In Imaging
Pages 64
A compendium on the latest in radiology
JANUARY 2017
EDITOR’S NOTE IN IMAGING | JANUARY 2017
Viveka Roychowdhury, Editor viveka.r@expressindia.com
A TIME TO INTROSPECT
H
ow far has our nation progressed in terms of health indicators in our seventy years of Independence? While we are no doubt far far better than we were in 1947, it is also true that we lag on all important parameters. A recent report by The Lancet, based on analysis of data from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) study between 1990 and 2015, revealed that India ranks 143 out of 188 countries, ahead of Pakistan (149) and Bangladesh (151), on 33 of the 47 health-related Sustainable Development Goals (SDG) indicators. Clearly, our healthcare delivery model has some gaps that need to be urgently addressed. And where does the radiology fraternity fit into India's healthcare delivery model? Is it only taking, developing and interpreting diagnostic images? Surely, radiologists of today do a lot more than their counterparts of a few past decades. As technology advances, radiology and imaging has evolved into a science. Albeit a science that is becoming less affordable to the common man. A 2014 Decision Resources Group (DRG) Report states that the Indian diagnostic imaging system market will
grow strongly through 2022, fuelled by favourable demographics and underpenetration of the market; increasing procedure volumes and government investment in healthcare will be important factors supporting market expansion. Another 2014 DRG report finds that global markets for diagnostic imaging systems -- including computed tomography (CT), general radiography, magnetic resonance imaging (MRI) and ultrasound systems, will be driven by demand from emerging markets, as mature European and US markets are currently characterised by slow or stagnant growth because of market saturation, leading to low incremental sales. As emerging markets increase their capacity to pay, and evolve to premium systems offering improved clinical outcomes and diagnostic accuracy, the speed breaker to this growth will be the lack of trained doctors to perform such advanced procedures. Hence, medtech companies able to facilitate this training will have the opportunity to build strong relationships with hospitals in these regions, says the DRG report. These predictions are playing out
as per script. As the representative body of radiologists in India, the Indian Radiological and Imaging Association (IRIA) will be holding its 70th annual meet from January 5th - 8th, 2017 in Jaipur, Rajasthan. IRIA 2017 will no doubt bear out these projected growth figures as medtech companies go all out to woo radiologists with the latest technologies. But across the world, governments are examining the costs of healthcare and are looking for ways to cut costs. India is still underinsured and most patients pay out of pocket, especially for diagnostic tests, which put a huge dent in their savings. The public image of healthcare, be it pharmaceutical companies, corporate hospitals and diagnostics service chains, is thus viewed with increasing suspicion. The angst against representatives of this community, who are seen as self serving opportunists instead of selfless healers, may be true for a few bad apples but unfortunately, the entire fraternity is being tarred with the same brush. One hopes that IRIA 2017 will introspect on ways to project a more inclusive rather than exploitative image of the imaging fraternity.
CONTENTS IN IMAGING | JANUARY 2017 22
UPDATE
12
10
Dr Vijay M Rao, named president-elect of RSNA
INSIGHT
34
40
12
Medical innovation: Improving and saving lives
22
MR Elastography of liver - A robust emerging technique
27
Evolving role of radiologists
30
New imaging technologies
32
Modernisation of radiology
EXPERT OPINION 27
34
Increasing job opportunities in imaging
36
Advancements in radiology
40
Multimedia enhanced radiology reporting
42
New solution for affordable OnSight 3D extremity exam
44
The significance of enterprise imaging in the delivery of value-based care
ONE ON ONE
ALSO FEATURING: 54 SSDigiTech 56 Modi Medicare 58 Sanrad
46
Suresh Ranganathan, GM, India & ASEAN, Agfa Healthcare
8 IN IMAGING
48
Dr Arjun Kalyanpur CEO and Founder, Teleradiology Solutions
50
Chander Shekhar Sibal EVP, Fujifilm India
62 Spectramed
JANUARY 2017
IMPRINTLINE Presented By
In Imaging A compendium on the latest in radiology
JANUARY 2017
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IN IMAGING 9
RADIOLOGY UPDATE
Dr VijayM Rao,named president-elect of RSNA Dr Rao has remained on the faculty at Thomas Jefferson University since completing her residency there in 1978
D
r Vijay M Rao, has been recently named as presidentelect of the Radiological Society of North America (RSNA) at the Society's annual meeting in Chicago. A global authority on head and neck imaging, and also recognised for her health services research in radiology, Dr Rao is The David C Levin Professor and Chair of Radiology at Jefferson Medical College of Thomas Jefferson University in Philadelphia. A graduate of the All India Institute of Medical Sciences, Dr Rao is the faculty at Thomas Jefferson University since completing her residency there in 1978. She was appointed associate chair for education in 1989 and vice chair for education in 2000. In 2002, she became the first woman chair of a clinical department in the university's history. She is a trustee of the Thomas Jefferson University Hospital System. As president-elect of the RSNA Board, Dr Rao will support RSNA's commitment to innovative initiatives to deliver high-quality educational materials to the radiology community by leveraging digital technology. "This will be a transformative journey for RSNA," Dr Rao said. "In an effort to drive excellence in patient 10 IN IMAGING
care, RSNA will continue to develop standards for image sharing, structured reports and shared decision making. I find it gratifying to see the RSNA Research and Education (R&E) Foundation increasing grants and awards to support brilliant young radiologists, allowing them to pursue their dreams, which also advances the field." Dr Rao has published more than 200 papers, 260 abstracts in medical literature, and a dozen book chapters, and she co-edited MRI and CT Atlas of Correlative Imaging in Otolaryngology. She is a highly regarded lecturer and educator and has given nearly 200 invited lectures at academic universities and meetings worldwide. Dr Rao has served on the editorial boards of multiple journals, including Academic Radiology, Journal of the American College of Radiology and American Journal of Roentgenology. She has served as a manuscript reviewer for Radiology, American Journal of Neuroradiology, American Journal of Roentgenology, Academic Radiology, Neuroradiology, Pediatrics and Health Affairs. She served as editor of ASHNR News, a publication of the American Society of Head & Neck Radiology, in 2001. An RSNA member since 1981, Dr
Rao has led numerous courses and sessions at RSNA annual meetings and served on the Health Services Policy & Research subcommittee of the RSNA Scientific Program Committee. She has served the RSNA R&E Foundation in a number of roles, and has been a member of the board of trustees since 2008. Dr Rao has held committee or leadership positions in a number of major radiologic organisations, including the American Society of Neuroradiology and American College of Radiology, as well as regional organisations. She has served as president of the American Society of Head and Neck Radiology, the American Association for Women Radiologists and the Association of Program Directors in Radiology, which bestowed on her its Distinguished Achievement Award in 2006. She is also the 2014 recipient of the gold medal award, presented by the Association of University Radiologists, and the Marie Sklodowska-Curie Award, presented by the American Association for Women Radiologists. Dr Rao was also honoured in 2005 by the Philadelphia Business Journal as one of 25 Women of Distinction throughout the region. EH News Bureau JANUARY 2017
RADIOLOGY UPDATE
Imaging links structural brain changes in Parkinson’s disease MRI technique called diffusion tractography was used to look for differences in the neural networks of PD patients with and without MCI PEOPLE WITH Parkinson's disease and cognitive impairment have disruptions in their brain networks that can be seen on a type of MRI, according to a study appearing online in the journal Radiology. Parkinson’s disease (PD) is a progressive disorder of the central nervous system characterised by tremors or trembling and stiffness in the limbs, impaired balance and coordination. It affects about 10 million people worldwide. As PD progresses, many patients develop Mild Cognitive Impairment (MCI), a decline in cognitive abilities, including thinking, memory and language. MCI can be identified in approximately 25 percent of newly diagnosed PD patients, and patients with MCI progress to dementia more frequently than those with normal cognitive performance. For the new study, lead investigator Massimo Filippi, from the Neuroimaging Research Unit at San Raffaele Scientific Institute in Milan, Italy, co-authors Federica Agosta, and Sebastiano Galantucci, and other colleagues used an MRI technique called diffusion tractography to look for differences in the neural networks of PD patients with and without MCI. Increasingly, the human brain is JANUARY 2017
understood as an integrated network, or connectome, that has both a structural and functional component. By applying an analytical tool called graph analysis to the imaging results, researchers can measure the relationships among highly connected and complex data like the network of connections in the human brain. "Cognitive impairment in PD is one of the major non-motor complications of the disease, as well as one of the major concerns of patients and caregivers at the time of diagnosis," Dr Agosta said. "Study of the changes related to cognitive impairment in PD is imperative in order to be able to answer patients' questions and finally be able to predict the future development of this condition." The study group was made up of 170 PD patients, including 54 with MCI and 116 without, and 41 healthy controls. Analysis of imaging results showed that only PD patients with MCI had significant alterations at the brain network level. Measurements of the movement and diffusion of water in the brain, an indicator of the condition of the brain's signal-carrying white matter, differentiated PD patients with MCI from healthy controls and
non-MCI PD patients with a good accuracy. Researchers said the results show that cognitive impairment in PD is likely the consequence of a disruption of complex structural brain networks rather than degeneration of individual white matter bundles. The results may offer markers to differentiate PD patients with and without cognitive deficits, according to Dr Agosta. "If confirmed and replicated by other studies, these results would suggest the use of MRI in PD to support the clinicians in monitoring the disease and predicting the occurrence of cognitive complications," she said. The researchers have obtained resting state functional MRI data from the patients and plan to study the functional connectome alterations associated with cognitive impairment in PD and how structural and functional abnormalities are interrelated. The study is part of an international collaboration between the San Raffaele Scientific Institute and the Clinic of Neurology at the University of Belgrade in Belgrade, Serbia, led by Vladimir Kostic. EH News Bureau IN IMAGING 11
INSIGHT
Medical innovation: Improving and saving lives Dr Sundeep Mishra, Prof of Cardiology, AIIMS, New Delhi and Editor-in-Chief, Indian Heart Journal elaborates on how innovation is tranforming radiology in India
T
he mission of the life sciences community is to prolong life, and to make it more healthy, comfortable and productive while it lasts. In this context, it can be argued that medical technological innovation has been the lifeblood for increasing life expectancy over the past century. Worldwide, the life-expectancy at birth was 31 years in 1900, 47 years in 1940, 61 years in 1980. This early improvement can be attributed to drug and chemical innovations: penicillin, streptomycin, vaccines, discovery of DDT, etc. But after this, between 1960 and 1997, there was a further 45 per cent increase in life expectancy in 30 developing and high-income countries, but now the focus shifted from infectious diseases to develop therapies for life-style diseases. For example during 1950 to 1995, the cardiac disease mortality in the US fell by more than half, increasing the overall life expectancy by three and half years. Nearly two-thirds of this could be attributed not to reduction in infectious diseases but to establish coronary care units, treatment of hypertension, and surgical treatment of CAD. Likewise, there was nearly 22 per cent decline in cancer deaths since 12 IN IMAGING
â– DR SUNDEEP MISHRA
and non-invasive.
Prof of Cardiology,AIIMS, New Delhi
NON-INVASIVE TECHNOLOGIES
Editor-in-Chief,Indian Heart Journal the 1990s. Thus medical innovation has been the prime mover for mortality reduction for humans in recent times.
Innovation and medical imaging The other goal of healthcare technology is to make healthcare management safer and less invasive. Since Roentgen discovered X-rays in 1895, there has been a near continuous innovation in medical imaging. After World War II, there has been a focussed interaction between computerisation and imaging technologies: computed tomography, magnetic resonance imaging, nuclear imaging, and ultrasound-positioned medical imaging, which has led to transformation of healthcare science. Currently, numerous techniques are available for imaging heart and provide valuable information for guiding diagnosis, patient assessment, and therapeutic intervention. They can be broadly divided into invasive
Nuclear cardiology Nuclear medicine is a branch of medical imaging that uses small amounts of radioactive material to diagnose and determine the severity, treat a variety of heart diseases. These techniques are minimally invasive and can reveal physiologically the blockage within the coronary arteries. Because nuclear medicine procedures are able to pinpoint molecular activity within the body, they offer the potential to identify disease in its earliest stages as well as after treatment. They are particularly useful in deciding if an invasive procedure like angioplasty or bypass surgery is required in a given patient. (See Figure 1) Cardiac SPECT (single photon emission computed tomography) scans assess the blood flow within heart vessels. The scans can use radio-sotopes like 201 thallium or 99mTc sestamibi or 99mTc tetrafosmin. MUGA (Multiple Gated Acquisition) Scan on the other hand is a test that is used to evaluate heart function. Positron emission tomography (PET) is the most recent advance in this area. It allows myocardial perfusion imaging i.e. JANUARY 2017
INSIGHT
assessment of regional myocardial blood flow more accurately than any other conventionally available technique like SPECT. The process involves intravenous injection of a positron-emitting perfusion tracer, such as 13N-ammonia, 15O-water, or 82 Rubidium, and tracking the flow of the radiotracer passing through circulation and heart. This assessment both at rest and during various forms of vasomotor stress provides insight into early and subclinical abnormalities in coronary arterial vascular function and/or structure, noninvasively. Further, it can throw light on myocardial flow reserve and even viability of myocardium, most accurately predicting whether patient will benefit from angioplasty / bypass surgery and even monitor therapeutic interventions. It serves as a surrogate marker for coronary vascular health. (See Figure 2). Echocardiography The ultrasound technique, or echocardiography, is perhaps the greatest revolution in imaging technology for heart. It is a noninvasive modality which has figured most prominently in the structural diagnosis of a variety of heart conditions (other than coronary disease), such as valve disease, septal defects, myocardial and pericardial abnormalities. Echocardiography, including tissue Doppler imaging offers useful flow assessment and other functional information. (See Figure 3) Echocardiography employs high-frequency sound waves to generate visual images of cardiac anatomy and function like sonar. It utilises two approaches; transthoracic (TTE) and trans-esophageal JANUARY 2017
Figure 1 Nuclear Cardiology
Figure 2 Cardiac PET Imaging
(TEE). There have been several advances in the field of echocardiography. Portable ultrasound devices that weigh less than five pounds are capable of performing a complete bedside echocardiographic examination. The information provided has become so reliable and useful that some clinicians have even predicted demise of the stethoscope. (See Figure 4).
Stress echocardiography: It is the combination of echocardiography with a physical, pharmacological, or electrical stress. The diagnostic endpoint for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy to nuclear imaging, but at a lower cost, without environmental impact, and IN IMAGING 13
INSIGHT
with no biohazards for the patient and the physician. 3-D Echocardiography - One of the most significant developments of the last decade in this area is the evolution of 3-dimensional (3D) imaging which has for the first time made assessment of complex cardiac anatomy possible. Significant advances in threedimensional echocardiography have made this modality a powerful diagnostic tool. It can provide accurate and reliable measurements of chamber size and function and offers novel views and comprehensive anatomic definition of valvular and congenital abnormalities, improving diagnosis and preoperative planning. Further, it can be extremely useful in monitoring the effectiveness of surgical or percutaneous transcatheter interventions so much so that 3-D echocardiography has become part of the routine clinical diagnostic armamentarium. (See Figure 4) Contrast echocardiography: It has evolved rapidly in the last decade, with major developments in both contrast media and ultrasound equipment. This technology employing the use of microbubbles has been used predominantly for the detection of intracardiac shunts, but can also be utilised to optimise assessment of left ventricular function during stress echocardiography and when imaging is suboptimal. Further with refinement in technology it can be used as a tool for the routine clinical assessment of myocardial perfusion. The future holds the promise of new contrast agents capable of imaging specific abnormalities in the vasculature, such as thrombi or 14 IN IMAGING
Figure 3 Conventional Echocardiography
Figure 4 Innovations in Echocardiography Technology
damaged endothelium, while the next stage in this rapidly developing field is likely to move ultrasound from diagnostic technique to therapeutics. (See Figure 4)
Magnetic resonance imaging Cardiac magnetic resonance imaging (MRI) is a medical imaging technology for the non-invasive assessment of the function and structure of the heart and cardiovascular system. It uses a JANUARY 2017
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congenital heart disease and intracardiac shunts. However, the key disadvantages are limited availability, expense, requirement of special skills/technical training needed to perform but most importantly interaction with metallic structures within body like metallic prosthesis, conventional pacemakers, neurostimulators, cochlear implants, bone growth stimulators, intracranial aneurysm clips, and women who are in the first trimester of pregnancy. Magnetic Resonance Angiography: MRA is an application of MRI which can produce 3D and 4D images of blood vessels and the flow of blood through the vessels. This modality is used to generate images of arteries (and less commonly veins) in order to evaluate them for stenosis or dilatations (at risk for rupture). (See Figure 5)
Figure 5 Cardiac MRI and MR Angiography
Cardiac CT and CT Angiography
Figure 6 Cardiac CT and coronary CTA
powerful magnetic field, radio waves and a computer to produce detailed pictures of the structures within the heart, to detect and monitor heart diseases and to evaluate the heart’s anatomy and function in patients with a variety of structural diseases. Unlike X-ray-based technologies, it does not use ionising radiation, and it may provide images of the heart that are better than other imaging methods for JANUARY 2017
certain conditions. The advantages of MRI include its high spatial and contrast resolution, its ability to obtain images in virtually any plane and large fields of view. It may be beneficial for determining several parameters, including chamber size, global and regional left ventricle and right ventricle functions, volume and mass, cardiomyopathies, valvular function, pericardial disease, complex
Cardiac computerised tomography CT is beneficial for determining a variety of structural abnormalities. They are coronary calcifications, pulmonary embolism, pericardial disease, congenital heart disease, cardiac thrombi and tumours, global and regional function and valvular heart disease. It utilises concentrated and focused X-rays for its evaluation. There are five important uses of cardiac CT; to screen patients with risk for heart diseases, to identify patients who do not need further cardiac evaluation, to consider serial imaging as ongoing management tool, to improve compliance and as a noninvasive angiography. CT angiography is another imaging modality which has revolutionised the field of cardiology. It has a high negative predictive value which means IN IMAGING 19
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that if negative it has a 98 per cent chance that there is no significant coronary artery disease. Thus it is a useful screening test and its use can help avoid unnecessary invasive coronary angiography. Further, it could be used for 3-D evaluation of not only heart vessels but entire cardiovascular tree. While in more than 90 per cent of cases the quality is excellent, poor visualisation of small vessels (<1.5 mm), requirement for stable low heart rate, radiation exposure and high dose of contrast required may be important limitation of the procedure. (See Figure 6)
INVASIVE IMAGING Intracardiac echocardiography An important advance in echocardiography is intracardiac echocardiography wherein a catheter can be introduced into the heart via a vein and navigated within right heart chambers to obtain detailed anatomical landmarks that may guide catheter based interventional procedures such as intracardiac ablation and closure of atrial septal defects and patent foramen ovale. Coronary angiography A coronary angiography is a minimally invasive procedure using catheter to image coronary circulation. As a matter of fact, this investigation remains the goldstandard in the evaluation of the severity of coronary stenoses. Recently, the technique of rotational angiography has been developed to enhance the number of images available, to more fully assess the complex coronary vasculature as well as provide a 3D view. It has been found to be clinically useful in decreasing contrast dose, radiation exposure, and 20 IN IMAGING
Figure 7 Coronary Angiography
overall procedure time with an adequate safety profile and comparable image content. (See Figure 7) Intravascular ultrasound Intravascular ultrasound (IVUS) is a medical imaging methodology using a specially designed catheter with a miniaturised ultrasound probe attached to the distal end of the catheter. IVUS enables accurately
IVUS HAS ENABLED IMPROVEMENTIN ANGIOPLASTYOUTCOMES AS ALSO BENEFITIN CLINICALRESEARCH
visualising not only the lumen of the coronary arteries but also the atheroma(membrane/cholesterol loaded white blood cells) ‘hidden’ within the wall. IVUS has thus enabled improvement in angioplasty outcomes as also benefit in clinical research. Virtual histology (VH) is a computer application of this technique which may permit plaque characterisation, which is shown in Figure 8. Optical Coherence Tomography Optical coherence tomography (OCT) is a novel invasive imaging technique that produces high resolution intracoronary images by a principle similar to IVUS, however, OCT uses infrared light, not ultrasound. The main applications of the OCT system are: atherosclerotic plaque assessment, stent struts coverage and apposition assessment, in-stent JANUARY 2017
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cardiology in recent times, which is shown in Figure 8.
How does medical innovation improve clinical practice For translation of a new technology into improved patient outcomes, or in other words for a new technology to become effective there are three underlying requirements: ◗ A decision taken by healthcare delivery organisations to adopt these new technologies, looking at pros and cons of the technology. ◗ Deployment of these technologies within the complex organisational structure of healthcare providers. ◗ Monitoring the use of these new technologies. Thus new technologies must not be only adopted by healthcare providers, but integrated into healthcare delivery systems adapting to their organisational structures to deliver the full benefit and impacting clinical outcome.
Conclusion
Figure 8 Innovations in Invasive Imaging
restenosis evaluation and for guiding angioplasty and its optimisation,which is shown in Figure 8. Near infra-red spectroscopy One of the most intriguing new technologies to help evaluate coronary atherosclerosis is near-infrared spectroscopy (NIRS). This modality provides real-time information regarding the lipid content of coronary plaques, which allows a new JANUARY 2017
dimension of atherosclerosis imaging — chemical composition — to augment the physiologic and anatomic determinations and planning an interventional procedure, shown in Figure 8. Cardiac thermography Thermography is a new method for the evaluation of the inflammatory process locally and permits the identification of vulnerable plaque, one of the cherished goals in
Within the course of last century, there has been a historic increase in life expectancy. This improvement in life-span can be closely linked to innovations in medical technology, drugs, vaccine or device. Cardiology remains a speciality where this marked reduction in mortality has corelated with medical innovations. Innovations in cardiac imaging are the latest ones which may in addition lead to a further improvement in quality of life. While development of echocardiography and coronary angiography represent a historic milestone, some new developments like CT angiography, MRI and PET imaging are redefining this field in altogether a new way. IN IMAGING 21
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MR Elastography of liver - A robust emerging technique Dr Parul S Garde, Consultant Radiologist, Global Hospitals, Mumbai talks about new techniques revolutionising the diagnosis and management of chronic liver disease
P
ast few decades have witnessed a major technological revolution in diagnostic as well as therapeutic aspects of medical science. As a practising radiologist in a tertiary care super speciality organ transplant hospital, I take this opportunity to write about one such revolutionary technique which has truly made its mark in the diagnosis and management of chronic liver disease - MR elastography.
Techniques This MRI technique quantitatively evaluates tissue stiffness by propagating low frequency mechanical waves through the liver. It is performed using an MRI safe passive driver that is applied to the right upper abdomen and lower chest overlying the right lobe of the liver while the patient is being scanned in the MRI scanner. The MRE sequence is carried out with four short breathholds and completed within one to two minutes, without the need for intravenous contrast injection. An active driver generates low frequency mechanical waves 22 IN IMAGING
JANUARY 2017
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(typically at 60 Hz) which are conducted to the passive driver through a long plastic tube. The passive driver vibrates and produces shear waves that are propagated across the liver. The wavelength of the propagating shear wave is directly proportional to the stiffness of the liver, that is, the stiffer the liver, the longer the wavelength. By applying an inversion algorithm to the raw data, elastograms or stiffness maps that depict tissue stiffness are generated. Elastograms may be displayed in a gray scale or with a colour scale. The result is obtained by placing the region of interest on the processed images. It is measured in Kilo Pascals.
Applications Staging of chronic liver disease : Regardless of the etiology, chronic liver disease can progress from inflammation to fibrosis (reversible in early stages) and finally cirrhosis (irreversible). Liver stiffness measured with MRE increases with increasing stage of fibrosis. The increase in stiffness increases significantly with advanced fibrosis and cirrhosis. MR elastography can non invasively detect various stages of fibrosis and thus obviate the need for liver biopsy, which has been the gold standard for detection, till the past decade. Patients who are treated in early stages of fibrosis stand a better chance of survival compared to those untreated, particularly due to availability of effective antiviral treatment for chronic viral hepatitis.
Quantification of fat content of liver JANUARY 2017
Non alcoholic fatty liver disease is widely accepted as a cardiovascular and insulin resistance risk factor. Fatty liver is diagnosed when the intra-cytoplasmic fat deposition is found in greater than 5 per cent of hepatocytes. Till present times, histological fat analysis is a semi-quantitative method at best, with high rates of misdiagnosis due to sampling error. Currently, there is no cutoff or limit where liver fat content is considered too much or harmful. However, it is foreseeable that as we understand this disease spectrum as there might arise a need to know the exact amount of fat in the liver for risk stratification or response assessment. Hence, there is a need for more precise quantitative methods of evaluating hepatic steatosis. MRI based methods of hepatic fat quantification have proved to be able to reflect much smaller changes in the degree of steatosis. Besides, the results thus obtained can be correlated with the patients’ body weights and serum alanine aminotransferase and aspartate aminotransferase levels. This makes MRI ideal as an imaging biomarker
for assessing response to treatment of fatty liver. In fact, recent papers have primarily used MRI as a means to quantify hepatic fat when studying the effects of prognostication and treatment of hepatic steatosis in relation to NASH and impaired glucose tolerance. There are two primary methods of evaluation for estimation of hepatic fat fraction on MRI. The first is an imaging-based, Chemical Shift Imaging (CSI) method which takes advantage of the fact that protons (hydrogen atoms) in fat and water molecules are quite different in magnetic resonance properties and that the signal intensity of the liver at different time-points of image data acquisition (echo time) varies, depending on the concentration of water and fat. The second method is MR spectroscopy (MRS), a purely quantitative method that measures the concentration of water and fat metabolites based on their resonant frequencies. Potentially, by combining the fat quantification information with MRE findings, one may be able to diagnosis simple hepatic steatosis from NASH and NASH with fibrosis.
Quantification of iron Content :
MRI BASED METHODS OF HEPATIC FAT QUANTIFICATION HAVE PROVED TO BE ABLE TO REFLECTMUCH SMALLER CHANGES IN THE DEGREE OF STEATOSIS
Iron overload cannot be detected reliably on any other imaging technique except MRI. Iron is a paramagnetic substance and causes rapid decay of MRI signal and generally results in signal loss where it is found abundantly. Quantification of the degree of iron deposition is important for two reasons: it influences the decision to treat and provides an objective means to monitor response to IN IMAGING 23
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treatment. In patients with chronic hepatitis C, liver iron overload is associated with disease progression and resistance to antiviral therapy. MRI can be used to estimate the degree of iron deposition in tissues by virtue of the fact that iron accelerates T2 and T2* signal decays in spin-echo and GRE pulse sequences respectively. In order to guide treatment initiation and therapy monitoring, a quantitative means of predicting the liver iron concentration (LIC) has been deviced.
Advantages MR Elastography assesses the fibrosis by depicting the tissue stiffness over the entire liver cross section. This is unlike the ultrasound-based method of elastography, where in only a portion of the liver is interrogated. Similar drawback is with percutaneous needle biopsy, where in if a sample from the normal liver is obtained would give wrong results in a patient with cirrhosis / fibrosis. Besides elastography performed with ultrasound has its drawbacks in obese patients or when the patient has ascites or colonic interposition between the liver and the anterior abdominal wall. Even after the injection of MRI contrast agents, there has been no influence on the liver stiffness measured with MR Elastography. Thus, it is considerably flexible in its use in the clinical liver MRI protocol. As it is the quantitative technique, MR Elastography has an advantage due to the fact that it has excellent intra-observer and inter-observer reproducibility. Thus it can be used as a robust tool for monitoring the 24 IN IMAGING
ADVANCEMENTS IN IMAGE ACQUISITION TECHNOLOGY WOULD REDUCE SCAN TIME AND MINIMISE RESPIRATORYMOTION ARTIFACTS.INSTEAD OF USING CONVENTIONAL GRADIENTECHO PULSE SEQUENCES FOR IMAGE ACQUISITION,SPIN ECHO, FASTSPIN ECHO AND ECHO PLANAR IMAGING METHODS MAYINCREASE SIGNALTO NOISE RATIOS,POTENTIALLY REDUCING THE LIMITATION OFHEPATIC IRON OVERLOAD disease progression as well as assessing the response to treatment.
Limitation Main limitation of the MR Elastography at the current time is that it may fail in patients having moderate to severe iron overload, where the liver MRI signal becomes very low and hence undetectable. Soon this limitation of MR Elastography would be overcome with newer MR sequence such as T1 mapping that are part of research at the moment. Another major drawback of this technique at this point is that it cannot differentiate inflammation
from fibrosis. 3D MR Elastography and multi-frequency MRE techniques are however underway, which would definitely help to overcome this drawback.
Future At present MRE suffers from lower spatial resolution, especially compared to standard anatomic MR images of the liver. Hence, MRE technique is also undergoing several modifications and improvements. Advancements in image acquisition technology would reduce scan time and minimise respiratory motion artifacts. Instead of using conventional gradient echo pulse sequences for image acquisition, spin echo, fast spin echo and echo planar imaging methods may increase signal to noise ratios, potentially reducing the limitation of hepatic iron overload. The 3D MRE technique would be useful to estimate liver fibrosis burden and also focal liver lesions. A multi-frequency MRE technique that can demonstrate changes in viscoelastic properties that can help separate inflammation, fibrosis and congestion is currently being developed. MRE of the spleen is also underway with simultaneous evaluation of liver and spleen stiffness. Spleen stiffness correlates well with portal hypertension and is useful for prediction of significant varices Future role of MRE in combination with contrast enhanced MRI is likely to go beyond determining liver stiffness and will perhaps allow it to discriminate between the effects of inflammation, passive congestion and fibrosis. JANUARY 2017
VALUE AD
MammoScan: Full field digital mammography system Mammoscan comes with various features which makes scanning easy and is comfortable on patients
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9 per cent deaths in developing countries are due to breast cancer. Unlike other cancers, breast cancer is eminently treatable if detected at an early stage. It is recommended by WHO that education and screening programmes are only ways to improve survival rate and reduce mortality. X-ray Mammography has been the gold standard for early detection of breast cancer – the commonest female malignancy in the developing world. However, despite technology improvements, dedicated film-screen analogue mammography does have its limitations especially in dense breasts where lesions are inherently difficult to detect. Dense breasts require higher exposure there by increasing the radiation dose. Two-thirds of premenopausal women and one fourth of post-menopausal women have dense breast tissue which increases the risk of developing breast cancer by four to six-fold. The award winning design, Mammoscan, a full field digital mammography system delivers uncompromised clinical value, workflow efficiency and patient comfort. Mammoscan’s industry best pixel size offers high quality image, JANUARY 2017
resolution and visualisation. Mammoscan is synchronised in the way the beam is always focussed on the digital X-ray receiver surface during the exposure process. This principle eliminates the need for the antiscatter grid, thus saving the dose to the patient. The digital X-ray receiver in mammoscan provides better visualisation of breasts thus ensuring more accurate detection of tumours and microcalcifications. Mammoscan comes with various features which makes scanning easy and is comfortable on patients. The swivel arm can be raised, lowered, and rotated to accommodate patient in all statures, standing and/or sitting, to produce mammographic images in all standard views. The breast compression device works in conjunction with breast support table to uniformly compress the breast for
X-ray imaging. Performing breast biopsies on a biopsy table solves the common problems encountered with the prone table and upright core biopsy techniques. Mammoscan comes with host of other features at affordable cost. Due to technology used in the system, maintenance cost is significantly reduced. For further enquiries on the product, feel free to revert at cura@cura.in. IN IMAGING 25
PRE EVENT
Healthcare Sabha 2017: Co-creating a manifesto for a healthy India The event will be held at Visakhapatnam from February 9-12, 2017
WITH AN aim to drive a revolution and facilitate a dialogue in public health, Express Healthcare, a publication from The Indian Express Group, launched Healthcare Sabha – The National Thought Leadership Forum on Public Healthcare. Healthcare Sabha 2017 will create a blueprint to facilitate evidence-based policy making, augment excellence in healthcare delivery and eliminate barriers to equitable access. Healthcare Sabha 2017 will work toward 'Co-creating a Manifesto for a Healthy India.' The event will be held at Visakhapatnam from February 9-12, 2017.
Key subjects at the forum include: Pillar 1-Tackling talent crunch: Improving capacity and competence ◗ Role of PPPs in training healthcare professionals. ◗ Strategies to attract doctors to public health (especially in rural India). ◗ An assessment of the Skill India Initiative and the way forward. ◗ Creating a large pool of efficient and skilled professionals. ◗ Medical education syllabus in India: In need of a major rehaul. 26 IN IMAGING
Pillar 2-Developing sustainable health financing systems ◗ Galvanising healthcare via insurance. ◗ Govt sponsored schemes: Meant for poor, but beyond their reach. ◗ Understanding health economics: A much needed remedy for a healthy India. ◗ Infrastructure essentials: Plan for an affordable healthcare system. Pillar 3-Ushering good governance in public health ◗ Technology for good governance in public hospitals. ◗ Revisiting our disease control strategies: Successes & failures (NCD, Anti-TB programmes etc.) ◗ Strategies to mitigate health infrastructure deficit. ◗ Uprooting corruption from healthcare: An urgent need.
Pillar 4-Ensuring access to quality health services and essential medicines ◗ Analysis of Mohalla clinics (Studying the efficacy of the model and their replicability). ◗ Universal Immunisation Coverage: Making it Mission Possible. ◗ Medicines for all: Roadmap for better accessibility and affordability. ◗ Sanitation: Is the Swachh Bharat campaign taking us closer to a Swasth Bharat? ◗ Eliminating malnutrition: Taking a multi-pronged approach. To be held concurrently with Healthcare Sabha, the Express Public Health Awards will honour Champions, Visionaries and Game Changers in Public Healthcare. The first edition (held from March 4-6, 2016 at Hyderabad Marriott Hotel and Convention Center) brought together significant stakeholders in public health to deliberate on cohesive, unified and innovative ways to achieve the National Health Mission’s Vision pertaining to ‘Universal Access to Equitable, Affordable and Quality Healthcare Services to All’. JANUARY 2017
INSIGHT
Evolving role of radiologists The role that today’s radiologist is expected to play is much more decisive and sometimes even proactive, says, Dr Kumar K S, Consultant - Interventional Radiology and Interventional Oncology, Cytecare
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ost technological progress in radiology and imaging in the past few decades has been in the direction of clearer and sharper images, safety (and convenience) of patients, steadily
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decreasing radiation doses and so on. This has resulted in the development of molecular imaging techniques such as MR spectroscopy and PET/CT on one hand and the entire field of interventional radiology (IR) on the other. Together they have also
allowed the radiologist and imaging specialist to play a significant role in planning and implementing the therapy for most forms of cancer.
Interventional radiology A significant number of pioneering IN IMAGING 27
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developments in the field of medicine and surgery have involved IR in one form or another. Medical procedures such as angiography and angioplasty (coronary as well as peripheral) would be difficult to imagine without the participation of an IR specialist. According to a factsheet published by the Fairfax, Virginia-based Society for Interventional Radiology (SIR), some recent advances in IR include: ◗ Non-surgical ablation of tumour cells without damage to surrounding healthy tissue ◗ Embolisation to cut off the blood supply to neoplastic tissue ◗ Vascular interventions including stenting, already mentioned above ◗ Thrombolysis with the help of a catheter to restore blood supply to a limb extremity
Chemo-embolisation An important addition to an IR specialist’s arsenal in recent years is chemo-embolisation, which is a technique for delivering anti-cancer drugs directly into a tumour. In addition, it enables the physician to occlude the blood vessel supplying the tumour cells and thus starve the malignant cells of vital nutrients and oxygen. The method is most commonly used for the treatment of liver cancer or metastasis to the liver from cancer located in other organs. Chemo-embolisation is particularly suited to liver cancer because of the unusual vascular arrangement: the portal vein supplies blood to the normal liver cells, while the malignant cells receive their blood supply through the hepatic artery. The actual technique involves passing a catheter through an artery in the groin, much in the same way as 28 IN IMAGING
RADIOLOGISTS CAN HELPTHE ONCOLOGISTS AND ONCOSURGEONS TO DECIDE WHETHER AVACUUMASSISTED BIOPSYIS SUFFICIENTOR ASURGICAL BIOPSYIS NEEDED it is done during an angioplasty. The catheter is then guided with the help of expert imaging to the hepatic system. Thus, a modified version of the same technique is also useful in colon cancer, carcinoid tumours, ocular melanoma, or even primary tumours in other parts of the body.
Other applications of IR IR can be put to good use in several other clinical situations as well. Examples are cancer of the breast, the prostate gland, the pancreas and several others. MRI-guided biopsy of the prostate gland is performed either through the rectal route with the patient lying on the back or using the perineal route. In the latter, the guidance grid is placed just below the scrotum and the tissue to be examined is removed with the help of a biopsy gun. A very similar procedure is used in MRI-guided breast biopsy where the MRI is used to locate the suspected breast lump and the tissue sample is drawn through a needle. In suspected cases of lung cancer, the nodule or swelling to be examined is located with the help of CT and the tissue is removed through a biopsy needle. As in the case of breast cancer,
the procedure is much less traumatic and invasive than a convention surgical biopsy. Pancreatic cancer is difficult to distinguish from chronic pancreatitis, pancreatic cysts, gall bladder stones and other conditions. For this, special CT and MRI scan techniques have been developed. A particularly useful test is MR-cholangiopancreatography, which implies an examination of the pancreas, the bile duct, the pancreatic duct and other surrounding structures with the help of MRI. In many such cases, however, MRI is best used as an adjunct to CT rather than a substitute.
Stages of development The early IR procedures that took place in the 1960s and 1970s were angioplasty of peripheral vessels, early stenting procedures, heparinised guide-wires for thrombolysis, embolisation of variceal bleeding in the GI tract, and so on. In 1978, Charles Dotter, who is described till today as the Father of IR, was awarded the Nobel Prize for his work in the field. During the 40-50 years that have gone by since then, IR has made tremendous strides in alleviating the suffering of human beings afflicted with diseases of various organs: the liver and hepatic system, the GI tract, pancreas and spleen, the kidney and uro-genital system and so on. This has made IR one of the most dynamic areas of medical advancement, scientific as well as technological, apart from making it a Board-certified specialty in the US. However, most patients do not come into contact with IR specialists who get almost all their work through JANUARY 2017
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surgeons practicing in different clinical specialties. The SIR leaders hope that with the passage of time and a better understanding of IR work, primary care physicians will refer patients directly to them. That is when IR would really come into its own.
Development of CT and MRI Computerised Tomography (CT) also known as Computerised Axial Tomography (CAT) was first developed in the 1970s under Sir Godfrey Hounsfield. It depends on a series of X-rays at very short intervals that are then integrated to create a complete image of the organ under examination. Later, it would be combined with special software to generate 3D images including coronary arteries (CT-angiography). Another direction of development was to combine CT with Positron Emission Tomography (PET) to create PET/CT. Nuclear Magnetic Resonance (NMR) imaging, later renamed as Magnetic Resonance Imaging (MRI), was first discovered in 1946 but really started becoming useful in 1973. That year, Paul Lauterbur demonstrated that the interaction of radiofrequency and magnetic fields could be utilised for imaging purposes. Soon, the technique was improved by other scientists till the images obtained were comparable to CT images and could therefore be harnessed for clinical applications.
Molecular imaging While IR is more focused on minimally invasive procedures for imaging of anatomical structures and in delivering or facilitating various treatment modalities, Molecular Imaging (MI) is more about examining JANUARY 2017
ADVANCES IN IMAGING HAVE ALLOWED THE RADIOLOGISTS TO PLAYASIGNIFICANTROLE IN PLANNING AND IMPLEMENTING THERAPIES FOR CANCER CARE biochemical activity at the cellular level. MI can help the treating physician at several stages of managing a disease, particularly the different forms of cancer. It can not only help to diagnose the disease at very early stages, and determine the stage to which the disease has progressed, but also help the medical team to decide which therapy would be most suitable to an individual patient. Besides, it enables the physicians to examine the progress or remission of the disease and to discover whether it has spread to distant locations within the body. Two important components of MI are Nuclear Medicine and PET/CT. Nuclear Medicine, which also took birth during the 1950s, underwent considerable improvements in the years that followed. Here the source of the X-rays is a set of radioactive compounds instead of an X-ray tube. PET scanning depends on emission of positrons, which are positivelycharged electrons, as opposed to ‘normal’ electrons which are negatively charged. When the positron meets an electron, it is destroyed and the time needed for this to happen can be recorded through specially designed detectors. A majority of PET equipment
works with a positron-emitting isotope of fluorine (F-18) incorporated into a glucose analog called fluorodeoxyglucose (FDG). Because cancer cells take up more glucose than normal cells, FDG can help PET to detect these cells with accuracy. Hence, it is widely used to diagnose both primary malignancy and metastasis to other parts of the body. The combination of PET with CT forms the basis for PET/CT. The two sets of images, the FDG-based from PET and X-ray images obtained through CT are integrated with the help of special software to produce details of both the structural and functional aspects of the tissues or organs under examination. PET/CT is useful for examining cancers in various parts of the body including the lungs, ovaries, prostate, etc.
Conclusion With all these investigative options available for the hospital physicians in general, and the radiologist in particular, treatment of most cancers has become a multi-disciplinary exercise. Thus, the radiologist can at times help the oncologist and oncosurgeon to decide whether a vacuumassisted biopsy is sufficient (in breast cancer) or a surgical biopsy is needed. Similarly, in some cancers where neoadjuvant therapy is being used, MI can help to evaluate whether the therapy is effective or not. Likewise, there are times when the pathologist’s findings may not support that of the radiologist or vice-versa. The medical team could then have to revisit their entire strategy. Thus, the role that today’s radiologist is expected to play is much more decisive and sometimes even proactive than what it used to be a few decades ago. IN IMAGING 29
INSIGHT
New imaging technologies Dr Rajeev Boudhankar, CEO, Bhatial Hospital, reviews the latest imaging techniques and cautions that there is a need to balance technology with affordability
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hile imaging technology has rapidly progressed in the last decade or so, it has had a dual impact on healthcare providers. On one hand, technology has helped to make difficult cases easy to diagnose, thus reduce errors in treatment modalities. It has also helped early detection so that early treatment is initiated, thus saving lives e.g in cancers of lungs, breasts etc. It also enhances accuracy of diagnosis where differential diagnoses has a wide spectrum. It has reduced medical – legal issues due to late/wrong diagnosis. It has reduced errors in invasive procedures too. On the other hand, it has made clinical diagnosis based on history and physical examination almost extinct. This has led to poor clinical skills in newly minted doctors from medical schools. Even senior doctors are slowly losing their clinical skills. The latest imaging techniques that have a potential in the near future would include: ◗ The hand-held ultrasound which would eventually replace the good old stethoscope for diagnosis in the cardio – respiratory arena. ◗ Invasive procedures would become safer and more accurate by the introduction of hyper spectral imaging. This would also reduce doctor’s liability and reduce indemnity insurance premiums in the long run. Hyperspectral imaging has been used
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■ DR RAJEEV BOUDHANKAR CEO,Bhatial Hospital
in defence sector and has now been applied to the healthcare imaging industry. It simply means, it entails use of optical semi conductor technology to an imaging technique. ◗ The University of Oxford has developed a modality called ‘Electromagnetic Acoustic Imaging.’ This modality makes use of electro – magnetic and acoustic waves to diagnose various types of solid cancers in the early stages of development. The imaging is claimed to be of far superior quality and clarity than conventional modalities. ◗ The University of Lincoln in the UK has developed a so called wafer scale mega microchip to enhance medical imaging techniques. The University claims that images that are produced by the chip will help doctors to detect accurately the effects of radiation on cancerous tumors, thus help early detection. ◗ The ‘University of California, Berkeley’ and the ‘Universidad Autonoma de Madrid’ of Spain, have jointly claimed to have made the use of 3D Meta material which enhances ultrasound images by a factor of 50X. If successful commercially, it would aid current ultrasound probes to capture
high resolution images for medical imaging for both diagnosis and interventional procedures. ◗ Scientists at Japan’s Railway Technical Research Institute, Tokyo, have developed a superconducting magnetic system which would be literally ‘palm-size.’ This would convert current MRI System into mobile imaging applications. ◗ The University of Medicine, Berlin and Max-Delbruck Centre for Molecular Medicine, Berlin, have claimed to have produced a technology for capturing images of the beating heart in its MRI systems. They claim the magnetic field of resolution would be 150,000 times the earth’s magnetic field. It would thus aid in clearly demarcating between blood and heart muscle, enabling early diagnosis of cardiac malfunction. ◗ Iron oxide nano crystal technology has now been proposed for medical imaging. Super paramagnetic iron oxide particles have a variety of applications in molecular and cellular imaging. Review of the most recent research has concerned cellular imaging with imaging of in vivo macrophage activity. According to the iron oxide nano particle composition and size which influence their biodistribution, several clinical applications are possible. For example, detection of liver metastases in cancers, metastatic lymph nodes, inflammatory and degenerative diseases. Ultra small super paramagnetic iron oxide JANUARY 2017
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particles are being researched as blood pooling agents for angiography, tumour permeability and tumour blood volume or steady-state cerebral blood volume and blood vessel size index measurements. Research is also being conducted for stem cell migration and immune cell trafficking, as well as targeted iron oxide nano particles for molecular imaging studies. ◗ Bio-printing: 3D bio-printing has undergone significant advancements in the recent times. This technique allows high precision fabrication of biological structures encapsulating cells and bioactive molecules, with applications in areas such as tissue engineering, drug development and bio-sensing. As such, static structures obtained from conventional 3D bio printing may be unable to elute realistic biological responses. What’s needed is a fourth dimension – time. Research is now being conducted at Harvard Medical School’s Biomaterials Innovation Research Centre by Ali Khadem Hosseni et al, for application and development of 4D Bio printing. They proposed 4D bio printing by combining smart, stimuli responsive biomaterials with 3D bio printing techniques, to introduce this fourth dimension into the fabricated system and emulate the dynamic processes seen in Biological tissues. The clinical application which is predicted is 4D printing dysfunction heart imaging and treatments. ◗ Virtual CT simulating high – dose: Siemens Healthcare has developed a process to synthesise a virtual target medical image based on a source image. The company claims that this method can be used to synthesise a virtual high dose CT image from a low dose CT image, enabling reduction of the radiation dose to which the patient is exposed. Siemens has reportedly JANUARY 2017
applied for a patent. ◗ PET segmentation scheme offering all-inclusive analysis: Researchers at John Hopkins University have developed a process for accurate characterisation of tumour burden and response to therapy from PET Scans. This new method provides reliable and reproducible PET tumour boundary definition and metabolic tumour volumetric quantification over a wide range of tumour sizes and shapes and for various levels of PET radiotracer uptake. This method will help clinicians
in diagnosis, staging and planning of radiotherapy and surgery as well as determining treatment response. It can also help in cancer therapy research. The patent for this method is awaiting approval. ◗ CT-based elastography for evaluating tissue stiffness: Researchers at the Ohio State University have researched a new method for performing CT-based elastography. This technique estimates local displacement of tissue in response to a mechanical stimulus from highresolution images. It can also be applied
to hard structures in the body like bone, teeth and cartilage as well as soft tissues. It can also be used to scan patients with pace- makers or metal implants that cannot undergo MR scans. The Ohio State University has applied for a patent for this method. ◗ MRI-enabling PET attenuation correction: GE has reportedly invented a method for joint reconstruction of activity and attenuation in PET images using MR-based priovs and applied for a patent as well. ◗ Ultrasound in the determination of blood flow velocity: Philips has applied for a patent for a new method in the determination of blood flow velocity. The method uses ultrasound pulse at one location and the pulse is detected at a second location by an ultrasound receiver. The calculation is then done for flow velocity of blood in a blood vessel between the first and second locations. ◗ Mapping distortion corrects wrap in MR Images: Synaptive Medical Company of Barbados has developed a new technique for correcting warping in MR images caused by non-linearities in gradient field profiles. The patent for this new technique is pending. Thus, it seems as technology advances, through helping doctors to give better and faster healthcare, it will make healthcare more expensive for the masses. Hence, the need of balancing ‘affordability and technology’ is imperative. IN IMAGING 31
INSIGHT
Modernisation of radiology Dr Minal Chaudhry, HOD, Radiology, Aakash Healthcare, talks about the evolving role of digital technology in diagnostic imaging
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he importance of radiology in modern day healthcare cannot be overstated. On November 8 every year, scientists and medical professionals throughout the world celebrate International Day of Radiology. It has been more than 100 years since radiology came into existence, and it has come a long way since its birth. It has evolved from purely diagnostic devices to interventional technologies taking active part in the treatment of the patient. Digitisation and technology play a crucial part in almost every industry and in our personal lives; simplifying things. Likewise, digitisation has revolutionised almost every facet of medicine. Medical service providers in India are heavily investing in information technology and breakthroughs in biotechnology and medical equipment have made notable involvement in improving health of people in India and around the world. Radiology has seen increased productivity and efficiency by the adoption of Radiology Information System (RIS), which is a networked software system for managing medical imagery and related data. RIS is useful for tracing radiology imaging orders, billing details, and is often used in combination with Picture Archiving and Communication
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■ DR MINAL CHAUDHRY Head of Department, Radiology,Aakash Healthcare
System (PACS) to manage image archives, record-keeping and billing. PACS provides electronic storage, retrieval, distribution, and presentation of images. Hitherto images were not accessible unless a physician had access to the hospital or imaging centre’s PACS. To view it outside the premises, CDs were burned and sent by courier, which did not always open and used to take very long time to view the data sets. Repeat imaging exams were often performed if the CD’s were corrupt or due to some other technical problems, increasing the cost and exposing the patient to additional radiation. Present day systems allow access to images and reports via e-mail through a module for PACS, thirdparty standalone systems or systems that are linked to the facility’s archive/storage. Most are cloud or web-based systems, and easily accessible from anywhere. The systems and the transmission of data is highly safe with encryption and password protection to meet HIPAA requirements, (Health
Insurance Portability and Accountability Act of 1996) which is the US legislation that provides data privacy and security provisions for safeguarding medical information. PACS assists the handling of digital radiology images so that they can be easily accessed and viewed by various clinicians in different locations and settings, improving operational efficiency. The digital images provide improved dynamic range and contrast, with exclusive screens and software for each process, which enables accurate diagnosis. Digitisation and PACS improves productivity, saves time as juxtaposed with analog readings, reduces errors and cuts costs. A few vendors have made it easier and less taxing for – tech savvy – patients to view their images by providing an access code, instead of a CD, which can be shared with physician(s) to view the data via an app on a tablet or a cell phone and hence the medical folder can be carried wherever one is mov ing. The flow of data is seamless and wireless in contemporary times, with digitisation in imaging. Ultrasound scans and other diagnostic imaging can be done without wires, for instance, new age probes let the radiologist do the ultrasound or a procedure, without the discomfort JANUARY 2017
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caused by the cord attached to it. Various digital detectors can now transmit less images wirelessly to the console without physically connecting the system to the console hence allowing increased efficiency. Radiology, along with the rest of the healthcare sector, is moving to cloud-based systems, and it is at an extremely fast pace. According to an article published in Applied Radiology, the initial upfront costs can vary between the intensity of building an organisation’s own private cloud, or the ease and flexibility of using public cloud architecture. The process efficiency, financial predictability of paying for only what the organisation needs, and long-term cost savings are making the cloud a worthwhile investment. Collaboration and communication is a must for healthcare facilities. No department can work in isolation, and the ‘patient experience’ has to be given importance. Vendor neutral archives (VNAs) have progressed from just being a repository for radiology. This has enabled storage and exchange of clinical content in DICOM and/or non-DICOM formats. It is extremely different from conventional competence of a VNA system. Currently, VNA’s embed intelligent lifecycle management and meta-data management to optimise the efficiency of multiple archives. This means that all the clinical data is easily accessible and usable, which leads to better patient care. Advancements in diagnostic imaging – digital detectors and softwares – has completely replaced investigative surgery and reducing radiation dose for various procedures by up to 75 per cent. Earlier clinicians used to do surgery, just to have a look JANUARY 2017
EARLIER CLINICIANS USED TO DO SURGERY,JUSTTO HAVE ALOOKATTHE INSIDES OFTHE BODY,AND TO FIND OUTWHAT’S WRONG at the insides of the body, and to find out what’s wrong. In preceding years, such practice has been replaced with
new age MRIs, ultrasounds and CT scans. In contemporary times, with the help of digitisation and new age post processing techniques the images taken from the scans look exactly the same as the insides of the body during operation. And for this reason, text-only reports are fading away. Multimedia Enhanced Reporting in Radiology (MERR) has improved understanding of radiology findings by correlating images to text reports. The study also found that the multimedia reports provided easier access to images while monitoring progression of a condition, and saved time understanding findings without supporting images. The unification of telehealth, teleradiology and medical equipment technology has also led to robotic surgeries where on occasions the doctors can operate remotely, and the patient can get operated in a hospital close to them, eradicating the stress and hassles of travelling. And, all this digitisation can sometimes come with a decreased price as well. For instance, several key imaging vendors showed how lowervolume hospitals can use one wireless digital radiography (DR) detector for multiple machines, eliminating the need for several at a cost of about $100,000 each. So, with upcoming advances in digitisation the future will bring new capabilities that have even greater medical value. We will see radiation dose continue to drop and utilisation of imaging services become more efficient, with fewer healthcare resources wasted, including the increasingly scarce commodity of time—to the benefit of patients, physicians and workers in the healthcare system. IN IMAGING 33
EXPERT OPINION
Increasing job opportunities in imaging Sonal Satelkar, Business Head of Kohinoor College of Paramedical Sciences, elaborates on the growing opportunities for radiographers and radiologists within the diagnostic imaging sector
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uman body, as we all know is made up of complex organs and is prone to various kinds of diseases. Radiology is a science for diagnosing diseases within the human body which can be done with the help of imaging techniques such as X- ray, Computed Tomography (CT Scan), Magnetic Resonance Imaging (MRI), Sonography, Mamography etc. Radiographic equipment uses electromagnetic radiation to view the internal structure of an opaque object such as a human body and makes an image of the same. Radiography science helps provide the right treatment to patients. It is very critical to get a correct and most accurate diagnosis or else the life of a person can be at stake. A radiology technologist will make an image of a particular organ or a part of the body with the help of radiographic equipment such as an X-ray or a CT scan. This image will be then provided by a clinical specialist at whose instructions the image was taken. This clinical specialist will then prescribe a treatment for the cure of diseases or irregularities if any. In the medical profession, there
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■ SONAL SATELKAR Business Head of Kohinoor College of Paramedical Sciences
are two categories of professionals who deal with radiography science. One category is that of medical doctors who have done their post graduation in the field of radiology. They are professionally qualified to certify the reports that are generated by radiographic equipments such as a Sonography Machine, a CT scan machine, etc. On the other hand there are radiology technicians or technologists. These are the people who assist a radiologist in performing his duties as a doctor. The technician is trained to operate the radiography equipments and does the entire job of taking the image of patients. Radiology technicians are trained to use advanced radiographic equipment such as CT scan, MRI along with basic X-ray equipment for creating images of a patient’s internal anatomy to diagnose injury or disease. In the early days, all radiography jobs were undertaken and done by doctors themselves. But over the period as
technology advanced and as super speciality started playing a vital role in medical science, a need emerged to have this category of technicians or technologists to do certain jobs and assist busy doctors. In today’s era, doctors completely rely upon radiology technicians for the reports. A good technician is in great demand and therefore there is a huge demand such professionals within the diagnostic industry. With research, the science of radiography and the technology ulitised in this field is advancing rapidly. Radiography technicians are in great demand as there are not too many qualified persons in this field. These technicians get jobs in hospitals, nursing home, diagnostic centres, equipment manufacturing companies and research organisations. They start as assistant technicians and grow up to the level of centre managers. There are institutions who offer B Sc degrees or advanced diplomas or diplomas in the medical imaging field. A good syllabus supplemented with an observership / internship in a good hospital or diagnostic centre, helps individuals to become a good technician. JANUARY 2017
EXPERT OPINION
The diagnostic industry is making a mark within thehealthcare sector and radiology players per day are leaving no stones unturned to acquire the number one position . India has around a lakh of diagnostic centres. Out of these, around 30 per cent centres are radiology and imaging centres. It is said that the diagnostic industry in India is set to grow at a 20 per cent CAGR. Most of these centres are backed by sophisticated technologies and hence there is a huge demand for manpower that has hands on experience in handling these technologies. According to the findings of Public Health Foundation of India there is a total skill gap of 97 per cent across the healthcare sector, the largest being in radiography and imaging segment. It is estimated that the current requirement for allied healthcare professionals (AHP) in India is nearly JANUARY 2017
6.5 million as against a supply of less than 3,00,000. National Skill Development Corporation, estimates that by 2018 the healthcare technician demand-supply gap in India will be 445,000 (which is around 84 percent of the shortfall). In India there are around 270 medical colleges and the number of PG seats in medical colleges for radiology is approximately 800. Radiology is a stream amongst the top four most sought for streams for specialisation amongst medical students. The other three are anesthesia, dermatology and ophthalmology. With private entities entering the healthcare market, specifically in the arena of diagnostic, there is a dire need of manpower in this segment. With the number of hospital beds increasing, the acute shortage of manpower is hitting the delivery chain at hospitals. Employment
opportunities for radiology technicians are good within India and abroad. There is a constant need for these technicians in diagnostic centres, super-speciality hospitals, clinical labs, MRI centres as well as nursing homes. In India, radiology technicians can work in private and government sector both. In India, average starting salary of a radiology technician is Rs 7,000- per month upto Rs 50,000- per month. In UK, average salary for radiology technician is around £17,000 per year. Medical profession has always been considered as a noble profession. There cannot be a better deed than saving some one’s life. Radiology plays a very critical role in this process. Radiography science is progressing and creating ample opportunities for careers. There is no dearth of employment in this field as jobs in this sector are increasing. IN IMAGING 35
EXPERT SPEAK
Advancements in radiology In the past 100 odd years, radiology has progressed from simple X-rays to complex functional MRI’s and nuclear scans, informs Dr Shrinivas B Desai, DirectorDepartment of Imaging & Interventional Radiology, Jaslok Hospital and Research Centre
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here have been immense technological and scientific advances in radiology over the last decade. Similarly, our understanding about pathology and disease has increased exponentially.
Conventional radiography Digital radiography has revolutionised the way we use radiographs in our daily practice. With portable direct radiography now being available, the radiograph is now displayed on the screen as soon as it is taken. Gone are the days when we had to check on the quality and exposure of the X-ray and probably repeat it if required.
CT Dual Energy CT (DECT) has revolutionised cross sectional imaging and opened new vistas in the scope of CT imaging. DECT uses high and low tube potentials to detect the chemical composition of tissues, and subtract bone, iodine or any other component from the tissues to get an unparalleled informative image. It has been used to detect the composition of renal stones, diagnosis and management of gout, creating lung perfusion maps enabling better detection of subsegmental pulmonary thrombi and detecting overall clot burden. The 36 IN IMAGING
â– DR SHRINIVAS B DESAI Director- Department of Imaging & Interventional Radiology,Jaslok Hospital and Research Centre virtual precontrast images can be obtained by subtracting iodine from post contrast CT, thereby completely omitting the need for plain CT. This has helped to reduce radiation dose, as there is no need to take a separate plain scan before giving iodinated contrast. Advances in iterative reconstruction (algorithms that are used to produce a CT image from raw data) mean that the dose can be reduced by as much as 30-40 per cent without affecting the image quality on CT. Improved quality and increased number of detector slices have made high quality CT coronary angiography a reality. Online subtraction of calcium in the coronary arteries will obviate the need for invasive coronary angiogram. The future CT scan may use a totally different substance like photon imaging for further technology breakthrough.
CT guided intervention Biopsies, drainages, the ganglion ablations for a pain therapy, vertebroplasty for osteoporosis and
RF / microwave ablations of cancer tumours are routinely done under CT guidance, obviating the need for surgical treatments in the operation theatres. These procedures do not need general anesthesia and long hospital stay.
MRI Better hardware, parallel imaging techniques, faster scan times, higher resolution and greater magnet strength had resulted in extracting better information in lesser amount of time. Whole body MRI with Dixon imaging has the potential to serve many indications of PET-CT for detection of distant metastases, without any radiation hazards. Perfusion MRI (including Arterial Spin Labelling (ASL), a non-contrast perfusion technique) helps to diagnose and monitor therapy response in tumours. MR Spectroscopy can detect the biochemical composition of tissues and is used to diagnose cancerous tumours and monitor their response to therapy.
Ultrasound Today, ultrasound scanners produce much higher resolution with better image quality as a result of hardware improvements. Volumetric JANUARY 2017
EXPERT SPEAK
ultrasound probes have enabled us to acquire 3D data with multi-player capabilities, much like CT/MRI scans. This has significantly enhanced fetal and gynecologic imaging. Ultrasound contrast agents are non-nephrotoxic and almost devoid of side effects. They have found applications in abdominal imaging, especially, liver imaging. Ultrasound elastography is a novel technique enabling us to objectively assess tissue hardness, thus enabling differentiation of benign from malignant breast masses and monitoring the progression of chronic liver disease, among other uses.
Digital subtraction angiography and interventional radiology Rotational angiography with high resolution fat panel X-ray detectors have completely changed the image acquisition and data processing. The 3D road maps and large monitors are of tremendous help in complicated interventional radiological (brain and 38 IN IMAGING
body) procedures, making endovascular surgery fairly safe and effective.
MR guided interventions MR guided Focused Ultrasound Surgery (MRgFUS) is a non-invasive treatment modality, where different body tumours are destroyed and treated by high intensity focused ultrasound waves with thermal ablation and coagulated necrosis. This has emerged as an alternative and more effective treatment modality than invasive surgery in uterine tumours, bone metastasis, prostate and breast cancer, bone tumours, arthritis and many brain pathologies. This is a revolutionary cutting edge technology, which will have increasing applications in the future.
Other MR guided interventions: MR guided biopsy (eg. breast and prostate) are now performed routinely.
Future trends Switching over to techniques that would reduce ionising radiation and replace existing modalities with those that completely avoid radiation are increasingly the focus of scientific research. Photo acoustic imaging, newer contrast media, which do not have gadolinium or iodine is the way imaging may proceed. PET MR is emerging as a mainstay in cancer diagnosis. MR imaging has certainly assumed a central role in medical research. In Winston Churchill’s famous words, “the farther back you can look, the farther forward you are likely to see”. In the past 100 odd years, radiology has progressed from simple X-rays to complex functional MRI’s and nuclear scans. The role of the radiologist has evolved from just providing the diagnosis to now being integral part of the management and treatment of the patient. JANUARY 2017
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Multimedia enhanced radiology reporting Dr Vivek Chail, Expert Radiologist, icliniq.com describes the areas where MERR is increasing utilised
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n the present day, multimedia services is found in most work places and it is being welcomed in medical sciences as an opportunity to upgrade the level of healthcare management and decision making. Radiology is one of the important areas in medicine which helps diagnose the medical condition in a patient and simplify managementas well as helps take critical decisions on the treatment options available. Including pictures and graphics in text reports enhances the understandability of the condition of the patient at a minimal extra effort from the radiologist’s end. In routine radiology practice, we have been providing ultrasound and doppler images with text reports for years and this has become common practice. However, while reporting radiological studies containing a large amount of pictures like CT scans and MRI scans, the reports usually contain text summary of findings and images are either printed on films or distributed as CDs or DVDs. Since CT scans and MRI scans often contain tens to hundreds of images, it can get confusing and tiresome for the referring physician 40 IN IMAGING
â– DR VIVEK CHAIL Expert Radiologist at icliniq.com
to take time and make sense of the images sent, with a minimal scope of misinterpretation of imaging findings, especially when there is more than one significant finding. Small clips and videos can also be attached to soft copies of reports to be visualised by the physician. Keeping the above in mind, providing the referring physician a few select images in the text report can be of immense help. Such images can highlight the points described in a report and illustrate the findings in greater detail and aid in complete understanding. There have been studies involving neurosurgeons, oncology physicians and pulmonologists and this concluded that over 80 per cent of the doctors preferred multimedia embedded radiology reports and felt that this format of reporting will encourage better patient care in follow up. Many radiologists mention measurements and few off them use
subjective terms to describe lesions. Multimedia enhancement radiology reporting can help in providing a common platform with more universally acceptable reports. Neurosurgeons usually handle life threatening conditions and it is important for them to have an accurate knowledge of the condition to help make the best treatment choice. In this situation, a few pictures added to the report will help them get a better idea of the problem and take the next step in treatment. In oncology, there is a requirement to know the exact location, dimensions, extent and nature of the problem area. Attaching a few pictures in the report can provide excellent detail and help the physician in discussing the medical condition more appropriately with the patient. Often a biopsy may have to be done, in this situation also a report containing pictures comes in handy for the doctor to explain the procedure to the patient. In cardiology imaging, dynamic MRI studies of the heart are being done in many institutions. We can add a short clip of the cardiac cycle in a soft copy of the report and this will JANUARY 2017
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give a better insight of the heart function to the referring physician and they can plan procedures based on the multimedia attachments. Chest imaging contains many images through the lungs and it can become a tedious job for the pulmonologist to go through each picture and search for any nodules mentioned in the report. Multimedia attachments containing important images will make it much easier for the physician to read through the report and provide accurate management. It is important to mention that typographical errors might creep into reports despite taking care. Providing multimedia reports can JANUARY 2017
provide a measure to double confirm a problem area with respect to the location, size and number. Any suspicious mismatch can be reconfirmed and possible harm to the patient can be avoided. Providing multimedia in the report can help better feedback and help to
PROVIDING MULTIMEDIA ENHANCED REPORTS WILL HELPTO DEVELOPBETTER TRAINING PROGRAMMES AND EASYUNDERSTANDING
maintain a closer relationship between radiologists and physicians. This can decrease the average consultation time spent on each patient and decrease patient waiting time at the physician’s clinic and increase the number of patient appointments. It is of note that emergency reports are often read by resident doctors and those who are still undergoing training. Providing multimedia enhanced reports will help to develop better training programmes and easy understanding in this group which will in turn provide an enhanced output in terms of decision making and patient care. IN IMAGING 41
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New solution for affordable OnSight 3D extremity exam Chandan Naphade, GM, XRS Business Solutions, India and Cluster, Carestream Health India speaks about the advantages of Carestream’s extremity imaging system
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njuries of the joints, elbows, knees and ankles, can happen at any age. In the young, it is usually sportsrelated, while in the middle-aged and elderly, it could be on account of arthritis, joint instability, etc. Both situations demand that the affected joint be examined with maximum speed and accuracy but cause minimum inconvenience to the specialist doctor and the patient. For meeting these needs of the orthopedic specialist as well the radiologist, the new OnSight 3D Extremity System from Carestream Health goes a long way. The extremity imaging system uses Cone Beam Computerised Tomography (CBCT) to capture weight bearing and other images of the affected limbs.
OnSight 3D Extremity System Our affordable, compact system provides high-quality, lower-dose 3D imaging studies. This makes it an ideal diagnostic tool for orthopaedic and sports medicine practices, hospitals, imaging centers, urgent care facilities and other healthcare providers. The OnSight 3D Extremity System offers an intuitive design that is totally different from the usual CT scan machines available in the market. 42 IN IMAGING
■ CHANDAN NAPHADE General Manager,XRS Business Solutions,India and Cluster,Carestream Health India There is a wide door opening to enable easy, step-in patient access essential for weight-bearing examinations. The larger than usual imaging bore makes it possible for the doctor to examine obese patients while enabling a wide field-of-view image capture. In addition, a dual-side positioning joystick offers the technologist the option to make convenient positional adjustments. This can optimize the workflow of the radiology department staff. Patient-support handles offer safety and comfort to the patient but can be moved out of the way when not required. Carestream’s extremity imaging system also enables health providers
to capture high-quality 3D images and conduct a patient consultation in a single visit. This helps both the specialist doctors and the patients to save time and decide on a treatment approach in the shortest possible time. In most sportspersons, it is imperative to get back in action as quickly as possible, and the latest Carestream offering can make this happen. An additional feature is that the equipment can be rotated to allow the affected leg to be examined in an upright position, that is, when it is actually bearing a part of the body weight. This helps the orthopedic surgeon to make a better assessment of the injury. Clinical studies conducted at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, US, show that the Carestream OnSight Extremity System is particularly useful in capturing 3D images of various joints. In this study, over 98 per cent of 3D images were rated to be of diagnostic quality therefore very useful to the practicing clinicians. The product is also being exhibited at the IRIA 2017 annual conference at Jaipur. JANUARY 2017
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Revolutionising diagnostics Rotograph Prime 3D has been designed as a comprehensive diagnostic tool
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otograph Prime 3D, the new 3D panoramic unit with CBCT technology, manufactured by Villa Sistemi Medicali SpA, Italy, is the natural evolution of the commercial success of Rotograph Prime. Rotograph Prime 3D has been designed as a comprehensive diagnostic tool, and, moreover, is offered with the new and powerful Villa 3D Planner software for implant planning.
Which kind of exams can Rotograph Prime 3D carry out? The new unit also performs 3D acquisitions of the patient’s dentition, with the possibility to select different acquisition volumes (FOV – Field of View), each one is optimised to examine a particular anatomic region of interest defined by size and resolution.The available 3D examination programmes are reported hereinafter: ◗ 3D Full dentition (85 x 90 mm volume) ◗D Single jaw (85 x 50 mm volume), with choice between two different FOV positions: Maxillary,Mandibular ◗3D Mandibular teeth (50 x 50 mm volume), with choice among five different FOV positions: Frontal, Premolars (right/left side), Molars (right/left side) ◗3D Maxillary teeth (50 x 50 mm volume), with choice among five different FOV positions: Frontal, Premolars (right/left side), Molars (right/left side ◗3D TMJ (85 x 93 mm volume), with choice between two different FOV positions: right TMJ, left TMJ JANUARY 2017
◗3D maxillary sinus (85 x 90 mm volume)
Who are your target customers? Rotograph Prime 3D
Rotograph Prime 3D is
addressed to: ◗Small and medium dental practices looking for a comprehensive system for implantology, guided surgery and diagnostic applications. ◗Dental clinics still using 2D acquisition mode who want to change or add a 3D digital unit based on the state-of-the-art technology ◗Structured dental practices searching a full-featured unit committed to increase their expertise in-dental procedures, thereby increasing productivity ◗Small and medium radiology centres which require a low budget backup unit to cope with dental diagnostics on behalf of third parts and already own devices used for dental or maxillo-facial applications (i.e. CT/Dental Scan/panoramic unit with Ceph)
What are the main features? ◗Rotograph Prime 3D has compact mechanical structure and the peculiar and refined design of Rotograph Prime. Thanks to its lightweight body and ingenious wall-mounting solution, it can be installed in a very short time in two simple steps. ◗An essential control panel is available
on board, while the selection of examination and exposure parameters is made through the virtual keyboard with graphical user interface on PC ◗The simplified face-to-face patient positioning allows the operator to check if the patient is correctly centred according to the two laser beams. Moreover, the focal layer is automatically adjusted ◗The device is equipped with different supports for the patient positioning, designed to optimise the execution of the different exams ◗New and exclusive support with automatic motorised positioning of chin rests in function of the selected exam, equipped with a LED light that also indicates when the right support is inserted ◗In order to preserve hygiene, the two support handles are coated with an antibacterial paint ◗High frequency tubehead with wide kV range (60 – 86 kV) and mA range (2 – 12,5 mA), X-ray tube with 0,5 mm focal spot ◗One flat panel detector able to perform 2D and 3D acquisitions, in order to optimise the workflow and to minimise the exam preparation time ◗Acquisition software QuickVision is also included ◗New and powerful software for dental implant planning, Villa 3D Planner integrated with the unit Rotograph Prime 3D but cannot be equipped with a cephalometric arm. For further technical details, refer to Rotograph Prime 3D product data. IN IMAGING 43
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The significance of enterprise imaging in delivery of value-based care Pranav Shah, Business Development Head, Healthcare IT, Agfa Healthcare, India, elaborates on how value-based care helps in building healthcare management strategy that focuses on cost quality and outcomes
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maging has witnessed exponential growth in the last 15 years. During the conversion from film to the digitisation of images, it has spawned very strong departmental solutions. Given the transformation from film to where we are today, workflow improvements have certainly been phenomenal. The development of these departmental solutions has resulted in the creation of silos of images and image related data. In some cases, silos were cross-departmental, but they were also created within the same department as part of acquiring specialised solutions (Mammography, Nuclear Medicine, Clinical Research, Invasive Cardiology, Hemodynamics, Electro-physiology, etc). There have been disparate attempts to try and get these images to other users via integrations and interfaces, but these attempts have been unsuccessful in completing the visual healthcare infographic of a patient.
Establish a converged enterprise imaging strategy Value-based care is all about building a 44 IN IMAGING
health care management strategy that focuses on costs, quality, and most importantly, outcomes. The goal is to create a culture within an organisation by removing barriers and enabling: ◗ Enhanced collaboration and care standardisation ◗ Meaningful use of medical imaging data from across and throughout the care continuum ◗ Immediate image exchange without heavy cost of data migrations ◗ Improvement of the patient experience This not only highlights the need for developing a consolidated Enterprise Imaging approach, but also calls for establishing a holistic purchasing strategy and vendor selection. Purchasing a Radiology PACS, Cardiology PACS, vendor neutral archive (VNA), image transfer tools, and universal viewer separately, perhaps from different vendors, is one approach. By definition, this approach creates multiple (pun intended) challenges, including duplicate caches, too many databases, too many interfaces, differences in vendor
vision and roadmap, dispersed management and monitoring, desynchronised upgrades, variance in disaster recovery and business continuity approaches, excessive labor to manage multiple vendors, and future disruption due to vendor mergers and acquisitions. In order to achieve the operational efficiencies expected not only today, but in the future, the need arises for a single converged platform strategy which provides multi-departmental informatics, PACS and imaging services, VNA, image exchange, mobile display and acquisition, physician collaboration, patient engagement, foreign study management, and regional health services, on a single converged platform. Imaging needs to follow the footsteps of the EHR, transforming into a comprehensive multidepartmental Enterprise Imaging platform. A singular platform that provides common enterprise services (interfacing, authentication, archiving, visualisation, etc…) as well as departmental imaging acquisition JANUARY 2017
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and management services from radiology to cardiology, GI to ophthalmology, dermatology to pathology, wound care to point of care, among others. In order to achieve the outcomes expected not only today, but in the future, our customers have informed us of the need for a single converged platform which provides multidepartmental informatics, PACS, and imaging services, VNA, image exchange, mobile display and acquisition, physician collaboration, patient engagement, foreign study management, and regional health services. Agfa Healthcare has developed a JANUARY 2017
care-centric workflow platform called Agfa HealthCare Enterprise Imaging. This solution is standards based, improves interoperability, is modular and enables a comprehensive patient imaging health record across departments within a single facility or between multiple facilities. We have combined traditional departmental PACS, like Radiology and Cardiology, traditional RIS, Advanced 3D, voice recognition, VNA and an Enterprise Viewer and a mobile platform, all into a single scalable application. For smaller health systems, our solution can be starting from entry level and scaled up
for larger health enterprises with all modules typically activated. All DICOM and non-DICOM data formats as well as documents are managed in one comprehensive multimedia platform We believe this new approach to medical imaging is the gold standard which others will try to emulate. â—— Single-strategies solve specific problems or workflows in a particular care area, lacking coordination across the continuum of care â—— A better strategy is to invest in building a consolidated platform and build an eco-system that brings clinical value across the carecontinuum. IN IMAGING 45
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SURESH RANGANATHAN General Manager, India & ASEAN, Agfa Healthcare
T We expect 2017 to be another stepping stone in the Indian radiologymarket landscape Agfa HealthCare is a global leader in the fast growing market of integrated IT and imaging systems, offering the best healthcare facilities. Express Healthcare interviews Suresh Ranganathan, General Manager, India & ASEAN, Agfa Healthcare, about the trends in the radiology sector in 2017
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ell us something about your company and your focus in the radiology industry? Besides being an influential player in the realm of film and print systems, computed radiography and direct radiography, Agfa Healthcare is also a leading provider of E-Health and IT solutions. With operations spanning across most geographies worldwide, Agfa enjoys a unique position of being a preferred supplier at one out of two hospitals worldwide. The range of our solutions include: ◗ Digital Radiogrphy – DR / CR solutions ◗ Enterprise Imaging – PACS, VNA, Universal Viewer, Image Exchange, ECM JANUARY 2017
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◗ Integrated care solutions-HER Portal, Clinical Analytics ◗ Hospital IT –HIS/CIS , EMR/HER, ECM In India, we have a two-pronged approach We have positioned our 'Enterprise Imaging (EI)' solution for large corporate and chain of hospitals. This allows physicians and care providers at all stages of the care continuum to have unified access to patients’ medical reports and clinically relevant imaging data that enrich the patient’s visual healthcare infographic. In the Indian context, we have offered these solutions also through 'Managed Services' offering to some of India’s leading healthcare providers like Fortis group of hospitals. On the imaging side, we focus on meeting growing demands of 'Digital India' with our innovative, matured and distinctive computed radiography and direct radiography solutions. For example, our unique CR solution model Easy Payment Scheme (EPS) is widely accepted by our customers, in tier II and tier III and rural towns as a leading solution to realise the objective of digitising X-ray rooms in the most cost-effective manner. What are new imaging techniques introduced by you in 2016? For IT products and technologies, year 2016 was a year of transformation for Agfa. Our Enterprise Imaging platform was launched in India and is well accepted by our valued customers. For imaging products, Agfa launched the next generation 'Gold Standard' Image processing MUSICA 3, a truly intelligent image processing, which consistently provides high-quality images needed to support the JANUARY 2017
diagnosis, while saving both time and effort. To meet specific Image presentation and processing demands from dentists, we introduced highly sensitive 'Needle Detectors' along with special software on our MUSICA, Image processing. Patient X-ray Dose Reduction is a prime focus for Agfa, while designing its DR solutions. Our efforts in providing such solutions was recognised by global research and consulting organisation Frost & Sullivan in their white paper which was published by them -’Raising the Bar by Lowering the Dose.’ We also introduced MUSICA for dynamic imaging to empower our new Fluro DR model DR 800 at RSNA 2016. List three trends to look out for in 2017 in radiology? ◗ Increasing digitisation of X-ray rooms through world class costeffective solutions offered for direct and computed radiography. ◗ Value-based care transformation through enterprise-wide imaging solutions at corporate and private hospitals ◗ Enhanced collaboration and care standardisation across group hospitals using enterprise-wide solution through managed services route. What role will digital technology play in transforming diagnostic imaging in India? Digital India drive by the government, supported by networking and technology companies, are extending the reach of network and Internet across India. This will obviously bring patients and care givers closer. Diagnostic imaging deals with large
size diagnostic data which needs to be exchanged with encryption to protect patient privacy. Medico legal needs will also mean that the image and report data needs to be stored and shared on more reliable solutions like diagnostic quality films / highly secure archiving solutions. Companies realising and acting with head start will be the preferred partners for the care givers in the future. How are radiology players leveraging digital technology to provide best radiology solutions to hospitals? Companies like us have realised that the speed of digitisation in India will continue to enhance in near future and public hospitals also will be following the digital path. Given our 100-year history in radiology, we bring deep insights and understanding. The nuances of integrating radiology solutions with IT can be best adopted by us and we will play an active role in connecting physicians to patients in rural India through EI extending beyond radiology to empower healthcare IT systems. Going ahead what will be your companies focus for year 2017? We expect 2017 to be another stepping stone in the Indian radiology market landscape. We would like to provide our customers the best value for their money through innovative and costeffective solutions like EPS (Easy Payment Scheme) for an entry level Digital X ray solution and extending the scope for other products. We will promote extensive collaboration and care standardisation across group hospitals using enterprise wide solution through managed services route. IN IMAGING 47
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DR ARJUN KALYANPUR CEO and Founder, Teleradiology Solutions
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Digital technologyin diagnostic imaging will be keyin 2017 Dr Arjun Kalyanpur , CEO and Founder, Teleradiology Solutions , in an interaction with Raelene Kambli, speak about the trends in dianostic imaging in India in the year ahead
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hat are the new imaging techniques introduced in 2016? Use of virtual reality imaging to image the foetus in utero is one of the new technique introduced in 2016. A demonstration of this was presented at the recent RSNA conference in Chicago. Another area is Multi-spectral (multi-energy) CT which is a recently introduced technique for imaging of cardiovascular disease applications. Quantitative Neuroimaging is an area of imaging that has greatly picked up momentum in 2016. Moreover, utilising advanced MRI sequences with algorithms that can process and analyse the data to generate objective and quantifiable data on conditions such as stroke, multiple sclerosis, Parkinson’s JANUARY 2017
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disease and tumour imaging is an area that has been newly highlighted over the last year. List three trends to look out for in 2017 in radiology? Machine learning and Artificial Intelligence – The use of big data analytic tools in medical imaging is a rapidly evolving area in which there is a great interest worldwide, as it becomes evident that radiologic data is outstripping the skilled manpower (read radiologists) available for its interpretation. Growth of teleradiology –Global radiologists continue unabated. Teleradiology solution to enhance productivity of radiologists worldwide and providing efficient tools for their interpretation, is a critical area to look for. Market reports point towards brisk growth in this sector of the healthcare industry. 3D printing technology combined with medical imaging – Medical imaging today has a strong 3D focus, and the use of modern 3D printing technologies in collaboration with 3D imaging workstations allows for generation of high quality 3D models of for example the pediatric heart, that can assist in planning of complex surgeries. What role will digital technology play in transforming diagnostic imaging in India? The digitisation of medical imaging is the key solution to the radiologist shortage crisis within India. This enables dignostic images to be transferred over a telecommunications network to a location where a radiologist is available to interpret the images. Given that most radiologists in India are located in metros, this allows JANUARY 2017
GEOGRAPHIC EXPANSION IN AFRICAAND THE GULF REGION AS WELLAS INCREASING SALES WITHIN THE US ARE BOTH FOCUS AREAS.ENGAGING WITH STATE GOVERNMENTS IN INDIAFOR TELERADIOLOGY PROJECTS IS ANOTHER FOCUS AREA
patients in rural areas to benefit from their diagnostic skills without either the patient or the radiologist facing the need to travel. It also allows for immediate diagnosis in the emergency setting where the radiologist may not be available at the site of the emergency, but is available in another location to which the images can be transferred electronically, and will therefore greatly impact on emergency medical service delivery. It will also enhance subspeciality imaging as images of complex or rare medical conditions can be transferred to the appropriate specialist (neuroradiologist, cardiac radiologist, etc.) for a second opinion so that the highest quality of report can be obtained by the patient. And how are radiology players leveraging digital technology to provide best radiology solutions to hospitals? Radiologist groups in the US have for over a decade using digital technology
to extend the reach of their practice via teleradiology, and radiologist groups in India are following their example. As an example a group of radiologists that covers three hospitals and five imaging centres can have a radiologist in any one of these locations reporting for all the centres simultaneously. This works best in the after-hours emergency situation and allows a teleradiology practice to efficiently report for multiple hospital sites without having to keep a radiologist awake through the night at each location. Innovative solutions such as the international model allow the radiologist to be located in a day time zone and report the night shift scans at a hospital on the other side of the world. Such practices allow for reporting to be done with extremely short turnaround time with high quality of service. What will be your company focus for 2017? Our focus is currently on growth and scale, while simultaneously remaining focussed on delivering high quality reports. Geographic expansion in Africa and the Gulf region as well as increasing sales within the United States are both focus areas. Engaging with state governments in India for teleradiology projects is another focus area. We will also be focused on growing our vertical Image Core Lab, which provides image analytics support for pharma and biotech companies engaged in clinical trials and research as well as to technology vendors require assistance in technology development. Increasing the reach of our radiology education portal www.radguru.net and our Telerad Foundation which provides pro-bono support to hospitals in remote areas, are also areas of interest. raelene.kambli@expressindia.com
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CHANDER SHEKHAR SIBAL EVP, Fujifilm India
W ‘Our aim is to strengthen presence in the Indian medical diagnostic space’ Chander Shekhar Sibal, EVP, Fujifilm India, in an interaction with Express Healthcare, elaborates on how Fujifilm has been continuously innovating, creating new technologies, products and services to cater to the Indian market
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hat is Fujifilm India's revenue mix, between various sectors that it operates in? What is the share of medical systems' business? Fujifilm has set up its whollyowned subsidiary ‘Fujifilm India’ in February 2008. Fujifilm India had been focussing on building the confidence of Indian customers by product performance and service capacity of the company. It provides world-class cutting-edge solutions in photo imaging, medical products, graphic arts, digital camera, recording media and industrial products. The company holds the number one market share in some of its photo JANUARY 2017
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imaging and medical products. Fujifilm’s medical division has been the key contributor in the company’s growth in India with its state-of-the-art X-ray devices, mammography and medical informatics. The general X-ray constitutes 51 per cent of the diagnostic equipment market in India which makes it a lucrative ground for the company. In which other segments Fujifilm has a leading market share? This fiscal year, our medical division grew by 15 per cent as compared to the last fiscal. Our main driving force in this segment is our CR, Imager and Dry Film. Our installation base has more than 20,000 units and we have sustained the number one market share in CR and Imager market. Furthermore, we have 30 per cent plus market share in DR segment and 25 per cent share in PACS. We always try to go an extra mile to meet our customers' needs and provide best in class services. With these initiatives, our aim is to strengthen our presence in the Indian medical diagnostic space. What are the growth prospects for the segment in 2017? Which new products/ services are scheduled to be rolled out to achieve these targets? At Fujifilm, we are continuously innovating, creating new technologies, products and services and depending on the market demand where we will introduce our new products. Public Private Partnership (PPP) is important as the government is moving towards digitalisation and JANUARY 2017
PUBLIC PRIVATE PARTNERSHIP (PPP) IS IMPORTANTAS THE GOVERNMENTIS MOVING TOWARDS DIGITALISATION AND VARIOUS STATE GOVERNMENTS ARE DIGITALISING THEIR X-RAY DEPARTMENTS
various state governments are digitalising their X-ray departments. DR and FFDM markets are growing at a fast pace, approximately at 20 per cent plus. We will launch new products in digital radiography and flat panel detector, which would definitely reduce the X-ray dose and enhance the image quality. Also, there are plans to launch Synapse 5.0 PACS with faster archiving time while utilising 50 per cent less bandwidth. We are expecting to grow by more than 50 per cent since last year. How does Fujifilm India view PM's 'Make In India' campaign? Are the incentives enough to make high-end medical equipment in India for both local and export markets? We are committed to 'Make in India' campaign and have started getting our mobile DR manufactured through Skanray, named as
MicroSkan DR, which provides exceptional image quality at lower dose and enhances efficiency of point of care X-rays. Right now, there is no big incentive for 'Make in India.' We will also start exporting mobile Xrays from India this year. Fujifilm's support for the Pink Ribbon campaign to promote early discovery of breast cancer has seen it tie up with both private players like NM Medical, Mumbai in April this year and more recently with Sri Ramachandra University, Chennai for the installation of Fujifilm’s Amulet Innovality. What are the special features of this machine? How many facilities in India today have this machine installed? We have installed the Amulet Innovality at Batra Hospital in Delhi and Tata ATREC and NM Medical in Mumbai, Sri Ramachandra University Chennai and the response has been very encouraging. Early diagnosis has been the biggest draw and also the fact that this machine has been designed in a way to ensure that there is minimal pain and discomfort. Fujifilm has developed a unique patented Fit Sweet Paddle that allows pressure to be more even and gently distributed across the breast compared to conventional flexible paddles. The design improves patient comfort during mammograms significantly. We have installed a total of 14 Amulet Innovality till date and are planning to install six to eight more in the current fiscal year. Globally, we have over 2500 installations for the Amulet Innovality. Our machines help in early diagnosis as we are able to detect 50 micron resolution which is best in IN IMAGING 51
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the industry and our dose is less than 1 mgy, so it gives highest image quality at lower dose. We have 3D Mammography in 2 modes high resolution - HD mode and standard mode which is unique. While oncologists decree that breast screening mammography should start at the age of 40 and earlier in patients with high risks like genetic predisposition, there is also the risk of radiation. How do today's digital mammography technologies fare on safety and efficiency (in terms of early detection)? Our flagship product, Amulet Innovality, is a full field digital mammography device, which has made early detection of breast cancer a reality with its 50 Micron 3D image quality and advanced tomosynthesis technology. Living up to our motto, which is ‘Value from Innovation’, we are committed to provide products and services that not only enhance image quality and work flow but also keep the patient’s well being in mind by delivering least X-ray dose to patients undergoing the procedure. We had recently run a programme titled ‘Early Detection Is Key To Control’ in order to spread awareness on breast cancer detection at early stages. Digitalisation has played a major role in the evolution of precision radiology and imaging. How is this reflected in Fujifilm's products and research innovation? We at Fujifilm India are at the forefront of digitalisation. We are installing CR in every nook and corner of the country and this
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digitalised X-ray means convert analog X-ray to digital. Digitalisation helps in better resolution, reduce repeat examination and thus reduction in X-ray dose. These images can be transmitted with the help of PACS/ tele-radiology to competent radiologist for reporting fast and efficient workflow. We have DR panel and full room DR mobile DR for direct digital radiography. The equipment improve workflow and bring down dosage to a very low level. We have FFDM which detect cancer on the onset with 50 micron resolution at 1 mgy dose. FUJIFILM Synapse is a one-stop shop. With an integrated mammography, RIS and PACS solution, high-end FDA approved 3D post processing applications cater to entire hospital's departments right from radiology, cardiology, surgery, orthopaedics, neurology, urology, dental and maxillofacial, podiatry, forensic science for virtual autopsies. Oracle database embedded in PACS helps better management of patient records. We have recently introduced Synapse VNA (Vendor Neutral Archive) for DICOM and non-DICOM modalities in hospitals so that patient's record is stored and archived in a seamless manner. This can also help in research and development of new procedures and data analysis of disease. We also specialise in POC point of care ultrasound sonosite. On a broader note, what is Fujifilm doing to increase patient access to its products and services? Are there PPPs with state governments etc? Fujifilm is taking technology to masses by digitalising X-ray rooms
interconnecting hospitals and diagnostic centres through PACS. We have recently joined hands with PPP vendor KRSNA for supplying CRs for their India wide requirements. We have supplied over 100 CRs to the Andhra Pradesh Government for digitalising their small scale hospitals and large scale medical colleges. We have also received orders from Government of Turkey for their mammo screening programme and have supplied 100 FFDM for that purpose. Our CR and PACS are at Medall which connect almost 50 diagnostic centres for high quality reporting through teleradiology. Also, we have installed FFDM at medical colleges like IGMC Shimla, Sri Ramachandra University, Chennai, Aurangabad Medical College, Tata Memorial Hospital Mumbai, Mahajan Imaging Delhi, NM Medical Hospital Mumbai for early detection of breast cancer. We have created a promising future for ourselves in the Indian market. Each category that Fujifilm has its presence in is driven by longterm commitment towards our customers and partners. Our growth drivers are coming from new age customers who are well aware of what they want and are quality conscious. We have made an effort to investigate the Indian market and we realised that Indian customers require not very low price but affordable product that best suits their need. Taking account of that, we are exploring the possibility of developing value for money products made especially for the Indian customer.
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SS Digitech Impex:
Catering to business partners with easiest,fastest and in the most reliable way Partners with PROTEC for their analog products like automatic film processors SS DIGITECH Impex was incorporated with the aim to focus on medical imaging and printing industry. The journey started with appointment as national distributors for the 'HITI' range of Thermal Dye Sublimation Printers from Taiwan. The company's vision was to cater to its business partners with the easiest, fastest and most reliable way by bringing in the latest printing technology and solution in the medical imaging field. With promoters having over 20 years of experience in the radiology and imaging industry, the company also tied up with Villa Sistemi Medicali, Italy for their dental range of X-ray systems. Villa, Italy is one of the leading dental equipment manufacturing company in the world having a huge installed base of Orthopantomogram (OPG) & Lat CEPH( Lateral Cephalometric) machines in India since 1995. Villa product range includes intra oral sensors, intra oral X-ray system, analog and digital OPG & 3D/CBCT. The company has also partnered with PROTEC for their analog 54 IN IMAGING
SS DIGITECH IMPEXHAS CREATED BEST-IN-CLASS SERVICE AND SUPPORT DIVISION,WITH DEDICATED AND QUALIFIED TECHNICALTEAM products like automatic film processors. Range includes table top models Optimax 2010 and Ecomax for small diagnostic centre to high-end model Compact 2 for big hospitals and government institutions. The company also represents them for their digital X-ray systems. After successfully implementing automatic film processors in India, we also introduced Protec’s NDT (NonDestructive Testing) processors which caters mainly to industries like oil refineries, power plants, , railways, defence, metallurgy industries, etc.
The introduction of OKI, Japan DICOM EMBEDDED plain paper Printers was the need of the hour, not only to complement the vision, but to introduce a revolutionary product in the radiology imaging field that could give environment-friendly printing solutions at fraction of cost as compared to the high-cost digital film media. SS Digitech Impex is a professionally-managed organisation, specialised in distribution and after sales services. To achieve stated goals, the company has incorporated marketing and service networks through channel partners and also at its own offices. With head office in Mumbai and branches in New Delhi, Kolkata, Chennai, Bengaluru, Patna and Ahmedabad, its reach is well coordinated nationwide. As part of its commitment to achieve 100 per cent customer satisfaction, it has created best-in-class service and support division, with dedicated and qualified technical team, who will help in promptly resolving any issues that may arise. JANUARY 2017
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OKI:
The first in digital printer technology OKI largely benefits hospitals and diagnostic centres and cut cost of using expensive polyester media OKI IS the first in digital printer technology, combining the cost effectiveness and high quality output of LED printer with DICOM software. This could largely benefit the hospitals and diagnostic centres to cut cost of using expensive polyester media (digital speciality films) and print patient referral on plain paper media thereby saving huge amounts of money. It is an inexpensive way to print very high quality glossy prints that physicians can use for treatment planning and consultation with colleagues and patients, especially when diagnosis is done on soft copy using high-end diagnostic monitors. DICOM (Digital Imaging & Communications in Medicine) is the primary international standard for handling, storing, printing and transmission of medical images and related information. OKI DICOM printer solution allows users to print medical images such as X-ray, MRI, CT scan, ultrasound and nuclear medicine on inexpensive media and in colour, for purposes such as medical discussions JANUARY 2017
and patient records. Normally, DICOM medical images printer prints on speciality film whereas in OKI printer, the same images can be printed on plain paper in either grey scale images or color images. OKI Printer receives DICOM images directly from modality and allows to print without the use of any conversion software or external print servers, thereby ensuring lossless/no resolution loss of image quality. One can further fine tune the print quality with easily accessible set defaults and adjust image quality output settings such as brightness, gray scale, and contrast for each modality. OKI printer is compatible with modalities using DICOM 3.0 standard, it fits effortlessly into existing work flows. Moreover, it does not require any special training as it gives almost near film quality output. From start to finish, working with film is expensive and labour intensive. Replace film with paper and images can be shared with minimal expense, eliminate the need
and cost for special processing, handling and storage, and reduce labour costs associated with tracking, filing and transporting film. Compliance and other environmental costs associated with using chemicalbased film can be saved, as well as minimise the impact on the environment. In fact, because the special printing, handling, storage, transportation, and other infrastructure needed for film can be eliminated, it actually simplify the work process and that of referring physicians. In India referring physicians want physical images in their hand in order to fully explain them to patients. They do not have to deal with DVD, search database or have their internet bandwidth choked by huge image files. For which they require high quality images which they can review and share easily. This is where OKI DICOM embedded paper printer is an effective solution. IN IMAGING 55
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Modi Medicare introduces MEDMAMMO
An independent FFDM mammography workstation Med Mammo is a mammography diagnostic workstation which combines ease of use and high performance features
MEDECOM’S MED MAMMO is enhancing reading and image management for diagnostic mammography. Breast imaging and women’s health clinics will benefit from Medecom’s fifteen years of radiology and image workflow experience. With Medecom’s Med Mammo breast imaging workstation, one can include reading of tomosynthesis images and other multi-modality radiology examinations in the regular mammography reading workflow. This significantly increases efficiency as the need to move to a dedicated modality workstation is eliminated. Med Mammo is among the first digital mammography solutions to offer support for import and review of the tomosynthesis DICOM format. Multimodality with relevant prior matching Users benefit from Med Mammo’s multi-modality support to pre-fetch clinically relevant priors including ultrasound, MRI and tomosynthesis, to be displayed side-by-side with the mammograms. Each imaging study is 56 IN IMAGING
vendor on a single client interface.
automatically associated with the corresponding modality imaging functions such as, measurements, stitching, MIP/MPR and modality display protocols. This ensures that they are hung with the precise tools according to radiologists’ preferences for optimal viewing and diagnosis. Mammography studies from multiple vendors are automatically scaled and aligned to ensure optimal side by side comparison. Medecom has improved this critical element of digital mammography reading, to make it possible to view and report on all forms of breast imaging (MRI, ultrasound, digital breast tomosynthesis and X-ray) from any
A complete digital mammography solution In order for you to take full diagnostic advantage of the tomosynthesis format you need to ensure the support of tomosynthesis images throughout the digital mammography workflow. This requires modules that complement legacy radiology systems to ensure compatibility or extend functionality offered by the new tomosynthesis format. Medecom provides tomosynthesis support throughout a vendor neutral, digital mammography, product line. Medecom's digital mammography modules include storage, reporting, printing, CD/DVD archive and Electronic Image Exchange. Compliant with the regulatory requirements and standards in many countries, Med Mammo is a true alternative to any manufacturer’s workstations. Contact Jigish B Modi Ph: 2506 5664, 98670 01110, Email: modimedicare@gmail.com Skype: modi.medicare JANUARY 2017
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Myrian XL Onco
A leading solution for oncology follow-up
THE UNIQUE solution for multi modality oncology follow-up, Myrian XL-Onco is the culmination of eight years of development of the Myrian platform. Dedicated to oncology follow-up, it manages the sequencing of tasks essential for the management of the cancer patients with elevated efficiency and in strict compliance with the international RECIST rules, consensually established by European, Canadian and American authorities. The Cheson protocol whose parameters can be set by the user is also available. Myrian XL-Onco was developed and validated jointly with leading French experts. It makes Intrasense a world leader in oncology follow-up software applied to medical imaging. It is intended for routine clinical practices of hospitals treating cancer patients as well as for pharmaceutical companies and CROs in the framework of phase I, II and II clinical trails to evaluate anti-cancer JANUARY 2017
patient's cancer by comparing the latest examination to prior results. This follow-up involves key steps managed by the software that considerably simplifies the radiologist's work.
therapies. Original technologies Automated retrieval of prior exams, dedicated clinical workflow obeying RECIST rules, automatic 3D registrations of examinations in elastic mode, automated production of reports and graphs. Applications It is used to follow the course of a
First rate partners The best specialised cancer teams contributed to the development of this module. They are: ■ Curie Institute (Paris, France) ■ Pitie-Salpetriere (AP-HP – Paris Public Hospitals Authority) (Paris, France) ■ Hopital Europeen Georges Pompidou (AP-HP – Paris Public Hospitals Authority) (Paris, France) ■ Civil Hospices of Lyon (HCL) (Lyons, France) ■ Montpellier University Hospital (Montpellier, France) Contact Jigesh B Modi Phone: 25065664, 9867001110 Email: modimedicare@gmail.com Skype: modi.medicare IN IMAGING 57
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SANRAD MEDICAL SYSTEMS:
SPREADING TECHNOLOGY
OVER THE past 18 years, the name Sanrad has become synonymous with affordable and reliable services for medical imaging equipment in India. Sanrad is a pioneer in the industry for services of CT & MRI equipment and is widely acclaimed by the medical fraternity for its excellent customer relationship. Sanrad has installed more than 370 refurbished Toshiba CT scanners in India, with highest uptime and cost effective services. The name Sanrad is a wellrecognised brand for medical imaging equipment. It has also become synonymous with low maintenance cost concept. This concept embraces a range of customer support protocols that has been designed for cost conscious customers of India. Sanrad maintains the largest inventory of CT scan parts and it is probably the biggest in Asia. With 58 IN IMAGING
service bases equipped with tools, technical backup of available spare parts and a skilled and efficient team of engineers we are able to provide excellent quality service to our customers. With is its high end products like the recently introduced Refurbished Toshiba 1.5T MRI System and highly efficient Refurbished Toshiba 64 Slice CT System, Sanrad takes technology
“MOSTOFTHE DIAGNOSTIC IMAGING EQUIPMENT BUSINESS IN OUR COUNTRY WAS CONTROLLED BYTHE MULTINATIONALS.TODAY, WE ARE PROUD THATWE DICTATED THIS CHANGE AND BROUGHTTHE STATE OFARTTECHNOLOGY WITHIN THE REACH OF EVERYONE.CUSTOMERS THOSE WHO HAVE EXPERIENCED US,WOULD SWEAR BYOUR PURPOSE AND EXISTENCE” - RATISH S NAIR, CEO and its accessibility to greater levels. Sanrad maintains the largest inventory of CT scan parts and it is probably the biggest in Asia. With service bases equipped with tools, technical backup of available spare parts and a skilled and efficient team of engineers we are able to provide excellent quality service to our customers. JANUARY 2017
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NEWLY INTRODUCED REFURBISHED TOSHIBA 1.5 MRI SYSTEM Sanrad has taken a forefront in supply and maintenance of MRI systems. With and already existing product range of permanent MRI systems, Sanrad has recently introduced yet another product in this category that is The Refurbished Toshiba 1.5T Super Conducting MRI. ◗ Silent magnet with painissimo technology that reduces sound by 90 per cent. ◗ Patient comfort taken to next level with the additional features of wide bore, patient camera monitoring and user friendly interface. ◗ Optimum scanning technique and high image quality
THE REFURBISHED 64 SLICE CT SCANNER THE refurbished Toshiba Aquilion 64 slice CT scanner is a multi-slice helical CT system that supports whole body scanning and comes with work flow enhancing software that delivers unsurpassed image quality, improved dose management and superior patient care. ◗ Selectable slice thickness for accurate diagnosis. ◗ Optimum for cardiac scanning with Breath holding techniques and ECG gating available. ◗ Applications of sure technologies available in the software, allow feasible options in the scanning. ◗ Dose reduction technologies and high image quality. Contact: Sanrad Medical Systems; 1, Manek SV Road, Santacruz (West), Mumbai-400054, India Ph: +91-22 26006060,26494702 Email: info@sanrad.in Web: www.sanrad.in JANUARY 2017
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ONE-ON-ONE
Pay-per-use rental scheme for CT & MRI systems Atul Sasane, CEO, Aucnet Sanrad India in an interview with Express Healthcare, talks about the unique pay-per-use model, which has been designed for immediate start-up of diagnostic centres and also updates about the company’s future activities How does Aucnet Sanrad India help imaging diagnostic centres? Diagnostic centres are facing immense competition due to increasing number of new centres, and newer technologies becoming available. To keep up with competition, they have to keep investing and procure the full range of equipment - from simple X-ray to CT scanner and MRI. But not all centres can afford to invest large amounts required to procure and maintain high- end equipment, particularly 1.5T MRI. That is where Aucnet Sanrad India helps diagnostic centres by offering pay-per-use rental solutions. We supply and install our CT/MRI machine imported from Japan, as suitable and desired by the customer. Cost of machine procurement, installation, annual maintenance, and even cost of replacing parts (in case of failure) is borne by us. Customers can focus on optimising operations of the centre and clinical matters. What are the equipment offered on payper-use rental contract? We offer X-ray tubes for CT scanner, CT scanners and MRI systems on payper-use rental contract. X-ray tubes include the full range from 2MHU, 60 IN IMAGING
Over and above the cost of the system, the maintenance costs can be prohibitively high. Our solution is particularly suited to solve the issues of getting and maintaining MRI system. Over the next year we expect more and more diagnostic centres to subscribe to our solution for MRI.
ATUL SASANE CEO, Aucnet Sanrad India 4MHU and 7.5MHU tubes. For CT scanners, the focus is on 4 slice, 16 slice CT scanners. We also offer other CT scanners, depending on the customers’ requirements. Leading edge 1.5T MRI systems from Japan are also included in our company’s offering. How is the response to the pay-per-use rental offering ? In the past one year, we have customers for all three types of equipment – 1.5T MRI, CT scanner as well as X-ray tube for CT scanners. The trend among customers is to get 1.5T MRI systems on the pay-per-use contract. The acquisition cost of 1.5T MRI systems is high in case the customer purchases it from the market.
How is your pay-per solution different from the leasing solutions offered by manufacturers and finance companies? Leasing solutions are based on charging ‘interest’ on the cost of the equipment. Eventually, the customer ends up paying the full cost of the equipment plus the interest cost for the term of the lease. Aucnet Sanrad India is not a financing company, so our solution is not based on charging interest. Instead, we share revenues with the customer, based on usage of the equipment. In this way we share the risk and rewards. Thus for a low usage in any month, the total rental fee for that month will be lower. Another difference is that we bear all the costs related to the machine, including parts. In case of CT machines, replacement of X-Ray tube is a major issue. Customers have to keep a constant watch on the condition of the JANUARY 2017
ONE-ON-ONE
tube to ensure smooth operation of their centre. We take full responsibility of the tube replacement also, which is one of the major advantages of using our pay-per-use rental. All costs related to the machine are covered in a single ‘per slice’ fee. There are no hidden costs, and customers can be assured that the machine in their premises is always in best operating condition, at our responsibility. Our solution also offers the same peace of mind to owners and operators of imaging diagnostic centres. They can focus on the scan, while we take care of all other hassles related to the machine. What are the financial terms and conditions? The pay-per-use rental fee is based on a variable tariff card. For high usage the rate per slice goes down. So customers end up paying a lesser portion of the patient scan fee to us. More the number of patients seen by the customer, more is the share of the scan fee which he gets to keep for himself. How do you ensure that the machine will be working in good condition? Our partners Sanrad Medical Systems support us for all installation and maintenance activities. As you are aware, Sanrad are the leaders and the most trusted name for supply and maintenance of CT and MRI. Sanrad’s infrastructure and skilled manpower ensure that the machine which we offer is always leading edge, and maintained in the best condition. What are the tax benefits of pay-per-use as compared to the benefit of claiming depreciation when purchasing equipment? When a customer purchases equipment, he can claim tax benefit for JANUARY 2017
Whyuse pay-per-use?
depreciation of the value of the equipment. However, according to the tax regulations, there is an upper limit on the maximum depreciation that can be claimed by the customer. Usually the limit is only 15 per cent of the residual value of the equipment. This benefit is fixed and is not related to the revenue which the equipment is generating. In case of pay-per-use, the full amount which is paid out as rental fee is treated as expense, for tax benefit. Since pay-peruse fee is linked to business volume, more the patients seen by the customer, more is the tax benefit. Which type of diagnostic centres are benefitting from your offering? New and emerging diagnostic centres face the biggest challenges in finance for procurement of CT and MRI systems. Not only is the total capital cost large, but the lending and leasing terms are also harsh on these newcomers. But at the same time, established diagnostic centres also have to keep upgrading their equipment and in many cases have to start “satellite” centres to cater to their increasing work load. We have customers and enquiries from both centres who are starting from scratch, as well as from established centres looking for machine
100 per cent financing: No down payment,unlike other financing. Maintain cash: Hold on to cash so it can be used for other areas – expansion,improvements,marketing or R&D. Manage risk: Mitigate the uncertainty of investing in equipment your business needs,until it delivers a return. Hedge against inflation: you don't pay the total cost of equipment up front in today's dollars. Plan expenses: For cash flow and business cycle fluctuations.Maintain greater certainty in budgeting by setting customised rent payment to match cash flow and even seasonal cash flows.You pay only for what you use. Keep up to date with new technology:Acquire more and better equipment than you could have without financing and even upgrade or replace it within the term. Avoid getting stuck with out-of-date equipment:We bear the risk of the equipment from becoming obsolete. replacement/ upgradation. Initially, we are offering this solution in Western and Southern parts of India and would slowly scale up to cover whole of India. As the costs of imaging diagnostic equipment keeps rising, pay-per-use rental solution will become the preferred solution for most of the entrepreneurs in the medical profession. Contact: Atul Sasane Phone: +91 22 2600 6060 Mobile: +91 9820703371 Email: sasanea@ns.aucnet.co.jp IN IMAGING 61
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SPECTRAMED:
DRIVEN BY PASSION FOR RADIATION PROTECTION PRODUCTS Spectramed boasts of a strong network of specialists, hospitals and manufacturers RADIOLOGY FOCUS AND playing an important role is the mission at Spectramed. Driven by passion for radiation protection products, Spectramed has become synonymous to light weight, lead free aprons and accessories Xenolite in India Xenolite aprons helps interventionalists and surgeons who work under fluoroscopy in reducing the back pain and fatigue considerably, caused by wearing heavy lead aprons. Spectramed Radiology, started as a marketing and distribution firm for contrast media and medical imaging products. Headed by one of the most learned and experienced leader in the industry, Spectramed boasts of a strong network of specialists, hospitals and manufacturers. Promoted by MV Vijayanandaraj whose rich experience in the business 62 IN IMAGING
of radiology products for nearly three decades has been in the forefront of launching and re-launching three contrast media MNCs in India, notably NYCOMED, a Norwegian Co from 1989. Vijayanandaraj recalls this as the period of renaissance in low osmolar and non-ionic contrast media in India and remembered as Nycomed Vijay even today for his contribution to contrast media business. Be it intervention, radiation
protection, radiation therapy devices, Spectramed’s goal is to bring in the best and latest to India. The company is proud of being the leader in the light weight and lead free aprons. The company has won many laurels through customer satisfaction and trust. New products on breast imaging, pancreatic imaging, markers in the field of radiology and radiation oncology are in the pipeline. JANUARY 2017