January 2017 and is expected to be completed by 2018.

Image: An artist’s rendering of the Zayed Centre for Research into Rare Disease in Children (Photo courtesy of GOSH).

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Industry News

Ethicon Endo-Surgery Acquires Electrosurgical Tool Maker thicon Endo-Surgery, Inc. (Somerville, NJ, USA; www. ethicon.com), a subsidiary of Johnson & Johnson, has acquired Megadyne Medical Products, Inc. (Draper, UT, USA; www.megadyne. com), a privately held medical device company that develops, manufactures and markets electrosurgical tools used in operating rooms.

Ethicon offers various surgical technologies and solutions including sutures, staplers, energy devices, trocars and hemostats. Megadyne's portfolio

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of electrosurgical tools complements Ethicon's advanced energy tools, such as monopolar and bipolar electrodes, patient return electrodes, generators and smoke evacuation systems.

"We are committed to meeting the evolving needs of surgeons and hospital systems, and the addition of Megadyne's state-of-the-art portfolio gives us a comprehensive suite of energy devices to improve patient care in surgeries across all specialties," said Michael del Prado, Company Group Chairman of Ethicon.

Mortara to Be Taken Over by Hill-Rom ill-Rom Holdings, Inc. (Batesville, IN, USA; www.hill-rom. com), a provider of patient care solutions to health care providers, has signed a definitive agreement to acquire Mortara Instrument, Inc. (Milwaukee, WI, USA; www.mortara.com), a privately held company offering diagnostic cardiology and patient monitoring solutions, technologies and devices.

Hill-Rom offers patient care solutions in five core areas: advancing mobility, wound care and prevention, patient monitoring and diagnostics, surgical safety and efficiency, and respiratory health. The company’s patient care solutions include hospital beds, wound therapy systems, support surfaces and mattresses, patient handling/support systems, respiratory care products, clinical workflow solutions, and surgical equipment, among

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others. Mortara's portfolio includes diagnostic cardiology devices for monitoring resting electrocardiography (ECG), cardiac stress exercise, Holter, ambulatory blood pressure, and cardiac and pulmonary rehabilitation and multiple patient parameters.

The USD 330 million cash deal is expected to enhance Hill-Rom’s presence in cardiac technology as well as allow it to offer a more comprehensive suite of continuous vital signs monitoring parameters.

"Our growing Welch Allyn franchise will be immediately strengthened by the addition of Mortara Instrument's experienced team, breadth of diagnostic cardiology and patient monitoring offerings and bestin-class ability to integrate with electronic medical record (EMR) systems," said Hill-Rom President and CEO John J. Greisch.

PENTAX Medical Buys Surgical Ablation Developer ENTAX Medical (Tokyo, Japan; www.pentaxmedical. com), a manufacturer of medical imaging equipment, has acquired medical device company C2 Therapeutics (Redwood City, CA, USA; www.c2therapeutics.com) for an undisclosed amount.

PENTAX Medical, a division of the HOYA Group, (Tokyo, Japan; www. hoya.com), offers a range of medical imaging equipment for physicians and hospitals including upper GI gastroscopes and duodenoscopes; lower GI colonoscopes and sigmoidoscopes; radial array, linear array, and Hitachi HI VISION 5500 digital endoscopic ultrasound systems.

C2 Therapeutics develops the C2 CryoBalloon Ablation System for the

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endoscopic ablation of unwanted tissue such as Barrett's esophagus. The use of the CryoBalloon allows the endoscopist to non-invasively eradicate pre-cancerous esophageal dysplasia by freezing the abnormal tissue. The technology uses an affordable and easy to use platform of a conformable and self-sizing balloon that can be used through the endoscope as a primary, curative therapy.

The acquisition of C2 Therapeutics will help strengthen PENTAX Medical's therapeutic endoscopy portfolio and expands the company's role in the gastroenterology suites around the world from being a provider of advanced imaging for diagnostics, to now providing advanced therapeutic solutions as well.

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

International Calendar, HospiMedica International P.O.Box 802214, Miami, FL 33280-2214, USA Fax: 1-954-893-0038 • E-mail: info@globetech.net

MARCH 2017 ECR 2017 – European Congress of Radiology. Mar 1-5; Vienna, Austria; Web: www.myesr.org KIMES 2017. Mar 16-19; Seoul, Korea; Web: www.kimes.kr ISICEM 2017 – The International Symposium on Intensive Care and Emergency Medicine. Mar 21-24; Brussels, Belgium; Web: www.intensive.org CHINAMED 2017. Mar 24-26; Beijing, China; Web: www.chinamed.net.cn ExpoMED Eurasia 2017. Mar 30-Apr 2; Istanbul, Turkey; Web: www.expo medistanbul.com Annual EAU Congress 2016- European Association of Urology. Mar 2428; London, England; Web: http:// eau17.uroweb.org

APRIL 2017 Medical Fair India 2017. Apr 6-8; New Delhi, India; Web: www.medicalfair-india. com 2017 AORN (Association of periOperative Registered Nurses) - Surgical Conference and Expo. Apr 1-5; Boston, MA, USA; Web: www.aorn.org 2017 ARRS Annual Meeting. Apr 30May 5; New Orleans, LA, USA; Web: www.arrs.org

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Ampronix Medical Imaging Technology . . . . . . . . . . . . . .3 Antmed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 CMEF 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 ECS Congress 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Gammex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Hans Rudolph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 HKTDC 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 HospiMedica.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Hospitalar 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Infinium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Italray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Joerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Medical Fair Thailand . . . . . . . . . . . . . . . . . . . . . . . . . .34 Medicall 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Mercury Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Parker Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Radiology Asia 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . .20 SEACare 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Sedecal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 TradeMed.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Varian / Varex Imaging . . . . . . . . . . . . . . . . . . . . . . . . .36 Vicotex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Vieworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

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