Medical Imaging International September 2018 by Globetech

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Vol.28 No.3 8-9 / 2018 ISSN 1068-1779

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IN THIS ISSUE Clinical News . . . . . 3-21 PACS/ IT Update . . 21-24 Product News . . . . . 6-24 Industry News . . . . . . 25 International Calendar . 26

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Cardiovascular MRI Aids Diastolic Heart Failure Diagnosis new study will investigate whether diastolic heart failure (DHF) can be better diagnosed with the help of cardiovascular magnetic resonance imaging (CMRI). Researchers at the German Centre for Cardiovascular Research (DZHK; Berlin, Germany; https://dzhk.de) and University Hospital Frankfurt (Germany; www.kgu.de) are launching a multicenter study to establish CMRI as the standard method for diagnosing DHF, also known as heart failure with preserved ejection fraction (HFpEF). The study will compare CMR diagnostic data efficacy with that of the present gold standard, invasive hemodynamics, in which patients are examined using a cardiac catheter. In order to obtain a more comprehensive picture of the diagnostic validity of CMR, the researchers will also compare CMR measurements to the results of ultrasound examinations and analyses of myocardial tissue samples. The data will also aid the researchers investigate whether CMR can help clarify why DHF disease arises, since unlike an ultrasound, CMR not only measures blood flow and ventricular filling, but can also identify an inflamed myocardium, pathological proliferation of the connective tissue, and change to small blood vessels. “Only once the causes are clear can patients receive targeted medicinal therapy, because the treatment of myocardial inflammation differs entirely to that of a circulatory disorder. Therapeutic studies are only possible once we can distinguish between the various patient subgroups,” said lead researcher Professor Eike Nagel, MD, of University Hospital Frankfurt. “It is the first multicenter study on the diagnosis of HFpEF worldwide. Beside Frankfurt am Main, the DZHK sites in Berlin, Heidelberg, Göttingen, and Bad Nauheim are also participating. If the results are positive, the study would lead to a modINTERACTIVE ification of the guidelines for diagDIGITAL EDITION nosing HFpEF.” HFpEF is a complex disease, encompassing a diverse cohort of patients and marked by the presence of multiple etiological mechanisms. Diastolic dysfunction, in which the heart contracts properly, but cannot expand enough so that blood can fill the chamber, is considered a crucial component of the disease, which affects approximately 50% of patients with chronic heart failure (HF). CMR is a medical imaging technology for the non-invasive assessment of the function and structure of the cardiovascular system that is based on the same basic principles as MRI, with optimizations that use rapid imaging sequences, requiring CMR images be acquired in steps. Patients breathe in and then hold their breath for each image, then recover before repeating the process for the next one.

Image: According to research, cardiac MRi could soon replace hemodynamic assessments (Photo courtesy of Siemens Healthcare).

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Smart 3D Camera Automates CT Patient Positioning new premium computerized tomography (CT) system leverages artificial intelligence (AI) in order to automatically assure precise and consistent patient positioning. The Siemens Healthineers (Erlangen, Germany; www.healthcare.siemens.com) SOMATOM Edge Plus 128-slice CT system enables quantitative imaging and improved tissue characterization using an imaging component based on TwinBeam Dual Energy technology. The split filter captures two spectral energies at the same time, permitting clinicians in many cases to avoid additional noncontrast exams, as it can thus generate virtual non-contrast images. An added feature is Tin Filter technology, which enables CT scans at very low doses by shielding patients from clinically irrelevant radiation. Fully Assisting Scanner Technologies (FAST) features a 3D infrared camera positioned above the patient bed that allows the system to recognize the head, torso, and other parts of the body using AI, which helps it to automate CT scan preparation. Once identified, the table aligns itself to the correct position required for scanning the body region at isocenter, based on the selected protocol. FAST thus simplifies the preparation of patients, accelerates workflows, and allows lower doses. The SOMATOM Edge Plus also enables scanning of obese patients with strong diag-

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nostic confidence due to the Straton MX Sigma X-ray tube, which provides high power reserves at every kV value in 10-kV increments, and the Stellar Infinity detector. The combination results in sharp, high-contrast images at high speed and low dose, even when passing through wide swaths of tissue. “Siemens Healthineers is excited about the potential of the SOMATOM Edge Plus with FAST Integrated Workflow to help healthcare providers improve workflow and patient management,” said Douglas Ryan, vice president of CT at Siemens Healthineers North America. “Integration of artificial intelligence into patient positioning not only improves image quality, but also expands precision medicine by reducing unnecessary variability for healthcare providers.” Image: The new CT scanner positions patients automatically using AI (Photo courtesy of Siemens Healthineers).

Advanced MRI Solution Cuts Scan Time in Half novel magnetic resonance imaging (MRI) device reduces scan times in half, with the same image quality, allowing radiologists to see more patients on a daily basis. The Royal Philips (Philips; Amsterdam, The Netherlands; www.philips.com) Igeniea Elition 3.0T MRI takes advantage of intuitive user interfaces, unique in-bore sensing technologies, and advanced artificial intelligence (AI)-driven SmartExam analytics to create bespoke planning, scanning, and exam processing protocols that can then be automated for easy reference and redeployment. A feature called VitalScreen offers operators fully guided patient setup, with a newly designed interface for workflow optimization. In addition, VitalEye technology and algorithms process over 200 body locations in parallel to intelligently extract signs of breathing, enabling respiratory signal detection without any interaction from the operator helping to reduces the number of rescans by 70%. Other features include Ambient Experience and an in-bore Connect solution, which provide an immersive audio-visual experience to calm patients and guide them through MRI exams,

further improving the patient experience. “Diagnostic imaging is at the core of many care pathways, with radiology departments facing growing pressure as demand for services increases year on year,” said Neil Mesher, CEO of Philips UK and Ireland. “To help address these challenges, Philips has created a solution that utilizes innovative and sophisticated technology to provide faster and improved image capture and analysis. Elition has been designed to support radiology professionals get to a complete and fast diagnostic picture, and in turn it helps to improve patient outcomes.” “Philips is committed to offering new intelligent solutions that help address the challenges radiologists face today,” said Robert Cascella, chief business leader of diagnosis and treatment for Philips. “Together with our clinical partners we continue to develop new and ground-breaking technologies that work seamlessly together, and are designed to augment the radiologist’s expertise. Our ultimate goal is to enable care professionals to make confident diagnoses, with the use of integrated solutions that provide high quality images, the first time.”

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Smartphone Addiction Alters Brain Neurotransmitter Chemistry new study suggests that teenagers addicted to digital technology may have an imbalance between the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and the excitatory neurotransmitter glutamate-glutamine (Glx). Researchers at Korea University (Seoul; www.korea.ac.kr) used magnetic resonance spectroscopy (MRS) to gain insights into the brains of people believed to have a pattern of smartphone-internet technology addiction, based on a standardized questionnaire. The questions were designed to elucidate the extent that excessive screen time affects daily activities, face-to-face social connectedness, productivity, sleeping patterns, and feelings. The study cohort included 19 teenagers diagnosed with digital technology addiction and a control group of 19 gender- and age-matched teenagers. A dozen addicted teenagers underwent nine weeks of cognitive behavioral therapy (CBT) designed to reduce addictive behaviors; MRS brain imaging scans were conducted before and after CBT, with a single MRS analysis conducted on the non-addicted control group. MRS was used to measure levels of GABA, the chief inhibitory neurotransmitter, and Glx, which electrically stimulates neurons. The results showed GABA/Glx ratio was significantly increased in the anterior cingulate cortex of addicted youth, prior to CBT. The study was presented at the annual meeting of the Radiological Society of North America (RSNA), held during November 2017 in Chicago (IL, USA). “Increased GABA levels and disrupted balance between GABA and glutamate in the anterior cingulate cortex may be related to the functional loss of integration and regulation of processing in the cognitive and emotional neural network,” said lead author and study presenter professor of neuroradiology Hyung Suk Seo, MD. “The good news for anyone who may be addicted to his or her smartphone is that after CBT,

GABA to Glx ratios significantly decreased or normalized in the young adults diagnosed with Smartphone-Internet addiction.” The glutamate-glutamine cycle maintains an adequate supply of the neurotransmitter glutamate in the central nervous system (CNS). Glutamate is also the precursor of GABA, converted automatically to maintain balance between the two. An excess of glutamate is a primary contributing factor to a wide variety of neurological disorders, such as Parkinson’s disease and Fibromyalgia, while insufficient levels of GABA play a vital role in alcoholism, drug addiction, and cravings for sugar and carbohydrates. Image: A new study shows smartphone addiction causes an imbalance in the brain (Photo courtesy of Shutterstock).

MRI Predicts Long-Term Recovery Following Cardiac Arrest agnetic resonance imaging (MRI) measures of cerebral functional connectivity measured within four weeks of cardiac arrest (CA) are associated with a favorable outcome at one year, according to a new study. Researchers at Johns Hopkins University School of Medicine (JHUSOM; Baltimore, MD, USA; www.hopkinsmedicine.org/som), PitieSalpetriere Hospital (Paris, France; pitiesalpetriere.aphp.fr), and other institutions conducted a prospective multicenter study of 46 patients who were comatose after CA in order to assess whether early brain functional connectivity is associated with functional recovery after one year. All participants underwent multiparametric structural and functional MRI about 12 days after CA. Within-network and between-network connectivity was measured in the dorsal attention network (DAN), default-mode network (DMN), salience network (SN), and executive control network (ECN). The results showed that 11 of the patients had a favorable outcome at one year. Higher within-network DMN connectivity was seen for patients with a favorable outcome, who also had greater anti-correlation between SN and DMN, and between SN and executive control network, when compared with patients with unfavorable outcome; the effect was maintained after adjustment for multiple variables. Compared with fluid-attenuated inversion recovery or diffusion-weighted imaging scores, anti-correlation of SN-DMN predicted outcomes with higher accuracy. The study was published on October 18, 2017, in Radiology. The set of identified brain areas that are linked together in a large-scale network are identified by their function, and provide a coherent framework for understanding cognition. Main networks identified include the DAN, involved in voluntary deployment of attention and reorientation to unexpected events; the DMN, active during introspection; the SN monitors the salience of external inputs and internal brain events; and the ECN is engaged during cognitive tasks that require externally-directed attention, such as working memory, relational integration, response inhibition, and task-set switching.

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Functional Neuroimaging Paves the Way for Brain Mapping series of functional near-infrared spectroscopy (fNIRS) devices measure chemical changes in the brain, such as hemoglobin levels and apparent arterial oxygen saturation (aSpO2) in the frontal lobe. The Spectratech (Yokohama, Japan; www. spectratech.co.jp) OEG-APD series of encephalography instruments are based on hemodynamics modality separation (HMS), which can extract data on blood flow in the scalp that is associated with brain function activity by deducting the regional blood flow component from the total fNIRS signal. The OEG-APD series include four products, the OEG-16, OEG-16H, OEG-SpO2, and the OEG17APD devices, and are intended only for encephalography research. The OEG-16 device is designed for use on the frontal lobe, and measures changes in invivo blood using a multi-channel method that simultaneously utilizes light absorption characteristics of near infrared to red light, depending on the mixture of in-vivo hemoglobin and oxygen. The OEG-16H device offers ultrahigh signal to noise ratio (SNR) technology, which can display ultra-weak pulse waves,

while also giving users the ability to perform multi-channel brain localization analysis. It is also provided with monitoring and measurement tools, including an index of aSpO2. The OEG-16H facilitates constant connectivity with 6 light injection points, 6 optical light-receiving points, and 16-channel measure points in a lightweight head module that allows it to translate brain waves into data, while simultaneously measuring hemoglobin from multiple points. The device runs on proprietary software, but can also be operated under Microsoft Windows 7 or 8. The OEGSpO2 module helps measure hemoglobin changes and aSpO2 occurring at multiple points in the brain, with an emphasis on the frontal lobe. The final device is the best-inclass OEG-17APD, which can measure the head in its entirety. The prefrontal cortex is considered to be in charge of the orchestration of thoughts and actions in accordance with internal goals, responsible for higher-level processing, such as memory, attention, problem solving and decision-making. When a person is learning a new skill, for instance, neural activity is greater in

this region. Increasing evidence shows that in Parkinsonâ&#x20AC;&#x2DC;s disease, profound dopamine depletion not only occurs in the striatum of the brain, but also in the prefrontal cortex, and this may be associated with cognitive and motor deficits. Image: The OEG-17APD fNIRS device can detect brain activity by measuring blood flow (Photo courtesy of Spectratech).

Overweight Women May Need More Frequent Mammograms new study suggests that women with higher body mass index (BMI) may need shorter intervals between mammography screening exams. Researchers at the Karolinska Institutet (KI; Solna, Sweden; www.ki.se) conducted a study involving 2,358 cases of invasive breast cancer incident between 2001 and 2008 in order to identify risk factors associated with tumors remaining undetected until larger than two centimeters, and to examine long-term prognosis as a factor of percent density (PD), body mass index (BMI), and patient characteristics. The main outcome measure was detection of tumor sized larger than two centimeters, as compared to smaller tumors. The results revealed that for screen-detected cancers, both BMI and PD were associated with having a large tumor at diagnosis. However, for interval cancers, only BMI was associated with having a large tumor, while PD was associated with having a small tumor. Women with a higher BMI had a worse prognosis than women with

lower BMI, but only among interval cancers, while large tumors were associated with worse prognosis than smaller ones. The study was presented at the annual meeting of the Radiological Society of North America (RSNA), held during November 2017 in Chicago (IL, USA). Numerous studies suggest that obesity increases the relative risk of postmenopausal breast cancer. A meta-analysis of 34 cohort studies that included over 2.5 million women shows that a 5-unit increase in BMI is associated with a 12% increase in risk, and that postmenopausal obese women have a 20-40% increase in risk of developing breast cancer compared with normal-weight women. The higher risks are seen mainly in women who have never used menopausal hormone therapy and for tumors that express hormone receptors. In premenopausal women, by contrast, overweight and obesity have been found to be associated with a 20% decreased risk of breast tumors that express hormone receptors. Medical Imaging International August-September/2018

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Medical Imaging International

Wide-Angle Mammography Improves Biopsy Workflow 50-degree wide-angle high definition (HD) breast tomosynthesis system obtains more targeted, accurate biopsies at a lower dose. The Siemens Healthineers (Erlangen, Germany; www.healthcare. siemens.com) Mammomat Revelation mammography system provides healthcare providers with a HD breast biopsy solution that enables oneclick targeting of suspicious areas with a +/- one mm accuracy. The 50degree scan angle can provide extremely high-quality three-dimensional (3D) images to increase diagnostic confidence and enable earlier detection of even subtle lesions. Mammomat Revelation also provides automated breast density measurements at the point of examination, enabling immediate, personalized risk stratification, facilitating supplemental imaging while the patient is still at the facility. As a result, patients receive results faster, minimizing uncertainty and stress. Mammomat Revelation also offers the InSpect integrated specimen imaging tool, which allows biopsy samples to be rapidly imaged and visualized at the workstation, and the Titanium Contrast Enhanced Mammography (TiCEM) tool, a cost-effective alternative to MRI as an adjunct examination. In addition, smart automation tools and the MoodLight help soothe anxiety and put patients at ease, and the system also offers personalized soft compression (PSC), with which the breast compression process is softened and the compression force is automatically and individually adjusted. When coupled with the ergonomic SoftComp Paddles, PSC enables better breast positioning, more consistent image quality, and reduced patient discomfort.

Image: The Mammomat Revelation mammography system (Photo courtesy of Siemens Healthineers).

Pelvic Radiation Recommended For Early Endometrial Cancer new study confirms that radiation alone offers better pelvic control and fewer severe side effects than a combination of brachytherapy and chemotherapy in women with early highrisk endometrial cancer. Researchers at the University of Kentucky (UKY; Lexington, USA; www.uky.edu), Memorial Sloan-Kettering Cancer Center (MSKCC; New York, NY, USA; www.mskcc.org), and other institutions conducted a phase III trial involving 601 women (mean age 63) with stage I endometrioid histology and high intermediate risk to determine if vaginal cuff brachytherapy and chemotherapy (VCB/C) could increase recurrence-free survival, compared to pelvic external beam radiation therapy (PXRT). Secondary objectives included comparisons of overall survival (OS), patterns of failure, and frequency/severity of adverse events. In all, 301 patients were assigned to PXRT and 300 to VCB/C; 74% had stage I disease, and 89% underwent lymphadenectomy. The results revealed that acute toxicity was more common and more severe with VCB/C, with grade 3 or higher adverse events reported in 32 patients on the PXRT arm, compared to 187 patients on the VCB/C arm. With a median follow-up of 53 months, the 36 month OS was 91% for PXRT, versus 88% for VCB/C. While no significant differences were noted between the two arms in terms of vaginal or distant failure, pelvic or paraaortic nodal recurrences were significantly more common in the VCB/C arm. The study was presented at the 59th annual meeting of the American Society for Radiation Oncology (ASTRO), held during September 2017 in San Diego (CA, USA). “Previous Gynecology Oncology Group trials confirmed that pelvic radiation is an effective, safe, and tolerable option to manage earlystage endometrial cancer,” said lead author Professor Marcus Randall, MD, of UKY. “The current trial confirms that this standard treatment is preferable to the experimental approach of vaginal cuff brachytherapy followed by chemotherapy, in terms of tumor control in the nodal regions and also in terms of acute toxicity. This finding holds true even for patients at a higher risk of recurrence.”

Medical Imaging International August-September/2018

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MRI Helps Determine 3D Architecture of Human Cervix new study describes how three-dimensional (3D) magnetic resonance imaging (MRI) can be used to monitor women for weaknesses in the cervix, helping to prevent miscarriage. Researchers at the University of Leeds (United Kingdom; www.leeds.ac.uk) conducted a cross-sectional study, which involved high-resolution diffusion tensor MRI (DT-MRI) ex-vivo measurements of seven cervices obtained at hysterectomy for a benign lesion, using a 9.4-T Bruker nuclear magnetic resonance (NMR) spectrometer. A deterministic algorithm was used to visualize underlying fiber organization in order to determine the microarchitecture of the human cervix, and identify occlusive structures in the region corresponding to the internal cervical os. The images revealed a fibrous structure running along the upper part of the cervix, which becomes much more pronounced near to where it joins the womb. The fibers are made of collagen and smooth muscle and form a ring around the upper aspect of the cervical

canal. During pregnancy, the fibers provide a strong supporting barrier that keeps the fetus and amniotic sac in place, and prevents microorganisms from entering the uterus. During labor, the body releases chemicals that open the cervix, allowing the fetus to enter the birth canal. The study was published on December 11, 2017, in BJOG. “By applying the imaging techniques that have been used on the brain, we can get a much clearer understanding of the tissue architecture that gives the cervix its unique biomechanical properties,” said Mr. Nigel Simpson, associate professor in obstetrics and gynecology at Leeds University. Water molecules undergo random Brownian motion, also known as diffusion. MRI is sensitive to this motion, as controlled by the bvalue. When the b-value equals zero, the images are not weighted by diffusion; when the b-value is greater than zero the images are diffusion-weighted. When the diffusion is hindered, by cellular membranes, the myelin shield, etc., the signal is higher. DT-MRI can

thus be used to visualize fiber structures, as it can readily differentiate water molecule diffusivities both along and against the fiber. Image: The fibers encircling the cervical canal provide strength and support (Photo courtesy University of Leeds).

No Evidence Gadolinium Causes Neurologic Harm new study concludes there is no evidence that accumulation in the brain of the element Gadolinium (Gd) speeds cognitive decline. Researchers at the Mayo Clinic (Rochester, MN, USA; www. mayoclinic.org) conducted a retrospective study of the Mayo Clinic Study of Aging (MCSA) cohort in order to examine the effects of Gd exposure on neurologic and neurocognitive function. The study included 4,261 cognitively normal participants (mean age 71.9 years) who received one or more gadolinium based contrast agent (GBCA) doses. The mean time from first Gd exposure was 5.6 years. All participants underwent neurologic evaluation and neuropsychological assessment at baseline and at 15-month follow-up intervals. After adjusting for age, sex, education level, baseline neurocognitive performance, Charlson comorbidity index, and ApoE4 status, the results showed that GBCA exposure was not a major predictor of cog-

nitive decline, diminished neuropsychological performance, or diminished motor performance. Dose-related effects were not observed among these metrics, and Gd exposure was not an independent risk factor in the rate of cognitive decline from normal cognitive status to dementia. The study was presented at the annual meeting of the Radiological Society of North America (RSNA), held during November 2017 in Chicago (IL, USA). 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. On its own, gadolinium can be toxic; therefore, when used in contrast agents, gadolinium is bonded with a molecule called a chelating agent, which controls the distribution of gadolinium within the body. In July 2015, the U.S. Food and Drug Administration (FDA) stated that it was unknown whether gadolinium deposits in the brain were harmful. Medical Imaging International August-September/2018

Medical Imaging International

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Cloud Platform Facilitates Medical Image Sharing n innovative image-sharing platform allows any doctor to easily send a medical image for instant review to any other doctor. The Anatomage (San Jose, CA, USA; www.anatomage.com) Cloud universal medical image sharing platform allows doctors to share medical images for instant review on any digital device by using a web browserbased three dimensional (3D) digital imaging and communications in medicine (DICOM) viewer, with no added software installation needed to view the image. Provided free to medical professionals for basic use, the Health Insurance Portability and Accountability Act (HIPAA)-compliant service obviates the need for CDs or USBs. Although originally designed in response to the growing number of specialists that utilize cone beam computerized tomography (CBCT) imaging, the service can now be used to share images from any imaging modality that uses DICOM as a standard for-

mat, such as magnetic resonance imaging (MRI). When used in conjunction with the company’s Invivo6 workstation software, Cloud enables users to rely on no other software tools or managing files. “The increased use of 3D CBCT scanners in dental, medical, and even veterinary practices has resulted in more patient 3D scans and the desire to collaborate with 3D images,” said David Skoff, business development manager of Anatomage. “For instance, an oral surgeon and orthodontist need to view the same patient scan to develop their treatment plan together. The process of sending the scan between offices by CD or USB is slow and cumbersome, but is typical because the file size is large and it requires dedicated viewing software.” “Anatomage Cloud solves both of these problems because it allows the doctor to send the case quickly and provides viewing capability on any device with a web browser-based 3D DICOM viewer,” added Mr.

Skoff. “This technology enhances the speed and ease of collaboration for dental specialists, medical professionals, veterinarians, chiropractors, ENT specialists, and more. Anatomage Cloud opens the door to the most comprehensive network of medical and dental collaboration through 3D visualization.” Image: A 3D CT scan visualized via the Anatomage Cloud platform (Photo courtesy of Anatomage).

CT Trunk Imaging Linked to Higher Nephrectomy Risk eople residing in regions with higher rates of abdominal and chest computerized tomography (CT) scan rates face a higher risk of nephrectomy, according to a new study. Researchers at Dartmouth College (Hanover, NH, USA; www.dartmouth.edu) and the Veterans Affairs Outcomes Group (White River Junction, VT, USA; www.vaoutcomes.org) conducted a cross-sectional analysis of Medicare data from 306 hospital referral regions (HRRs) in the United States in order to determine geographic variation of CT imaging referral, and the corresponding association with one of the most consequential sequelae of incidental detection, partial or total nephrectomy. The study, which included information from 15 million fee-for-service Medicare beneficiaries aged 65-85 years, showed that 43% received either a chest or abdominal CT from January 2010 to December 2014. Risk varied across HRRs, ranging from 31% in Santa Cruz (CA) to 52% in Sun City (AZ). Increased regional CT risk was associated with a higher nephrectomy risk, particularly among HRRs with more than 50,000 beneficiaries. After controlling for adult smoking rates, imaging an additional 1,000 beneficiaries was associated with 4 additional nephrectomies. The study was published on December 26, 2017, in JAMA Internal Medicine. “Medicare beneficiaries are commonly exposed to CT imaging. Those residing in highscanning regions face a higher risk of nephrectomy, presumably reflecting the incidental detection of renal masses,” concluded lead author Gilbert Welch, MD, MPH, of Dartmouth University, and colleagues. “We believe surgeons

Medical Imaging International August-September/2018

should routinely offer active surveillance for small renal masses, and that patients, after being informed about the small risk of developing metastatic disease, should give the option serious consideration.” “The results of the study reinforce the need for clinical decision support tools that consider overdiagnosis as harm, as well as the development of consistent standards on how to perform and interpret CT scans,” said Rebecca Smith-Bindman, MD, of the University of California San Francisco (UCSF) in an accompanying commentary. “But that is easier said than done. Once a suspected cancer is found, it is nearly impossible to ignore. The suspected di-

agnosis opens a Pandora’s box, so the only way to decrease overdiagnosis is to avoid unneeded tests in the first place.” The advent of CT scanning transformed medicine in the early 1970s, enabling clinicians to see details of internal organs that cannot be seen in conventional X-rays. While invaluable in diagnosing the acutely sick and injured, the widespread use of CT scans has an unintended side effect: the identification of what’s known as incidental tumors, unrelated to the clinical symptoms that initiate the test. Such coincidental findings have the potential to lead to overdiagnosis and to overtreatment, including unnecessary surgery.

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Xoran Technologies

Aspect Imaging

The Viera handheld ultrasound delivers accurate diagnostic images at the POC. It is ideal for quick visual confirmations, interventional procedures, vascular access and imaging small parts, enabling optimization of clinical workflow.

The LuminX FMTS features a tube-mounted touch screen interface. It is available with a choice of fixed or height-adjustable patient tables, motorized or manual system positioning, and detectors of various sizes.

The Embrace features a dedicated head coil for brain imaging and produces diagnosticquality images of neonates while sited within the NICU. It allows for continuous monitoring of vital parameters during scan in an incubator-like environment.

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New Guidance for Child X-Ray Exams he U.S. Food and Drug Administration (FDA; Silver Spring, MD, USA; www.fda.gov) has issued a new guidance that recommends medical X-ray imaging exams in children and younger patients be optimized to use the lowest radiation dose needed. In addition, the new guidance recommends that optimization of image quality and radiation dose in the X-ray imaging depend more on a patient’s size than their age, as smaller patients require less radiation to obtain a medically useful image. However, X-rays and computerized tomography (CT) scans should never be withheld from a child or adult who has a medical condition, if the exam may provide important healthcare information that may aid in the diagnosis or treatment of a serious or life-threatening illness. The FDA guidance adds that healthcare professionals are responsible for ensuring there is justification for all X-ray imaging exams – including CT, fluoroscopy, dental, and conventional X-rays – performed on pediatric patients, and that they should also consider if a different type of imaging exam, which does not expose the patient to ionizing radiation, such as ultrasound or magnetic resonance imaging (MRI), could be used to obtain the same result. “Technically, the patient’s body thickness, the distance an X-ray travels through the body to create the image, is the most important consideration when “child-sizing” an image protocol,” declared the FDA Center for Devices and Radiological Health (CDRH) in the new guidance. “Because children have longer expected lifetimes ahead of

them for potential effects to appear, and the risk for cancer is not fully understood, it’s important to use the lowest radiation dose necessary to provide a diagnostic exam.” Information is limited on cancer risks associated with diagnostic radiographic, CT, and fluoroscopically guided procedures during early childhood. Because of the dramatic increase in the numbers of children undergoing CT examinations internationally, it is particularly urgent to study occurrence of pediatric, adolescent, and adult cancer risks associated with these procedures. Image: New FDA guidance recommends that imaging in children should be reduced to the necessary minimum (Photo courtesy of Shutterstock).

Image-Guided RF Treatment Relieves Lower Back Pain omputerized tomography (CT)-guided pulsed radiofrequency (RF) is beneficial for patients with acute or subacute neuroradicular pain and sciatica, according to a new study. Researchers at Sapienza University (Rome, Italy; www.uniroma1.it) conducted a prospective study involving 80 patients who presented with acute or sub-acute neuro-radicular lower back pain (LBP) refractory to standard treatments, such as medication and steroid injections. The patients underwent a pulsed RF procedure using a 22-20 G needleelectrode with the probe tip directed to the symptomatic dorsal root ganglia (DRG) under CT guidance. Pulsed RF was administered for 10 minutes at 45V with a constant local temperature of 42°C. Clinical evaluation was conducted using a visual analogue scale (VAS), the Owestry disability index (ODI), and the Roland-Morris (RM) score; questionnaires were obtained at baseline and at one week, one month, and three-month follow-up. The results revealed that of the 80 patients treated, 81% were pain-free one year after a single treatment session, while six patients required a second pulsed RF session; 90% of

the patients were able to avoid surgical treatment. The study was presented at the annual meeting of the Radiological Society of North America (RSNA), held during November 2017 in Chicago (IL, USA). “There’s a big gap between conservative treatments for disc compression and herniation and surgical repair, which can lead to infection, bleeding, and a long recovery period. Evolving technologies like this image-guided treatment may help a substantial number of patients avoid surgery,” said lead author Alessandro Napoli, MD, PhD. “The results have been extraordinary. Patients have been relieved of pain and resumed their normal activities within a day. With relaxation of the muscles, the distance between the vertebrae returns.” The sciatic nerve is the largest single nerve in the body and is made up of individual nerves emanating from individual DRG in the lumbar spine, which then combine and merge to form the sciatic nerve, which runs down the back of the leg. Sciatica symptoms occur when the large sciatic nerve is irritated or compressed at or near its point of origin, usually as a result of disc compression. Medical Imaging International August-September/2018

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Medical Imaging International

Compact Radiation System Delivers Conformal Radiation Therapy Treatments ovel pencil beam scanning (PBS) technology uses hyperscanning to deliver faster, sharper, and more robust radiation therapy (RT) treatments. The Mevion Medical Systems (Mevion; Littleton, MA, USA; www. mevion.com) S250i Proton Therapy System with Hyperscan PBS technology is designed to shape the delivered radiation dose by “painting” tumors spot-by-spot and layer-by-layer with the sub-atomic proton particles. Hyperscan technology helps overcome clinical challenges faced by first generation PBS systems by reducing delivery times to less than five seconds, thus reducing errors resulting that can undermine the high precision of PBS due to the target tumor shifting under normal organ motion, such as breathing. In addition to Hyperscan, the system utilizes an adaptive, robotically controlled aperture proton multi-leaf collimator (pMLC), which is capable of trimming the edges of the beam at every layer of delivery. This capability can deliver up to a three times sharper drop off in radiation at the delivery field edge, sparing healthy tissue and limiting unnecessary radiation to sensitive locations. As other members of the S250 Series platform, the S250i includes a gantry mounted superconducting synchrocyclotron, a six degree-of-freedom treatment couch, and advanced in-room image guidance. “Delivering sharp field edges has been a real challenge for PBS, especially in shallow fields. In intracranial procedures, where critical structures are in close proximity to tumors at shallow depths, having the sharpest lateral penumbra is essential,” said Skip Rosenthal, VP of clinical education at Mevion. “The sharp penumbras of the adaptive aperture system have substantial benefits for these patients. In addition, the

enhanced speed of Hyperscan PBS could enable greater confidence in treating thoracic tumors.” Proton therapy is a precise form of RT that uses charged particles instead of x-rays. It can be a more effective form of treatment than conventional radiotherapy as it directs the RT more precisely, with minimal damage to surrounding tissue. Evidence is growing that protons can be effective in treating a number of cancers, in particular in children and young people with brain tumors, for whom it appears to produce fewer side effects such as secondary cancers, growth deformity, hearing loss, and learning difficulties. Image: The S250i proton therapy system with Hyperscan PBS (Photo courtesy of Mevion Medical Systems).

PET Technique Detects Bacterial Infections new non-invasive PET imaging technique has been developed that can detect bacterial infections, and monitor antibiotic therapy. Bacteria are developing antibiotic resistance by mutating, and this has led government healthcare authorities to call for the development of new diagnostic techniques that can detect and help manage infectious diseases. The scientists from the Stanford University (Stanford, CA, USA; www.stanford.edu) published their research, part of a pre-clinical study, in the October 1, 2017, issue of The Journal of Nuclear Medicine. The researchers developed a new Positron Emission Tomography (PET) tracer called 6”-18F-fluoromaltotriose that is derived from maltose, labeled with radioactive fluorine-18 (18F), and evaluated it with a number of clinically-relevant bacterial strains, and a micro-PET/CT scanner.

The results show that both gram-negative, and gram-positive bacteria took up the new tracer, and that the tracer could be used to diagnose most bacterial infections, and could change the clinical management of bacterial infectious diseases in patients. Sanjiv Sam Gambhir, MD, PhD, Stanford University, said, “The hope is that in the future when someone has a potential infection, this approach of injecting the patient with fluoromaltotriose and imaging them in a PET scanner will allow localization of the signal and, therefore, the bacteria. And then, as one treats them, one can verify that the treatment is actually working – so that if it’s not working, one can quickly change to a different treatment (for example, a different antibiotic). These kinds of findings are very important for patients, because they will very likely lead to entirely new ways to manage patients with bacterial infections, no matter where those infections might be hiding in the body.”

Study Shows MRIs Safe for Patients with Implantable Devices he results of a new study show that Magnetic Resonance Imaging (MRI) appears to be safe for patients with various implantable cardiac devices such as defibrillators, and pacemakers, and even for chest imaging. MRI scanning has long been considered dangerous for patients with implantable cardiac devices, but the new study shows that MRI can be safely performed on such patients after all. The researchers from the Intermountain Medical Center Heart Institute (Salt Lake City, UT, USA; www.ihc.com) published the results of their study in September 28, 2017, issue of the Journal of Clinical Electrophysiology. The researchers evaluated the MRI studies of 178 patients with cardiac implantable electronic devices, between February 2014 and August 2016, but could not find any problems that needed to be fixed. The study however did not investigate the safety of an MRI scan in direct proximity to the implantable cardiac

Medical Imaging International August-September/2018

rhythm devices. According to the authors, the new study confirms that MRI can safely be used to scan the heart or lungs in patients with implantable devices, and confirms the MagnaSafe findings. Senior author of the study, Jeffrey L. Anderson, MD, said, “Magnetic resonance imaging has become very popular. It’s excellent for looking at soft tissue changes. But it involves very high-strength magnetic fields, which means if a patient has any implanted metal devices containing iron, it could potentially cause harm. X-rays can see bone, but they don’t provide much information about soft tissues like the brain, the heart or other internal organs. MRIs are marvelous for that. That’s a pretty big number of leads exposed to these very strong MRI fields. You would think if there were even a one percent chance of having a problem, it would have shown up. Not even one generator or lead needed more than a minor adjustment, if any at all.”

PRODUCT NEWS DR SYSTEM

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PORTABLE X-RAY

UGPIV DRESSING

Italray

OR Technology

Parker Laboratories

The X-FRAME DR2T features high device automation, anatomical programs, predefined working positions and short time for imaging. It works with wireless cassette-sized detectors that can be positioned directly in contact with the patient.

The Leonardo DR mini II is one of the world's lightest portable X-ray case systems, weighing only 8.9 kg. The x-ray solution supports its users in outpatient digital radiology in the areas of human and veterinary medicine.

The UltraDrape is intended for use during Ultrasound-Guided Peripheral Intravenous procedures. It was designed to be user-friendly and facilitate a no-touch aseptic procedure without compromising efficacy or impeding visualization.

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Automated Ultrasound Analysis Transforms Patient Care dvanced automated tools enable quick, accurate, and reproducible ultrasound imaging analysis, accessible anywhere and anytime via Google Cloud. A collaboration between Google (Mountain View, CA, USA; www.google.com) and DiA Imaging Analysis (DiA; Be’er Sheva, Israel; www.dia-analysis.com) will provide users with access to advanced cognitive image processing software, pattern recognition technology, and proprietary sophisticated machine learning algorithms that automatically imitate the way the human eye identifies borders and motion, producing accurate and reliable data. The image quantification and analysis tools enhance decision support for both immediate and remote evaluations, starting with automated echocardiography. Tools currently available include LVIVO EF, a quick and accurate, fully automated analysis of ejection Fraction (EF) by effectively tracking left ventricular (LV) images, including all frames and beats, thus saving up to 30% of EF evaluation time; LVIVO SWM, an automatic solution to analyze true segmental wall motion (SWM), providing wall motion score, segmental score index, and motion information from 17 LV segments; and LVIVO Strain, a fully automated tool that quickly and accurately produces both segmental and global strain analysis (GLS). “One of DiA’s obvious advantages is its ability to operate cross platforms. Our automated tools can be easily implemented into any ultrasound device and any healthcare IT system, including cloud based platforms, all as part of the physician’s workflow,” said Hila Goldman Aslan,

CEO of DiA. “Once Google Cloud announced its engagement with the medical imaging industry, it was natural that we join forces to offer our quick and accurate auto ultrasound analysis, together with Google’s cloud-enabled capabilities, in order to improve patient outcome.” Google Cloud Platform is a suite of cloud computing services that runs on the same infrastructure that Google uses internally for its enduser products, such as Google Search and YouTube. Alongside a set of management tools, it provides a series of modular cloud services including software as a service (SaaS) computing, data storage, data analytics, and machine learning. Image: Ultrasound imaging analysis is accessible anytime via Google Cloud (Photo courtesy of DiA).

Next-Generation CVIS Upgrades Communicability and Security n updated cardiovascular imaging and Information system (CVIS) enhances communication and efficiency across the care continuum. The newest iteration of the Siemens Healthineers (Erlangen, Germany; www.healthcare.siemens.com) syngo Dynamics software emphasizes enhanced security, widespread access, enterprise consistency, and structured reporting. Improved workflow capabilities and fast and secure readings from any location via a single point of access ensure that all data is included in one place and available to users at a glance. Using HTML 5, users can remote access a common worklist on a variety of platforms and access images across imaging modalities and on any device. The new version of syngo Dynamics comes equipped with intuitive and streamlined tools for reading and reporting, such as an all new measurement and calculation palette. In addition, users can produce fast, precise, and smart structured reporting with individually customiz-

able reports and worksheets that can auto-populate measurements, calculations, and observational data, thus providing healthcare organizations consistency throughout their enterprises. As a cardiology picture archiving and communication systems (PACS), syngo Dynamics can support the physician in interpretation and evaluation of all examinations within healthcare institutions by enabling a bi-directional data flow with the electronic health record (EHR). Advanced features such as graphical diagrams for congenital heart disease (CHD) and vascular results show relevant findings at a glance with the aid of customizable report templates, and a rules-based decision support functionality that helps find missing or inconsistent data in the procedure report before sign off. As the syngo Dynamics CVIS platform can be deployed easily and efficiently in every hospital within a healthcare system at once, it can manage many users across the enterprise in a centralized way. The centralized user management also enables faster and easier system upgrades. Medical Imaging International August-September/2018

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Medical Imaging International

Mobile CT Scanner Provides Real-Time POC Imaging n innovative 16-slice computerized tomography (CT) scanner delivers high quality non-contrast CT, CT angiography, and CT perfusion scans at the point-of-care (POC). The new Samsung NeuroLogica (Danvers, MA, USA; www. samsungneurologica.com) OmniTom uses a combination of rapid scan time, an ultra-small footprint, and the advantage of immediate image viewing to make it an indispensable tool for collecting real time data on critically ill patients. OmniTom features an array of unique mobility features, including a small footprint and omnidirectional wheels to maximize maneuverability and allow easier and quieter movement in small spaces. In addition, OmniTom features an internal drive system, making portability less strenuous, while also offering smart-sensing collision avoidance software to maximize control and patient safety. An increased gantry opening of 40 cm allows improved coverage of the adult head and neck area, and full-body pediatric scanning. The 16-slice (0.625 mm per slice) advanced data acquisition system offers effective dose optimization and highly advanced noise data acquisition system (NDAS) detectors which NE DES W have been combined with a 24-bit IGN processing chain that never compresses the data, leading to clearer images with ultimately low artificial noise. In addition, automatic exposure control (AEC) provides mA WORLD’S MEDICAL PRODUCT MARKETPLACE modulation during helical and axial scanning in order to regulate dose and image quality. The system is controlled via an SIGN UP intuitive user interface based on FOR FREE! Windows 10 that offers touch control, vocal feedback, and animations. Advanced reconstruction is available for three dimensional (3D) and multiplanar imaging, mean slab, maximum/minimum intensity projection, and oblique datasets. Metal artifact and other correction algorithms can also be added to the primary reconstruction, including noise reduction, Iodine delivery rate (IDR), windmill artifact reduction, automatic bolus tracking and contrast injector triggering to maximize workflow efficiency. “OmniTom embodies Samsung’s commitment to providing leading technologies to healthcare providers by combining our key values of access, accuracy, and efficiency,” said Dongsoo Jun, President of Health and Medical Equipment at Samsung Connecting Buyers with Electronics, and CEO of Samsung Suppliers Worldwide Medison. “We’ve made a CT prodReach new sources of supply uct that’s lighter, more mobile, more Identify latest products and technologies accurate and faster, and we hope the Send inquiries directly to suppliers many doctors and technicians will be Receive latest product alerts able to use it to benefit their paChat live with suppliers tients.”

Image: The OmniTom mobile CT (Photo courtesy of Samsung NeuroLogica).

Medical Imaging International August-September/2018

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.

PRODUCT NEWS DIAGNOSTIC SYSTEM

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ULTRASOUND SYSTEM

NIR IMAGING SYSTEM

Radcal

Siemens Healthineers

Shimadzu Medical Systems

The Rapid-Gold+ is the solid-state diagnostic x-ray measurement system in the Accu-Gold family. Rapid-Gold+ systems feature multisensors along with optional probes to provide accuracy, reliability and reduced sensitivity to positioning errors.

The ACUSON Juniper features a lightweight, ergonomic design and complete maneuverability for use across a wide variety of clinical segments. It adapts to virtually any exam environment, with sleep and boot-up times of seconds.

The LIGHTVISION is designed for visualizing lymph and blood vessels to support the treatment of breast cancer based on the detection of near-infrared fluorescent light emitted from ICG. It produces high quality, RT images on a single monitor.

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Isotropic MRI Application Images the Knee in 3D n innovative magnetic resonance imaging (MRI) application can significantly reduce the time required to perform comprehensive diagnostic exams of the knee. The Siemens Healthineers (Erlangen, Germany; www.healthcare. siemens.com) GOKnee3D app is designed to acquire high-resolution three-dimensional (3D) isotropic images to enable evaluation of the knee in all planes, including double oblique and curved planar. Volume acquisition is based on the controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA) SPACE protocol, a proprietary parallel imaging technique used primarily for breath-hold abdominal imaging which enables higher scan speeds and optimal image reconstruction, with better signal quality. Supported by dedicated, high-channel Tim 4G knee coils, as well as automated field-of-view adaptation based on machine learning and artificial intelligence (AI), the MR scanner acquires the volume data of the knee joint at the touch of a button, enabling diagnostic 3D knee exam in just 10 minutes. GOKnee3D is available for the Siemens Healthineers Magnetom Aera 1.5T and the Magnetom Skyra 3T MRI scanners, with an eventual rollout planned for additional scanners in the company’s MRI portfolio. “The fully automated CAIPIRINHA SPACE protocol provides highquality MR imaging in ten minutes and ensures consistency of image quality and operational efficiency,” said Jan Fritz, MD, assistant professor of radiology and radiological sciences at Johns Hopkins University School of Medicine (Baltimore, MD, USA). “The high spatial resolution isotropic da-

ta sets help to visualize abnormalities with high accuracy, enable reformations of virtually any imaging plane, and create high-quality 3D-rendered MR images.” MRI of the knee provides detailed images of structures within the knee joint, including bones, cartilage, tendons, ligaments, muscles and blood vessels, from many angles. The detailed images allow physicians to evaluate knee function and determine the presence of anomalies and defects. Knee examinations are the third most common type of MRI, accounting for 11% of all scans. Image: High-resolution 3D isotropic images using the GOKnee3D app (Photo courtesy of Siemens Healthineers).

Imaging Table Provides Extended Positioning Capabilities new mobile imaging table for vascular surgery and endovascular procedures provides unique features, including maintaining focused anatomy centered even when rolled laterally. The Image Diagnostics (IDI; Fitchburg, MA, USA; www.imagediagnostics.com) Aspect ISR G3 Mobile Imaging Table provides an affordable state-of-theart solution for C-Arm imaging, with a four-way floating tabletop motion that can effortlessly provide such movements as panning, up and down motion, the Trendelenberg position, and lateral and isocentric roll. The table is operated via a mounted panning hand controller with automatic lock functions that effectively eliminate inadvertent float release by patients or staff during procedures. When used in conjunction with a motorized flat detector C-Arm, surgeons have direct control over the movement of both devices at their fingertips. The float top carbon fiber table has 32” of longitudinal travel and a large artifact free imaging area on a small and compact efficient platform.

Nominal bilateral rail sections optimize oblique imaging with a rail artifact. It also includes integrated mini-rails, allowing for an articulated headrest or peripheral extension to be attached, thus providing a maximum of 203 cm of artifact free imaging area. The table height, which includes a 5 cm low attenuation pad, can be raised to 115 cm, while still maintaining an extremely low tongue profile, thus minimizing the object image receptor distance (OID) and helping to maximize image quality. Onboard batteries provide instant-on capabilities for all table functions in the event of a power outage. In addition, the ISR is free from the complexities of hydraulic systems and pneumatic drive systems, making it extremely reliable and economical, since costly maintenance and seal replacements are avoided. “Image Diagnostics is dedicated to offering superior mobile imaging products and delivering the highest level of innovation, quality, versatility, and safety with all of our products,” said Mark Hansen, director of business development at IDI. Medical Imaging International August-September/2018

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Medical Imaging International

Flexible Robotics Platform Advances Bronchoscopy revolutionary flexible endoscopic technology with multiple degrees of freedom allows physicians to diagnose hard-to-reach, small peripheral lung nodules with high precision. The Auris Health (Redwood City, CA, USA; www.aurishealth.com) Monarch Platform is designed to provide visualization of the bronchial tree during bronchoscopic procedures. The system consists of four major components - the patient side system (PSS), a controller cart, a master device workstation used by the surgeon, and the bronchoscope and accessories. The system is based on a master/slave model, with a controller-like interface used to navigate the flexible robotic endoscope to the periphery of the lung with improved reach, vision, and control. The PSS includes the robot cart, two robotic arms with six degrees of freedom, and an instrument drive mechanism (IDM) with four actuated axes. The robotic arms are used to steer the flexible bronchoscope attached at the end effector of the robotic arm, which includes the camera and a working channel for irrigation and aspiration. The PSS also holds the servo drives box, the endoscope camera control box, power and illumination controllers, and all cabling between the IDM and the robot cart. The Controller Cart houses the electronic systems required to power and operate the robotic systems. “Technology has advanced significantly since the development of the earliest robotics platforms used in medicine. The Monarch Platform is designed to address the limitations of current technology with the introduction of a new era of flexible robotics,” said Frederic Moll, MD, founder and CEO of Auris Health. “We intend to deliver on the promise of improving patient care, starting with earlier and more accurate diagnosis of pulmonary nodules. We envision additional uses for the technology across future endoscopic clinical indications.”

Perfusion Imaging of Stroke Victims Improves Emergency Treatment new study suggests that advanced brain imaging can identify stroke patients that could benefit from restoring blood flow in an extended treatment window. Researchers at Stanford University School of Medicine (CA, USA; med.stanford.edu), the University of Calgary (Alberta, Canada; www. ucalgary.ca), the University of Iowa (Iowa City, USA; www.uiowa.edu), and other institutions conducted a multicenter, randomized trial of stoke patients who had remaining ischemic brain tissue 6-16 hours after the event, and who had not yet infarcted. All patients underwent perfusion imaging using automated software to analyze perfusion magnetic resonance imaging (pMRI) or computerized tomography (CT) scans to identify patients thought to have salvageable tissue. In all, 182 patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion were randomly assigned to thrombectomy plus standard medical therapy (92 patients) or standard medical therapy alone (90 patients). The results showed that thrombectomy patients had substantially better outcomes 90 days after treatment than those in the control group. For example, 45% of thrombectomy patients achieved functional independence, compared to 17% in the control group. Thrombectomy was also associated with improved survival, with 14% of the treated group dying within 90 days, compared to 26% in the control group. The study was published on January 24, 2018, in NEJM. “Endovascular therapy 6 to 16 hours after stroke onset plus standard medical therapy resulted in less disability and a higher rate of functional independence at three months than standard medical therapy alone,” concluded lead author Professor Gregory Albers, MD, of Stanford University. “These striking results will have an immediate impact and save people from life-long disability or death,” said Walter Koroshetz, MD, director of the U.S. National Institute of Neurological Disorders and Stroke (NINDS).

Medical Imaging International August-September/2018

More patients die every year from lung cancer than from prostate, breast, and colon cancers combined. More than 90% of people diagnosed with lung cancer do not survive, in part because it is often found at an advanced stage. There are a variety of diagnostic options currently available for lung cancer, but all have limitations in accuracy, safety, or invasiveness, which can lead to false positives, false negatives, or side effects such as pneumothorax (collapsed lung) and hemorrhage. Image: An advanced bronchoscopy robotic platform helps diagnose lung cancer (Photo courtesy of Auris Health).

PRODUCT NEWS C-ARM

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ULTRASOUND SYSTEM

WIRELESS ULTRASOUND

Ziehm Imaging

Konica Minolta Medical Imaging

Healcerion

The Ziehm Vision FD delivers excellent image quality via a liquid cooling system and is designed for continuous use. The system’s workflows and software help optimize patient outcomes, increase productivity, and optimize safety.

The SONIMAGE MX1 incorporates Dual Sonic technology to provide high-resolution image quality and features an intuitive touch screen interface for simplified workflow. It is designed for MSK, anesthesia and pain management exams.

The SONON 300L provides flexible ultrasound technology at less than 1/10 the cost of a traditional ultrasound machine. The device uses a paired tablet or smartphone as display, where images can be analyzed and shared quickly.

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Smart Mammography Workstation Offers Multimodality Views new mammography workstation offers personalized configuration and an intuitive and flexible image layout designed around the unique requirements of mammography. The Fujifilm (Tokyo, Japan; www.fujifilm.com) Aspire Bellus II smart mammography workstation offers a multimodality view for radiologists via high-resolution displays. Features include detailed image data (including 50 m pixel pitch images); immediate image display, even when scrolling quickly between cases; customized reading protocols for streamlined, seamless reporting workflows; and individual reading protocols that ensure images are automatically displayed according to each user’s personal preference. Through use of a thumbnail window, users can instantly obtain an overview of all available images and intuitively rearrange the image layout as needed, including presetting the order of image display. The workstation also incorporates key diagnostic features, such as current and prior image comparison, two-dimensional (2D) and tomosynthesis comparison, quadrant view, and tomosynthesis inversion. A new feature called intelligent shuttering allows users to systematically assess and compare tissue in each segment of the breast, helping to identify subtle asymmetries in breast structure. Aspire Bellus II supports a wide range of reporting workflows, including single reading, double reading, over read, double reading with a final reader, and double reading with automatic correlation of results and assignment to a third reader. For those patients with no abnormality detected, a report can be generated with a single click, dramatical-

ly reducing reporting time in a screening environment. Users can also choose customizable predefined comments when describing structures of interest. “With early detection as the leading defense against breast cancer, it is crucial that radiologists are armed with the right technology to inform diagnoses,” said Rob Fabrizio, director of strategic marketing for digital radiography and women’s health at Fujifilm Medical Systems USA. “The Aspire Bellus II, a one-stop workstation solution designed specifically for mammographic diagnosis, aims to streamline workflow and optimize image displays enabling radiologists to make a more precise diagnosis.” Image: The Aspire Bellus II smart mammography workstation (Photo courtesy of Fujifilm).

MRI Helps Interpret Ambiguous Mammography Results new study shows that magnetic resonance imaging (MRI) is the best choice for clarifying ambiguous mammography tests. Researchers at the Medical University of Vienna (MedUni; Austria; www.meduniwien.ac.at) and Diagnostikum Graz (Austria; www.diagnostikum.at) conducted a retrospective study of 302 consecutive women (mean age 50 years) who underwent 3T breast MRI as an additional workup to conventional and clinical mammography findings. The aim of the study was to investigate diagnostic performance and incidental lesion yield when using MRI as a problem-solving tool. All images were read by experienced, board-certified radiologists, with the reference standard being histopathology or follow-up after two years. The researchers also developed a multiparametric protocol, which al-

lows the examination of up to four patients per hour. The results revealed 53 true-positive, 243 true-negative, 20 false-positive, and two false-negative breast MRI findings. In 16 (5.3%) of all patients, incidental MRI lesions were detected, 37.5% of which were found to be malignant. Breast composition and the imaging findings that had led to referral in the first place had no significant influence on the diagnostic performance of breast MRI. The study was published on January 2, 2018, in PLOS One. While breast MRI provides a very high sensitivity and negative predictive value, particularly in non-calcified breast lesions, problem-solving definitions are not well defined, and the empirical evidence about specific indications, such as architectural distortions, is sparse. Medical Imaging International August-September/2018

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Medical Imaging International

3D Software Improves Orthopedic Surgery Outcomes ovel three-dimensional (3D) planning software can provide orthopedic surgeons with advanced visualization tools for treating complex trauma cases. The Sectra (Linköping, Sweden; www.sectra.com) 3D Trauma preoperative planning solution aids trauma surgeons visualize body structure and improve operating efficiency by rendering standard computerized tomography (CT) images into a 3D interactive image that can be segmented, manipulated, mirrored, templated, and 3D printed. Surgeons can thus study a joint surface or hidden objects, such as the acetabulum in a pelvic fracture, minimizing the risk of surprises and stress during surgery and shortening the time spent in the operating room. Tools included in Sectra 3D Trauma include a bone segmentation tool that allows users to mark bone fragments and choose whether they remain on screen, are hidden from view, or are marked for repositioning. Each fragment is color-coded for easy visualization; after marking a bone fragment, the system automatically creates a new color. An explode function moves all the marked bone fragments away from the center of the fracture, helping to confirm that no fragments have been left behind, and that no other structures will potentially interfere with implants. When bone segmentation is complete, the marked fragments can be repositioned manually using the mouse or a touchscreen interface. Bone alignment can also be done automatically by simply choosing landmarks for the software to identify. Subsequently, template from major manufacturer and generic templates that include screws, nails, plates, and a full library of other components can be overlaid so that the most suitable implants are available during surgery. Bone fragments can be saved and exported as STL and OBJ files to 3D printers, allowing for further surgical planning and educational use. In addition, a contouring template function allows users to add screws and holes if needed to the on-screen or 3D printed model, which can then be used as a guide to select plate shape, size, length, and screw placement, as well as pre-bend implants even before entering the operating room. Other features include a mirror bone function, which can be used as a support tool to reduce fractures or analyze malalignment,

and a split bone feature for planning surgical correction of an impacted fracture. “Sectra’s innovative 3D solutions will enable us to make full use of the acquired images, resulting in cutting edge delivery of care to our orthopedic patients,” said William Ricci, MD, chief of the orthopedic trauma Service at the Hospital for Special Surgery (HSS, New York, NY, USA; www.hss.edu), which has implemented the system. “This 3D platform will improve the quality of pre-operative planning with potential for improved surgical outcomes.” Image: The 3D planning software is designed to improve oprthopedic trauma surgery outcomes (Photo courtesy of Sectra).

Autism May be Linked to Greater Depth of Prenatal Ultrasound in Maternal Obesity he dramatic increase in autism spectrum disorder (ASD) incidence may be linked to adverse effects of ultrasound exposure on the developing fetus, claims a new study. Researchers at Boston University School of Medicine (BUMC; MA, USA; www.bumc.bu.edu/busm), the University of California, San Francisco (UCSF; USA; www.ucsf.edu), and other institutions conducted a case-control study involving 420 participants (78.1% boys and 21.9% girls; mean age 6.6 years) in order to quantify prenatal ultrasound exposure – frequency, timing, duration, and strength – in children with later ASD, developmental delay, and typical development. Ultrasound exposure was quantified and compared per trimester and for the entire pregnancy, with adjustment for infant sex, gestational age at birth, and maternal characteristics. The study included 107 patients with ASD, 104 controls with developmental delay, and 209 healthy controls. The researcher found that the ASD group received a mean of 5.9 scans, the developmentally delayed group received a mean of 6.1 scans, and the typical-development group received a mean of 6.3 scans. In terms of maternal features, the mothers of children with ASD were more likely to be obese, compared with the mothers of children with developmental delay. The mothers of children with ASD were also more likely to be 35 years or older, and to have begun prenatal care later. The researchers clarified that while they found no statistically significant difference in the timing of the initial ultrasound or the total time of ultrasound exposure between groups, the ASD group did have a greater mean depth of ultrasonographic penetration. According to the researchers, this could be related to maternal obesity, because greater depth is required for imaging fetuses in obese mothers. The study was

Medical Imaging International August-September/2018

published on February 12, 2018, in JAMA Pediatrics. “Ultrasound on the fetal skull can convert to thermal energy, conducted to the soft tissue of the brain,” wrote lead author Paul Rosman, MD, of BUMC, and colleagues. “Doppler studies pose the highest risk for thermal effects on the fetus, because the intensity and acoustic power are the highest among all types of ultrasonography, and may cause substantial temperature increase in the fetal skull and surrounding brain tissue.” “As ultrasonographic depth increases, wave frequency and strength decrease, but the volume of fetal tissue exposed to ultrasonic energy increases because the wave energy dissipates in a wedge shape,” concluded the researchers. “Therefore, use of greater-depth ultrasonography may be more likely to alter [certain cell migration in] the developing brain. There could be other factors related to the strength of the ultrasound beam, and more research is needed.” V

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The DIAMENTOR M4-KDK simultaneously measures dose, dose rate and dose area product (DAP). It displays the dose and dose rate of the chamber plane besides DAP and calculates dose and organ doses using DiaSoft software.

The LuminX ceiling-suspended system is available with fully motorized auto-positioning tracking and synchronization or lightweight manual positioning. Other features include tube-mounted interface and automated or manual stitching.

The Senographe Pristina 3D is designed for the detection of breast cancer and provides superior imaging at the lowest dose. Its ergonomic design reduces physical strain while dedicated functionalities allow for easier patient positioning.

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Lead-Free Aprons Offer Alternative Radiation Shielding prons made of thermoplastic polymer alloys and high atomic number elements can provide a highly effective barrier to x-ray radiation. The Artemis Shielding (Ft. Payne, AL, USA; www.ArtemisShielding.com) NanoTek x-ray apron is a unisex front protection apron made of non-toxic, lead-free, and cost-effective thermoplastic polymer alloys bound to various dispersed high atomic number elements with readily accessible outer shell electrons to deliver highly efficient attenuated shielding products. As a result, NanoTek x-ray apron aprons weigh about 50% lighter than their lead counterparts. An added advantage is that the aprons are machine washable after the inner core is removed by unzipping the bottom of the apron, which is reinserted once the apron housing is dry. NanoTek x-ray aprons are available in three protection levels: 80, 100, and 120 kVp; three colors: red, gray, and blue; and four sizes. In addition to aprons, Artemis Shielding also provides highly effective lead-free products such

as x-ray curtains and mobile barriers, and custom solutions for a range of end use applications in industrial, medical, dental, neutron, and experimental facilities. The patented material can be extruded, injection molded, cast, or blow molded to fit almost any length or shape, and also eliminates the needs for special crews or equipment for safe handling, as in lead. “Medical professionals across the world leave their careers prematurely due to pain and disability brought on from years of wearing heavy lead vests. The world needs more doctors and nurses, not fewer,” said Joe Priest, a retired U.S. Special Forces medic and COO of Artemis Shielding. “We can greatly prolong and enhance their work life by providing them a low-cost apron that is significantly lighter than lead and shields just as well.” “There is just no place for lead in a hospital, but unfortunately there was no economical alternative, until now. Our mission is to eliminate lead and reduce radiation exposure in the hospital environment,” concluded Mr.

Priest. “Our products work as good or better than lead. They can be about fifty percent lighter and thinner depending on the application, and we are zeroing in on being as affordable. When you account for the installation and disposal costs of lead, it is no contest.” Image: The NanoTek x-ray apron uses polymers instead of lead (Photo courtesy of Artemis Shielding).

Novel PET Imaging Agent Targets Copper Atoms novel positron emission tomography/computed tomography (PET/CT) imaging agent that traces copper accumulation in tumors can help detect prostate cancer (PC) recurrence, according to a new study. Researchers at Galliera Hospital (Genoa, Italy; www.galliera.it), Humanitas Research Hospital (Milano, Italy; www.humanitas.net), and other institutions conducted a study that prospectively evaluated 50 PC patients with relapse after surgery or external-beam radiation therapy (EBRT), as identified by rising prostate-specific antigen (PSA) levels. All patients underwent 64CuCl2 PET/CT, 18F-choline PET/CT, and multiparametric magnetic resonance imaging (mpMRI) within a 15-day period in order to evaluate and compare the biodistribution, kinetics, and radiation dosimetry of 64CuCl2 in humans. Experienced readers interpreted the images, and the detection rate of each imaging modality was then calculated. Histopathology, clinical or

laboratory response, and multidisciplinary follow-up were used to confirm the site of disease. The results revealed that maximum 64CuCl2 uptake at PC sites relapse was observed one hour after tracer injection. 64 CuCl2 PET/CT proved positive in 41 of 50 patients, with an overall detection rate of 82%; detection rates of 18F-choline PET/CT and mpMRI were 56% and 74%, respectively. The study was published in the March 2018 issue of The Journal of Nuclear Medicine. Copper-64 is a positron-emitting isotope of copper, with applications for molecular radiotherapy and PET. The coordination chemistry of copper allows for its reaction with a wide variety of chelator systems that can be linked to antibodies, proteins, peptides, and other biologically relevant small molecules. The longer half-life of 64Cu delivers optimal biodistribution of slower clearing agents, such as monoclonal antibodies, nanoparticles, and higher molecular weight polypeptides requiring longer imaging times. Medical Imaging International August-September/2018

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Medical Imaging International

Imaging Apps Provide Wound Assessment and Documentation suite of smartphone based imaging and documentation apps allow doctors and community-based nurses to track patient wound healing. The Applied Research Associates NZ Medical (ARANZ Medical; Christchurch, New Zealand; www.aranzmedical.com) Silhouette ecosystem includes the wireless SilhouetteStar camera, a laser-guided threedimensional (3D) measurement camera for wound photography and documentation, the Silhouette 4.0 web-based user application, and the SilhouetteLite and SilhouetteLite+ applications. The SilhouetteLite app is intended for simple wound imaging and notes using Apple iPads and iPhones, while the SilhouetteLite+ app is intended for wound imaging, two-dimensional (2D) non-contact wound measurement, and more detailed notes. All of the products in the Silhouette eco-system connect with a cloud-based proprietary database called the SilhouetteCentral data repository, which enables providers to review, report, securely share, and analyze data collected by Silhouette point-of-care devices. SilhouetteCentral software can be accessed using the Microsoft Internet Explorer web browser. Silhouette can also export data in a standard .csv file format, and can interface with other electronic medical record (EMR) systems using standard formats, including HL7 and DICOM, and is designed to support HIPAA compliance. “Silhouette enables healthcare providers to easily transition to rapid quantitative wound assessment. The new Silhouette products make field-based assessments easier and the data accessible at the speed of telemedicine, enabling centralized staff to instantly access data and improve the care of their patients,” said Bruce Davey, MD, CEO of ARANZ Medical. “We design our products with patients and their caregivers at

Head Circumference Determines Brain Damage in Newborns new cranial ultrasound study reveals that a large head circumference at birth increases the risk for brain damage by tenfold. Researchers at Ruhr University (Bochum, Germany; www. ruhr-uni-bochum.de) and Wilhelmshaven Hospital (WHV; Germany; www.klinikum-whv.de) conducted a study that prospectively screened 4,725 term-born infants by cranial ultrasound in order to explore both the incidence and morphometric risk factors for white matter damage (WMD), an acknowledged prime risk factor for cerebral palsy (CP). The researchers related growth variables and risk factors of the term-born infants using odds ratios of z-score bands. The results revealed that of the 61 term-born neonates identified with WMD, head circumference was a prime and unique index over the whole range of centiles, suggesting different mechanisms for WMD in the lowest and highest z-score band. While in the highest z-score band, cephalic pressure gradients and prolonged labor with preserved neonatal vitality prevailed, in the lowest band, acute and chronic oxygen deprivation with reduced vitality predominated. The study was published on February 28, 2018, in Obstetrics and Gynecology. “The fact that seemingly healthy term-born neonates are not screened by head imaging, in spite of both large head circumference and prolonged labor, is considered to be the missing link between the insult that escapes diagnosis and the development of unexplained developmental delay and cerebral palsy in childhood,” said lead author Professor Arne Jensen, MD, of Ruhr-University. Cephalopelvic disproportion exists when the capacity of the pelvis is inadequate to allow the fetus to negotiate the birth canal. This may be due to a small pelvis, a nongynecoid pelvic formation, a large fetus, an unfavorable orientation of the fetus, or a combination of factors. From an evolutionary point of view, upright gait, a growing brain volume, and general growth acceleration will aggravate the problem and will lead to increased caesarean section rates in the highest z-score bands of head circumference in the future to prevent WMD.

Medical Imaging International August-September/2018

the forefront of our minds. It just makes good sense for patients to be assessed whenever possible in their own community or homes.” An essential part of weekly wound assessment is measuring the wound, and consistent technique is vital for accuracy. The most common type of measurement is linear measurement, also known as the “clock” method, measuring the longest length, greatest width, and greatest depth of the wound, using the body as the face of an imaginary clock. However, such linear methods are inaccurate, as they do not take into account changes in wound shape and depth. Image: A camera-based system provides accurate wound measurements (Photo courtesy of ARANZ Medical).

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The ddRAura features a touch screen, collimator, system position, patient procedure list selection and image preview at the patient’s side. It offers automatic positioning and combines multiple images with automated single focus stitching option.

The Presto DR offers a wide choice of Pixium detectors and system configurations including x-ray generators, tables, DAP and buckys. Built for all radiography requirements, it provides the perfect alternative to film screen and CR.

The NEONA is designed for critically ill infants in the NICU and features a compact design to minimize patient transport issues. Its MRcompatible incubator monitors and stabilizes the patient's physiological and environmental needs.

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Bio-Inspired Imager Improves Cancer Surgery new camera that mimics the intricate visual system of a butterfly can improve sensitivity in near-infrared (NIR) fluorescence image-guided surgery, claims a new study. Developed at the University of Illinois (UI; Urbana-Champaign, USA; www.illinois.edu) and Washington University in St. Louis (WUSTL; MO, USA; www.wustl.edu), the new camera is comprised of an artificial multispectral sensor – inspired by the Morpho butterfly’s compound eye – that interlaces nanoscale spectral tapetal filters with a photodetector array, thus enabling collection of color and NIR fluorescence information on one imaging device. The single-chip multispectral imager is 1,000 times more sensitive and offers seven times better spatial co-registration accuracy than current clinical imaging systems. The unique design allows each pixel to take in the number of photons needed to build up an image; by changing exposure time so as to allow each pixel to detect the photons necessary, bright fluorescence images can be created without overexposing the color image of

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the tissue. Testing showed the camera seamlessly integrates into the surgical workflow, providing real-time information on cancerous tissue and sentinel lymph nodes. Integrating the detector array and optics into a single sensor makes it small, inexpensive, and insensitive to temperature changes. The study was published in the April 2018 issue of Optica. “We realized that the problems of today’s infrared imagers could be mitigated by using nanostructures similar to those in the Morpho butterfly. Their compound eyes contain photoreceptors located next to each other such that each photoreceptor senses different wavelengths of light in a way that is intrinsically coregistered,” said lead author Missael Garcia, PhD, of UI. “The bioinspired imager would be useful for removing various types of cancers, including melanomas, prostate cancer, and head and neck cancers.” “During surgery, it is imperative that all the cancerous tissue is removed, and we’ve created an imaging platform that could help surgeons do this in any hospital around the world because it is small, compact and inexpensive,”

said senior author Professor Viktor Gruev, PhD. “Under bright surgical lights, our instrument was 1,000 times more sensitive to fluorescence than the imagers currently approved. Because the bioinspired imager can reveal fluorescence that is deep in the tissue, it sped up the process of lymph node identification and helped surgeons find lymph nodes that couldn’t be seen by eyesight alone.” Image-guided surgery can enhance cancer treatment by decreasing, and ideally eliminating, positive tumor margins and iatrogenic damage to healthy tissue. Current state-of-theart NIR fluorescence-imaging systems are bulky and costly, lack sensitivity under surgical illumination, and lack co-registration accuracy between multimodal images. As a result, an overwhelming majority of physicians still rely on unaided vision and palpation as primary sensing modalities for distinguishing cancerous from healthy tissue. Image: Missael Garcia, Professor Viktor Gruev, and the Morpho butterfly (Photo courtesy of SWNS/ Getty Images). Medical Imaging International August-September/2018

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Medical Imaging International

Multiparametric MRI Effective for Fatty Liver Assessment new study concludes that non-invasive multiparametric magnetic resonance imaging (MRI) liver scanning technology could halve the number of potential liver biopsies required. Researchers at the University of Birmingham (UB; United Kingdom; www.birmingham.ac.uk), the University of Oxford (United Kingdom; www.oxford.ac.uk), and other institutions conducted a study to investigate the performance and cost of the Perspectum Diagnostics (Oxford, United Kingdom; www.perspectum-diagnostics.com) LiverMultiScan multiparametric MRI device, which is designed to enable non-invasive and quantitative liver fat characterization, especially in non-alcoholic fatty liver disease (NAFLD). For the study, 50 patients and six healthy volunteers underwent multiparametric MRI, blood sampling, and transient elastography within two weeks of liver biopsy. A summary of three biochemical liver characteristics, as well as the LiverMultiScan images, was then compared to histology as the gold standard. The results revealed that LiverMultiScan accurately identified patients with steatosis, stratified those with non-alcoholic steatohepatitis (NASH) or simple steatosis, and reliably excluded clinically significant liver disease. The study was published in the March 2018 issue of Alimentary Pharmacology and Therapeutics. “Whilst liver biopsy remains an important part of advanced hepatology practice, clearly we need better non-invasive tools at our disposal to evaluate the nature and severity of liver disease,” said senior author Professor Gideon Hirschfield, MD, of the University of Birmingham. “In this work we were able to compare and contrast different approaches to this challenging problem, and show where scanning technology could help contribute to optimized diagnostic, prognostic and treatment pathways.” LiverMultiScan uses MRI data to calculate images of proton density fat fraction, T2, and T1 in the liver, which have been shown to correlate with histological measures of steatosis, hemosiderosis, and fibrosis. The strong magnetic field in an MRI machine is used to excite water and fat molecules, which relax at different speeds. As they relax, they emit a sig-

nal, which is used to create the T1 and T2 MR images. T2 is influenced by iron deposits, which can therefore be used to assess hepatic iron overload, while T1 is influenced by the type and structural organization of a tissue. Image: A LiverMultiScan image of a post-bariatric liver (Photo courtesy of Perspectum Diagnostics).

Connected Dosimeter Lowers Radiation Exposure Risk Bluetooth-enabled dosimeter provides immediate dose reads transmitted to smart phones, tablets, or Internet-enabled computers. The Mirion Technologies (San Ramon, CA, USA; www.mirion.com) Instadose + dosimeters use Bluetooth low energy (BLE) technology to transmit dose data automatically and continuously. Added benefits of connectivity include eliminating the badge collection process, increasing user compliance, tracking and controlling dose for high-risk employees, and alerting radiation safety officers (RSO) via e-mails when a dose exceeds a user-specified level. On-demand reports are also available and eliminate the need to ship badges to create and access reports. A configurable calendar is used to set automatic read dates. At the scheduled date, the badge will attempt to transmit data to Mirion’s secure servers. If communication does not occur, the badge will attempt to communicate every hour for 24 hours without intervention. If the dosimeter is unable to communicate, the data will be stored until the next successful connection is established. Additionally, manual reads can be performed at any time by pressing the button on the back of the badge. Data collection is facilitated for the healthcare facility by instaLink HotSpot stations, which securely capture and transmit the dose data to Mirion’s servers when the dosimeter is within BLE communication range of 7.5 meters or more, depending on the physical environment and straight line of sight. The dosimeter is controlled by the Instadose app (available for android and Apple iOS), which reads the radiation dose accumulated on dosimeter. The app allows the user and RSO’s to view dose history, dosimeter assignment details, dose reads, and status.

Medical Imaging International August-September/2018

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The Z-Table four-way float top table is specifically designed for U-Arm and Straight Arm xray systems. It offers maximum flexibility to position patients, and large casters are lockable by color-indicated foot controls.

The XRD 0822 A0 and AP provide a dynamic range and a frame rate of up to 30 frames per second (fps) and 100 fps. Both detectors support a broad range of energy levels and are available with several shielding and scintillator options.

The i_Magnate 1.5T uses optical fiber transmission and parallel acquisition technology for faster scanning. Its short bore, large aperture improves patient experience, while dual screen, graphic reporting offers an intelligent imaging platform.

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Shortwave Infrared Fluorescence May Enhance Imaging new study shows that indocyanine green (ICG) dye also fluoresces in shortwave infrared (SWIR) wavelengths, resulting in images much clearer than those taken in the near infrared (NIR) band. Researchers at the Massachusetts Institute of Technology (MIT, Cambridge, MA, USA; www.mit.edu), Tufts University (Medford, MA, USA; www.tufts.edu), and Massachusetts General Hospital (MGH; Boston, USA; www.massgeneral.org) conducted a study to examine if commercially available NIR dyes possess optical properties that could make them suitable for SWIR, as fluorophores can then offer better contrast and clarity than in shorter wavelengths, due to greatly reduced scattering and improved tissue penetration. They found that even though their emission spectra peak in the NIR, both ICG and IRDye 800CW dyes outperformed commercial SWIR fluorophores, even beyond 1,500 nm. Real-time fluorescence imaging using ICG at clinically relevant doses, including intravital microscopy, noninvasive imaging in blood and lymph vessels, and imaging of hepatobiliary clearance, demonstrated increased contrast compared with NIR fluorescence imaging. They also found that IRDye 800CW could image cancerous tumors in the SWIR range, by using it to label trastuzumab. The study was published on April 6, 2018, in Proceedings of the National Academy of Sciences (PNAS). “What we found is that this dye, which has been approved since

1959, is really the best, the brightest fluorophore that we know of at this point for imaging in the short-wave infrared,” said senior author professor of chemistry Moungi Bawendi, PhD, of MIT. “Now clinicians can start to try short-wave imaging for their applications, because they already have a fluorophore which is approved for use in humans.” High-contrast SWIR fluorescence imaging can be implemented alongside existing imaging modalities by switching the detection of conventional NIR fluorescence systems from silicon-based NIR cameras to new SWIR cameras, which are based on indium gallium arsenide (InGaAs). While these cameras have historically been prohibitively expensive, their prices have been dropping in the past several years. Image: Capillary imaging using NIR (L), as compared to SWIR (R), using ICG dye (Photo courtesy of MIT).

Hybrid User Interface Aids Radiological Diagnosis new study describes a radiology display interface that provides simultaneous two-dimensional (2D) and three-dimensional (3D) visualization of medical images. Developed at the University of Canterbury (Christchurch, New Zealand; www.canterbury.ac.nz), the University of Otago (Christchurch, New Zealand; www.otago.ac.nz), and other institutions, the 2D/3D desktop virtual reality hybrid user interface focuses on improving the 3D manipulation required in some radiologic diagnostic tasks. The system combines a zSpace (Sunnyvale, CA, USA; https://zspace.com) AIO stereoscopic virtual reality device with a standard 2D display, mouse, and keyboard, all connected via a single workstation computer. The 3D component includes a stereoscopic display embedded with motion-tracking cameras, polarized glasses, and a 3D stylus. The wearer of the stereoscopic virtual reality device must first open an image dataset

in the 2D part of the interface. Once loaded, a marching cubes algorithm automatically extracts a 3D model from the images in real-time, and displays it on the 3D interface of the virtual reality device. Via the stylus, the image can then be rotated, annotated, measured, and marked for regions of interest. The position and orientation of the object in the 2D and 3D displays are synchronized. An evaluation of the system by medical students and radiology residents who examined CT scans on the hybrid interface showed that they were able to diagnose scoliosis more accurately than when using a 2D or 3D interface alone. In addition, the 2D/3D hybrid interface was more efficient for the novice users, and more accurate for both novice and experienced users, when compared to traditional 2D interfaces. In addition, diagnostic accuracy of the medical students improved to match that of the residents. The study was published in the February 2018 issue of Journal of Digital Imaging. Medical Imaging International August-September/2018

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Medical Imaging International

Total-Body PET Creates New Patient Care Possibilities

first-generation total-body positron emission tomography/ computed tomography (PET/CT) scanner could revolutionize the understanding and treatment of disease, claims a new

study. Under development at the University of California Davis (UCD, USA; www.ucd.edu), in collaboration with United Imaging Healthcare (Shanghai, China; www.united-imaging.com), the prototype total-body PET/CT scanner, called EXPLORER, will offer the ability to detect focal pathologies throughout the whole body at once, including cancer, infection, and inflammation, and at considerably lower levels of disease activity than currently possible. It will also reduce the time taken to scan the whole body by at least a factor of 10, leading to scan times that could be less than one minute. By covering the entire body at once, sensitivity is increased by a factor of ~40 for total-body imaging, or a factor of ~4-5 for imaging a single organ such as the brain or heart. Significant improvements in timing resolution could lead to even further sensitivity gains. According to the researchers, the combination with total-body PET could produce overall sensitivity gains of more than two orders of magnitude, when compared to existing state-of-the-art systems. The study was published in the January 2018 issue of the Journal of Nuclear Medicine (JNM). “One total-body PET scanner could take on the work load of threeto-four conventional PET scanners, and being able to receive imaging biomarkers from more distant distribution centers will minimize the need for costly in-house biomarker production,” said Terry Jones, DSc, clinical professor of diagnostic radiology at UCD. “As the impact of high-sensitivity, total-body PET scanning becomes apparent, this will provide a major stimulus to physicists, chemists, and engineers to de-

Innovative X-Ray FPS Provides Bedside Imaging Capabilities new flat-panel source (FPS) makes portable, low-dose, and lowcost three dimensional (3D) digital tomosynthesis (DT) more accessible. The Adaptix (Begbroke, United Kingdom; www. adaptiximaging.com) FPS is composed of an array of cold cathode field emitters sealed into a unit, together with a power supply. Each field emitter generates a conelet of X-rays, while a proprietary system, designed to avoid the common problem of high-voltage switching, allows for each Xray emission to be addressed and individually controlled, thus eliminating large numbers of overlapping X-rays. An additional benefit of the design is that the FPS can cover many different angles, allowing depth information to be derived through DT. The multi-angle imaging is possible without the need to physically move the emitting source, which reduces acquisition time and therefore the risk of motion artifacts. A reduced standoff distance results in reduced power requirements and thermal challenges, compared to conventional X-ray sources, and a further benefit is that beam focal spots are in the sub-millimeter range, providing enhanced resolution. A proprietary image reconstruction solution, developed in conjunction with the University of Oxford (United Kingdom; www.ox.ac.uk), uses sparse data techniques to optimize image reconstruction. “Avoiding the need to take patients from ICU to the imaging suite for a CT exam would be valued by clinicians and administration in order to avoid the loss of staff on the ward; typically, a transit from ICU to radiology commits a doctor, nurse, and porter for circa 30 minutes,” said the company in a European Commission report summary. Cold-cathode vacuum tubes do not rely on external heating to provide thermionic emission of electrons. One example of the technology is the Neon lamp, used to produce light as indicators and for special-purpose illumination. The addition of a trigger electrode allows glow discharge to be initiated by an external control circuit. Cold cathodes vacuum tubes sometimes have a rare-earth coating to enhance electron emission.

Medical Imaging International August-September/2018

velop lower-cost detectors for total-body surveillance.” PET is a nuclear medicine imaging technique that produces a 3D image of functional processes in the body. The system detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide tracer. Tracer concentrations within the body are then constructed in 3D by computer analysis. In modern PET-CT scanners, 3D imaging is often accomplished with the aid of a CT X-ray scan performed on the patient during the same session, in the same machine. Image: The EXPLORER total-body PET/CT scanner (Photo courtesy of Martin Judenhofer /UCD).

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The DRYPRO ∑II dry imager utilizes the latest precision optics to produce the highest available resolution for diagnostic images. It uses powerful image-processing algorithms to optimize the image smoothness and text sharpness.

The Mobile Adjustable Height Clear-Pb Barrier allows users to position the clear lead at any height level between 45-74 inches. The base provides 1.0mm lead equivalent protection, while the upper clear lead provides 0.5mm equivalency protection.

The Vision FD Vario 3D integrates multiplanar reconstructions and 3D volume rendering into a space-saving design. Its crystal-clear and distortion-free 3D images provide maximum intraoperative visualization of anatomical structures.

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Cost-Effective Ultrasound Device Boosts Diagnostic Confidence new ultrasound system provides a cost-effective imaging solution without compromising image quality. The Canon Medical Systems ( tawara, Japan; https://global.medical.canon) Aplio i600 ultrasound system is the entry-level scanner of the Aplio i-series, but uses the same lightweight transducers as the Aplio Platinum Series. The wideband transducers feature outstanding clinical versatility and signal processing technology, delivering outstanding sensitivity, penetration, and spatial resolution for all Doppler modes. Superb micro-vascular imaging (SMI) visualizes low-velocity microvascular flow together with high frame rates, allowing diagnostic confidence when evaluating lesions, cysts, and tumors. Features include Precision+ smoothing of images for sharpened outline of lesions, enhanced image uniformity, and reduced clutter; ApliPure+ compounding, which delivers increased imaging contrast and reduced speckle noise; differential tissue harmonics for higher spatial resolution and greatly increased penetration; contrast-enhanced ultrasound (CEUS) for perfusion dynamics in a wide range of clinical settings; shear wave technology for quantitative measurement of tissue elasticity; a comprehensive strain elastography suite with raw data functionality; and advanced myocardial wall motion dynamics for cardiac imaging. Aplio also provides a host of intelligent workflow support and automation tools, including mode-sensitive on-screen navigation via a central trackball; an interface that visually guides the user through the exam, simplifying system operation and helping improve efficiency; iSense design, which makes it easy for clinicians to adjust the console to virtually any scanning position, and iPerformance, an imaging technology

which reduces clutter, strengthens the signal, and improves visualization. The device can also be remotely operated from a wireless tablet, which can be particularly helpful during vascular exams. “The Aplio i600 was designed to expand the clinical utility of ultrasound by delivering outstanding image quality that allows health care providers to feel confident in every diagnosis,” said Dan Skyba, director of the ultrasound business unit at Canon Medical Systems USA. “The cost-effective solution also improves productivity with an intuitive user interface that enhances workflow and reduces training needs.” Image: The entry-level Aplio i600 ultrasound system (Photo courtesy of Canon Medical Systems).

Oncology Information System Supports Comprehensive Care next-generation oncology information system (OIS) connects all oncology disciplines, enabling users to fluidly coordinate tasks and ensure optimal use of resources. The RaySearch Laboratories (Stockholm, Sweden; www.raysearchlabs. com) RayCare OIS is intended to support comprehensive cancer treatment by enabling a truly integrated approach across oncology disciplines, including radiation therapy (RT), chemotherapy, and surgery. Automated active workflows are highly configurable, and tasks for specific staff members can be created automatically, triggered by defined events. By continually monitoring the status of the workflow, RayCare will know the moment a task is completed, actively selecting the next step in the process without any further user interaction. RayCare also provides total control over treatment scheduling and use

of resources, ensuring optimal allocation of treatment machines, accounting for treatment needs, clinical staff schedules, and other key parameters. New tools support time management during tumor board meetings and provide a single interface for notes and data gathering. The system also automatically documents the discussion and decisions made for each patient. Follow-up actions can then be set within the system. RayCare is also designed to store all clinical data acquired during workup, planning, treatment delivery and follow-up in a structured and accessible format that is suitable for data analysis, enabling advanced automated follow-up of treatment outcomes for future research. In addition, RayCare was designed as a machine learning OIS with unique capabilities that can be used to coordinate oncology tasks, supporting comprehensive cancer care organized around each patient’s needs. Medical Imaging International August-September/2018

Industry News

GE to Spin Off Healthcare Business n line with a sweeping strategic reorganization, General Electric Company has announced the decision to spin off its Healthcare business segment as an independent company. The move comes on the heels of a lengthy managerial review conducted by GE management under newly-appointed CEO John Flannery, and is expected to be fully implemented in the course of the coming 12 to 18 months. The once-sprawling industrial conglomerate is making the move in order to focus on aviation, power, and renewable energy sectors. The decision follows a similar healthcare business segment spin-off realized earlier in the year by arch-rival Siemens AG (Munich, Germany; www.siemens.com). GE (Boston, MA, USA; www.ge.com) is betting that these sweeping changes will

strengthen its balance sheet and allow it more financial flexibility by reducing corporate risk in the future. The turnaround plan was announced by GE on the same day of the company's removal from the Dow Jones Industrial Average. GE Healthcare (Little Chalfont, UK; www. gehealthcare.com) recorded over $19 billion in revenues in 2017 and posted 5% revenue growth and 9% segment profit growth in the same year. The business provides medical imaging (including contrast agents), monitoring, biomanufacturing and cell therapy technology, leveraging deep digital, artificial intelligence and data analytics capabilities. Its products and services serve customers in some 140 countries around the world. Kieran Murphy, president and CEO of GE Healthcare, will continue to lead GE Health-

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

Intel and Philips Partner to Speed Up Imaging Analysis with Artificial Intelligence ntel Corporation (Santa Clara, CA, USA; www.intel.com) and Royal Philips (Amsterdam, Netherlands; www.philips.com) have tested two healthcare use cases for deep learning inference models: one on X-rays of bones for bone-age-prediction modeling and the other on CT scans of lungs for lung segmentation. In these tests, which were conducted using Intel Xeon Scalable processors and the OpenVINO toolkit, the researchers achieved a speed improvement of 188 times for the bone-age-prediction model and 38 times for the lung-segmentation model

over the baseline measurements. These tests show that healthcare organizations can implement artificial intelligence (AI) workloads without expensive hardware investments. The size of medical image files is growing along with the improvement in medical image resolution, with most images having a size of 1GB or greater. More healthcare organizations are using deep learning inference to more quickly and accurately review patient images. AI techniques such as object detection and segmentation can help radiologists identify issues faster and more accurately,

which can translate to better prioritization of cases, better outcomes for more patients and reduced costs for hospitals. Deep learning inference applications typically process workloads in small batches or in a streaming manner, which means they do not exhibit large batch sizes. Until recently, graphics processing unit (GPUs) was the prominent hardware solution to accelerate deep learning. By design, GPUs work well with images, but also have inherent memory constraints that data scientists have had to work around when building some models.

Global POC Ultrasound Device Market To Reach USD 3 Billion by 2025

Guerbet and Imalogix in Alliance on Dose Optimization with Artificial Intelligence

he global point-of-care ultrasound (PoCUS) device market is expected to reach USD 3.1 billion by 2025, driven by a surge in the geriatric population, rising prevalence of chronic diseases, technological advancements in PoCUS devices, growing awareness of the benefits of portable ultrasound devices and increasing healthcare expenditure. These are the latest findings of Research and Markets, (Dublin, Ireland; www.researchandmarkets.com), a global market research company. Based on type, the therapeutic devices segment is expected to register a faster CAGR of 8.4%, due to their non-invasive feature and ability to relieve pain and inflammation, reduce muscle spasms, offer fast healing, and increased range of motion. In 2017, the trolley/cart-based segment dominated the PoCUS device market with the largest share of 75.4% due to their increased usage in acute care setting and emergency care in hospitals and healthcare institutions. Based on application, the emergency medicine segment is expected to witness the fastest growth during the forecast period due to the benefits of these PoCUS devices, such as procedural safety, timeliness of care, diagnostic accuracy and reduced costs, leading to their increased adoption in emergency departments. Geographically, the PoCUS device market in Asia-Pacific is expected to register the fastest CAGR of 7.5% during the forecast period, driven by the growing need for PoC in emergency departments, increasing prevalence of chronic and lifestyle diseases, and strengthening of networks of international device manufacturers in the region. Japan remains the largest market for PoCUS devices in Asia-Pacific, led by a surge in its geriatric population, technological advancements and the countryâ&#x20AC;&#x2122;s high healthcare expenditure.

uerbet LLC USA (Bloomington, IN, USA; www.guerbet-us. com), the US affiliate of the the Guerbet Group (Paris, France; www.guerbet.com), which specializes in contrast product and solutions for medical imaging, has entered into a commercial partnership with Imalogix (King of Prussia, PA, USA; www.imalogix.com), a provider of artificial intelligence (AI) process and workflow solutions. Guerbet offers a comprehensive range of pharmaceutical products, medical devices and services for diagnostic and interventional imaging, to improve the diagnosis and treatment of patients. Imalogixâ&#x20AC;&#x2122;s AI and workflow solutions support healthcare providers in better understanding and managing process, quality and safety relation to diagnostic imaging services, interventional procedures, and comply with evolving regulatory standards. The Imalogix self-learning neural network enables organizations to understand and benchmark in real-time best practices from the mass learnings across a network of providers to drive continuous improvement. Deep learning recommendations highlight where and how changes can be made to enable organizations to proactively change behavior down to the scanner, protocol and operator level. Insights into procedure length, utilization, and workflow help organizations understand how to become more efficient and optimize patient flow. The commercial partnership combines Guerbet's leadership in diagnostic and interventional imaging with the cloud-based human and machine-intelligence capabilities of Imalogix to proactively identify areas that impact care delivery to reduce variability and improve the quality, safety and efficiency of care around radiation dose management.

Medical Imaging International August-September/2018

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