HospiMedica International April 2016 by Globetech

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Vol.34 No.2 • 4/2016

L E A D E R DAILY CLINICAL NEWS

ISSN 0898-7270

Wearable Defibrillator Protects Children at Risk novel wearable defibrillator now offers an advanced protection and monitoring option for children at risk of sudden cardiac arrest. The LifeVest is a wearable defibrillator, which unlike an implantable cardioverter defibrillator (ICD) is worn on the body (under clothing), rather than implanted into it. Weighing less

Dramatic Reduction in Hospital-Acquired Conditions he incidence rate of hospital-acquired conditions (HACs) in the United States has dropped by 17% over a 4-year period, according to a new report by the US Department of Health and Human Services (HHS; Washington DC, USA; www.hhs.gov) Agency for Healthcare Research and Quality (AHRQ).

The report, a compilation of data from more than 3,000 hospitals, showed that the measured interim rate for 2014 held steady, at 121 HACs per 1,000 discharges, down from 145 in 2010. In all, the cumulative total of HACs experienced by hospital patients over the four years (2011, 2012, 2013, and 2014) was

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Procedureless Gastric Balloon Generates Weight Loss novel gastric balloon A offers an alternative treatment option for over-

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Telerobotic Ultrasound Enables Remote Imaging esearchers are testing whether telerobotic ultrasound technology could be used to provide critical healthcare services to resource-poor areas of the world with results comparable to those of manual ultrasound examinations. The new technology, called Tele Robotic Ultrasound for Distance Imaging (TRUDI), enables an operator to perform an ultrasound exam using an Internet connection, from any

n advanced application that captures seven dimensions of data (three in space, one in time, and three in vectorial) could greatly simplify cardiac magnetic resonance imaging (MRI). The GE Healthcare ViosWorks software was designed to simultaneously provide key elements of a cardiac MRI exam, including anatomy, function and flow, thus helping to solve several cardiac MRI challenges

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INSIDE

Fusion Device Could Revolutionize Back Surgery

Health IT . . . . . . . . . . . . . . . . 24 Industry News . . . . . . . . . . . . 33 International Calendar . . . . . 34

n innovative spinal fusion device designed to reduce chronic back pain could negate the need for invasive surgery and bone grafts.

News Update . . . . . . . . . . . . . 6 Product News . . . . . . . . . 8-12

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News Update . . . . . . . . . . . . 14 Product News . . . . . . . . 14-16

New App Helps Monitor Disease and Injury Trends

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Software Simplifies Cardiac MRI Workflow

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weight and obese individuals. The Elipse procedureless gastric device is a thin, flexible polymer film balloon that is delivered in a swallowable capsule, thus eliminating the need for any invasive procedure. See article on page 21

revolutionary new app for tablets and mobile phones captures and records accurate global causes of death data. The app, developed by an international consortium of researchers led by the Institute for Health Metrics and Evaluation (IHME; Seattle, WA, USA; www.healthdata.org) at the University of Washington (Seattle, WA, USA;

www.washington.edu), and the University of Melbourne (VIC, Australia; www.unimelb.edu.au), is basically a shortened verbal autopsy instrument (VAI) for recording mortality data in settings with no or unreliable vital registration systems. The researchers first established a rank order of individual Cont’d on page 4

News Update . . . . . . . . . . . . 18 Product News . . . . . . . . .18-22

Hospital News . 32 I

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Software Simplifies Cardiac MRI Workflow cont’d from cover

at once. The delivery of three-dimensional (3D) spatial- and velocity-encoded dataset at every time point during the cardiac cycle allows the software to yield high resolution, time-resolved images of the beating heart, thus supplying a measure of the speed and direction of blood flow at each location. The exam is simplified for the patient by using a free-breathing scan that can be acquired in less than 10 minutes, compared to a conventional cardiac MRI that takes over an hour to complete, helping to reduce the error-prone and timeconsuming aspect of slice positioning. This is achieved due to the fact that co-registered anatomic images can be used to assess cardiac functioning and contextualize flow abnormalities. ViosWorks is a product of GE Healthcare (GE; Little Chalfont, United Kingdom; www.gehealthcare.com), and is designed for use on the Signa Pioneer 3.0T, Signa Explorer, and Signa Creator 1.5T MRI scanners. A key element of ViosWorks is the Arterys (San Francisco, CA, USA; www. arterys.com) cloud-based medical imaging, machine-learning platform that is designed to deliver ultra-fast visualization and quantification with automatic analysis. Arterys uses software as a service (SaaS) analytics powered by powerful algorithms that allow the large datasets to be evaluated in real time, via cloud-based software that significantly reduces the time spent on data processing, and helps promote new visualization routines. “We are excited to collaborate with Arterys and introduce this innovative cardiac MR solution that can capture seven-dimensional viewing capabilities of the heart,” said Ioannis Panagiotelis, chief marketing officer of Global MR at GE Healthcare. “With cardiovascular disease as the leading cause of death in the world, we believe that this cloud-enabled technology will help us to provide value not only for clinicians by delivering advanced visualization and quantification of cardiovascular function, but also help simplify cardiovascular examinations and address significant patient needs in cardiovascular disease.” “We are extremely pleased to announce our partnership with GE Healthcare in conjunction with the launch of our first cardiac care solution, the first self-learning system of its kind to visualize and quantify blood flow leveraging a standard MRI machine,” said Fabien Beckers, PhD, founder and CEO of Arterys. “This pivotal milestone for the company is directly in line with our vision to transform medical imaging by bringing automatic quantitative data and deep learning to healthcare applications through a GPU smart cloud platform that can be applied to many areas of medical imaging including neurology and oncology.” GE Healthcare hopes that the new, simplified process will help it gain ground in the US market, where it currently only makes up about one percent of MRI exams, due to the time and complexity needed. Image: The ViosWorks color representation of direction and velocity of cardiac blood flow (Photo courtesy of GE Healthcare).

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New App Helps Monitor Disease and Injury Trends cont’d from cover

questions based on the Population Health Metrics Research Consortium (PHMRC) gold standard VAI according to their importance in predicting causes of death. Second, they reduced the size of the instrument by dropping questions in reverse order of importance. They then assessed the predictive performance of the instrument as questions were removed at the individual level by calculating chance-corrected concordance, and at the population level with cause-specific mortality fraction (CSMF) accuracy. The final result was an app that shortened the full PHMRC VAI by almost 50%, without a significant drop in performance. While the full PHMRC VAI had 183, 127, and 149 questions for adult, child, and neonatal deaths (respectively), the shortened instrument developed had 109, 69, and 67 questions, respectively, representing a decrease in the total number of questions of 40%–55%. App performance was then validated using hand-held electronic tablets. A study describing the development and testing of the app was published on December 16, 2015, in BMC Medicine. “Without accurate cause of death information, we can’t monitor disease and injury trends, we can’t keep track of emerging health problems, and we don’t have any markers to show us whether programs and policies are actually working,” said senior author Professor Laureate Alan Lopez, PhD, of the University of Melbourne. “Up-to-date, reliable information on what people are dying from and at what age is really important for policies to prevent premature death. “Our app provides a way to do this, quickly, sim-

Under development by researchers at the University of New South Wales (UNSW; Sydney, Australia; www.unsw.edu.au) the Thru–Fuze device is made of porous titanium that promotes bone growth and fusion both on and through the device after it is placed between the vertebrae. Over time, the device acts as a bridge between adjacent vertebrae for additional bone growth, resulting in rapid biomechanical fixation, without the need for a bone graft procedure or supporting metallic hardware. According to the researchers, the device will allow faster, simpler surgery with minimal radiation exposure compared to current methods. Preclinical and laboratory testing in animal models has demonstrated rapid biomechanical fixation between the fusion device and the vertebrae. Human trials of the Thru-Fuze are expected to begin at the Prince of Wales Hospital (Sydney, NSW, Australia) in late 2016, with future commercialization of the device exclusively licensed to Intellectual Ventures (Bellvue, WA, USA; www.intellectualventures.com).

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ply, cheaply and effectively, in real time, with the power of technology. Our method involves data collection by health workers, registrars and village officials, who use the app to administer the surveys,” concluded Prof. Lopez. “It requires very minimal training. The data is fed into a computer, which makes a diagnosis. This way doctors are free to do what they do best, which is providing essential medical care to their communities.” Worldwide, two in three deaths – about 35 million deaths each year – are unregistered. In addition, around 180 countries that are home to 80% of the world’s population do not collect reliable cause of death statistics. Another problem is that in many regions around the world that do collect data, only registered doctors are qualified to determine a cause of death, but the process is expensive, timeconsuming, and can be unreliable. Image: A health worker collects information via the VAI app (Photo courtesy of the University of Melbourne).

Fusion Device Could Revolutionize Back Surgery cont’d from cover

Patents for the technology have been filed in Australia, Europe, China, and the United States. “Existing methods of spinal fusion use rod or cage systems that require screws to be drilled into the spine and a painful bone graft harvested, which is the material used to form the bridge and obtain the fusion between the vertebrae in the spine,” said device inventor Prof. Bill Walsh, MD, director of surgical and orthopedic laboratories at UNSW. “These systems are very costly, difficult and time consuming to implant and they also have variable rates of fusion success. Existing methods rely on the bone to make its way right across the vertebrae and it can take up to a year to find out if the surgery has been a success.” “New technologies such as the Thru-Fuze are of paramount importance, as surgeons strive to deliver better patient outcomes with less invasive and more effective implant and prostheses options,” said neurosurgeon Ralph Mobbs, MD, who will lead the human trials. “The potential of the device is significant.”

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ISSN 0898-7270 Vol.34 No.1 • Published, under license, by Globetech Media LLC Copyright © 2016. All rights reserved. Reproduction in any form is forbidden without express permission. Teknopress Yayıncılık ve Ticaret Ltd. S¸ti. adına ˙Imtiyaz Sahibi: M. Geren • Yazı is¸leri Müdürü: Ersin Köklü Müs¸ ir Dervis¸ ˙Ibrahim Sok. 5/4, Esentepe, 34394 S ¸ is¸ li, ˙Istanbul P. K. 1, AVPIM, 34001 ˙Istanbul • E-mail: Teknopress@yahoo.com Baskı: Promat Web Ofset Tesisi • Orhangazi Mahallesi 1673. Sokak, No: 34 • 34510 Esenyurt, B. Çekmece • ˙Istanbul Yerel süreli yayındır. Yılda sekiz kere yayınlanır, ücretsiz dag˘ıtılır.

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Telerobotic Ultrasound Enables Remote Imaging cont’d from cover

location. The ultrasound system is part of a robotic kiosk and can be moved rapidly to perform an examination by the remote operator. The ultrasound system is based on a Personal Computer (PC) platform and was made by Telemed Ultrasound Medical Systems (Milano, Italy; www. telemedultrasound.com). The system is still in the early stages of development, but has the potential for providing critical healthcare to resource-poor areas of the world. The technology could cut life-threatening waiting times for diagnosis of patients with heart failure for example, who often do not have access to a specialist. The technology could also be used in the future for advanced cardiac procedures such as transcutaneous valve replacements. Other uses could be for examinations by a fetal ultrasound specialist in hard-to-reach rural communities, anywhere in the world, reducing maternal mortality by providing access to antenatal care in developing countries. Vikram Dogra, MD, director of ultrasound and professor of radiology and biomedical engineering, University of Rochester (New York, USA), said, “Telerobotic ultrasound has the potential to revolutionize telemedicine by connecting the remote underserved areas of the world with a real-time imaging capability for diagnosis of acute diseases such as acute appendicitis and ectopic pregnancy.” Image: A new clinical trial testing the feasibility of telerobotic ultrasound exams over the Internet (Photo courtesy of RSNA).

Dramatic Reduction in Hospital-Acquired Conditions cont’d from cover

2.1 million fewer than the number of HACs that would have occurred if rates had remained steady at the 2010 level. The researchers also estimated that nearly 87,000 fewer patients died in the hospital as a result of the reduction in HACs, with almost USD 20 billion in health care costs saved. The biggest reductions were in adverse drug events (accounting for 40% of the total reductions in HACs), pressure ulcers (28%), and catheter-associated urinary tract infections (CAUTIs, 16%). According to the report, although the precise causes of the decline in patient harm are not fully understood, the increase in safety did occur during a period of concerted attention by hospitals throughout the United States to reduce adverse events, an effort that was spurred in part by Medicare payment incentives and catalyzed by the HHS Partnership for Patients (PfP) initiative. “Having been involved in this business for much longer than I care to remember, to see the progress here – 87,000 fewer people dying over the last four years than would have died if the 2010 rates remained in place – is very heartwarming for me,” said Richard Kronick, PhD, director of the AHRQ. “Progress was also made possible by investments made by AHRQ in producing evidence about how to make care safer, investing in tools and training to catalyze improvement, and investing in data and measures to be able to track change.” “As a practicing physician in the hospital setting, this work in improving patient safety is one of, if not the most important, thing we could do for patients,” said Patrick Conway, MD, chief medical officer at the Centers for Medicare and Medicaid Services (CMS; Baltimore, MD, USA; www.cms.gov). “Patients want to avoid infections and adverse harm events, and we need to have health system that’s as safe as possible for all patients.”

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PRODUCT NEWS INFANT VENTILATOR

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DISPOSABLE CPAP SYSTEM

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The Crossvent 2i+ features patient-triggered ventilation using a proximal flow sensor sensitive enough to allow the smallest of patients to trigger the vent. The vent features a touch screen display visible under all lighting conditions, and the rechargeable battery provides 3 hours of run time.

The Flow-Safe II is a ready-to-use, all-disposable system that is easy to transport, uses 50% less oxygen consumption and standard flowmeters. Designed for emergency care, the advanced mask design also features a built-in pressure gauge and pressure relief valve.

The M.A.P system continuous bedside pressure monitor ensures bed-bound patients benefit from pressure distribution to reduce the risk of pressure ulcers. It increases patient comfort and improves outcomes, reduces costs associated with pressure ulcers, and simplifies the work of nurses.

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Germ-Fighting Screen Protector Defends Healthcare Facilities n innovative overlay film reduces germs and protects the display surfaces of mobile devices and stationary computers in healthcare environments. NuShield Triple A film offers continuous antiglare, antimicrobial, and anti-fingerprint protection to inhibit the growth of germs on all terminals and touch display surfaces used by healthcare facilities for patient monitoring and electronic documentation systems. Available for any device with a liquid crystal display (LCD), light emitting diode (LED), or plasma screens up to assize of 80 inch diagonal, NuShield Triple A currently supports over 12,000 different devices, including televisions, computer monitors, laptops, tablets, telephone displays, thermostats, control panels, and handheld devices. Properties of the protective shield include resistance to abrasion and erosion by harsh chemical solvents, without degrading inherent antimicrobial protection; physical protection and preservation of the devices; an antiglare feature that prevents transmission and reflection of 99% of ultraviolet B (UVB) light from reaching the user’s eyes, which could cause increased eye strain and computer vision syn-

Image: The Triple A screen protector offers a powerful weapon to fight germs on LCD screens and LED surfaces (Photo courtesy of NuShield).

drome; and a slightly tacky silicone rubber adhesive backing that is easily applied and removed and does not trap air. In laboratory tests, Triple A showed a wide antibacterial spectrum and heat resistance. When tested against colon bacillus and Staphylococcus aureus bacteria, the film’s inorganic coating showed a

germicidal reduction rate of 99% over a 24-hour period. NuShield Triple A film is a product of NuShield (Newton, PA, USA; www.nushield.com), and can be cleaned with solvent, bleach, rubbing alcohol, dilute alkalis, esters, and other disinfectants to reduce germs on the screen, and will not dilute its antimicrobial properties.

Repeated Blood Donation Not Associated with Premature Death new study concludes that regular blood donors are not at a greater risk of a premature death than those who rarely donate blood, and may actually live longer. Researchers at the University of Copenhagen (KU; Denmark; www.ku.dk), Karolinska University Hospital (Stockholm, Sweden; www.karolinska.se), and other institutions scoured the Scandinavian Donation and Transfusion database (SCANDAT) to assess the association between annual number of donations in five-year windows and donor mortality by means of Poisson regression analysis. The analyses included adjustment for demographic characteristics and for an internal “healthy donor effect” that was estimated among elderly donors exempt from continued donation due to age criteria.

The results showed that of 1,182,495 donors, 15,401 died during 9,526,627 person-years of follow-up. Analyses adjusted only for demographic characteristics showed an inverse relationship between donation frequency and mortality, with an accumulating 18.6% reduction in mortality per additional annual donation. After additional adjustment for the internal healthy donor effect, the association was weakened, with each additional annual donation associated with a 7.5% decreased mortality risk. The study was published in the October 2015 issue of Transfusion. “My response to the results is primarily of relief. Those who have donated a lot of blood live longer than those who have donated a little, and there is no evidence that it is dangerous to donate blood,”

said lead author Prof. Henrik Ullum, MD, of the University of Copenhagen. “The study can be used to reassure blood donors and the blood banks. It says that it appears to be healthy and safe to donate. But we are still working to identify other effects that may impact upon your health.” The Healthy Donor Effect was coined from the Healthy Worker Effect, originally used in occupational medicine. In 1885, a comparison between those who worked with those who did not suggested that workers were the healthiest; but this was simply because it was only the fit and healthy ones that could actually work. Similarly, only healthy people can donate blood, and scientists risk drawing the wrong conclusions by comparing donors with non-donors. HospiMedica International April/2016

Robotic Device Assists Intubation In Medical Emergencies prototype autonomous robotic device could help guide patient intubation with greater accuracy than human vision, improving emergency airway management. Researchers at Ohio State University (OSU; Columbus, USA; www.osu.edu) have developed a robotic endoscopic device for intubation that is propelled by an electric motor and is controlled by a small computer. The device receives real-time three-dimensional (3D) information on its own anatomical position by means of a small speaker placed near the laryngeal prominence (Adam’s apple) that emits both soundwaves and magnetic waves that are detected by accelerometers and magnetic fields, respectively. The device has just completed proof of concept testing. “Medical professionals often are unable to see important parts of airway anatomy because of the presence of blood, vomit, swellings, and lesions. A laryngoscope or other intubation tools currently available require human visual guidance,” said co-developer anesthesiologist Hamdy Awad, MD. “During intubation, it is critical to locate or identify the vocal cords so that the breathing tube passes between them into the trachea instead of into the esophagus.” “The progress made by this diverse team is extraordinary,” said co-developer mechanical engineer Professor Emeritus Bob Bailey, PhD. “Our next steps include refining computer software, optimizing the motor, and embarking on human tests. That is going to take some money, but I think the potential benefit of this technology makes it a great investment.” Intubation, the placement of an endotracheal tube to maintain a clear air pas-

sage to the lungs, must usually be visually guided into the trachea. If mistakenly sent down the esophagus, the patient may not be able to breathe and could even perish. Image: The prototype endoscopic robotic device for intubation (Photo courtesy of OSU).

Wearable Defibrillator Protects Children at Risk cont’d from cover

than one kilogram, the device consists of two main components: an electrode belt and vest-like garment that surround the patient’s chest, and a monitor that the patient wears around the waist. The pediatric device is intended only for children weighing at least 18 kg and with a chest size of 66 cm or more, which is about the size of an average eight year old. The device continuously monitors the patient’s heart using dry, non-adhesive sensing electrodes that detect abnormal heart rhythms. If such a lifethreatening cardiac rhythm is detected, the device alerts the patient prior to delivering a shock, thus allowing a conscious patient to postpone the

Image: The LifeVest defibrillator (Photo courtesy of ZOLL).

HospiMedica International April/2016

treatment shock. If, on the other hand, the patient is unconscious, the device releases a special gel over the therapy electrodes and delivers an electrical shock to restore normal rhythm. The LifeVest Wearable Cardioverter Defibrillator is a product of Zoll Medical Corporation (Zoll; Chelmsford, MA, USA; www.zoll.com), and has been approved by the US Food and Drug Administration (FDA) for children who are at risk for sudden cardiac arrest, but are not candidates for an ICD due to certain medical conditions or lack of parental consent. The device was previously approved in 2001 for patients 18 years of age and older. “The pediatric medical community is often forced to use adult devices offlabel without appropriate labeling or instructions for use in pediatric patients,” said Vasum Peiris, MD, MPH, chief medical officer of pediatrics and special populations in the FDA Center for Devices and Radiological Health (CDRH). “Doctors now have important information that may help them safely prescribe this life-saving device to young patients who may benefit from the device.” Ventricular fibrillation (VF) and ventricular tachycardia (VT) are lifethreatening abnormal heart rhythms that are the most common cause of sudden cardiac arrest (SCA), according to the US National Heart, Lung and Blood Institute (Bethesda, MD, USA; www.nhlbi.nih.gov). Certain

diseases and conditions that can lead to SCA include heart disease, inherited disorders, and structural changes in the heart due to infection or congeni-

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tal heart disease. Most people who have SCA die from it, often within minutes. Rapid treatment with a defibrillator can save lives.

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PATIENT-WORN MONITOR

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The Radius-7 features parameter and waveform views for on-the-spot assessment of patient status, and a configurable display shut-off that minimizes patient distraction and supports privacy while ambulating. Other benefits include a singlepatient use armband, and 12-hour battery life.

The BeneVision N22/N19 optimizes user experience with ease of use, confidence-maximizing innovations and workflow-transforming interoperability. Key features include an extra large touch screen, rotatable landscape/portrait layout, ultra slim main unit, and plug-n-play modules.

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Silver-Coated Foley Catheter Helps Prevent Urinary Infections n innovative Foley catheter that is permanently lubricious also helps reduce the likelihood of catheter-related urinary tract infection (CAUTI). The SilverCoat Foley Catheter is made of 100% silicone and is covered with a permanently lubricious coating that is impregnated with silver ions. The silver is retained in the hydrophilic coating through ionic bonding, which in turn is covalently bonded to the catheter silicone surface through patented surface modification technology. The coating thus provides a protective zone of bacterial inhibition that surrounds the catheter surface and resists microbial colonization, reducing the likelihood of CAUTI. A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine; since it may need to stay in place for an extended period of time, it is al-

so called an indwelling catheter. It is held in place with a distal inflatable balloon filled with sterile water to prevent it from being inadvertently removed. The urine drains through the catheter tube into a bag, which is emptied when full. The SilverCoat Silicone Foley Catheter is a product of Covalon (Mississauga, Canada; www.covalon.com), and has been approved by the US Food and Drug Administration (FDA). “We believe our patented technology that is incorporated into our SilverCoat Foley provides superior protection for patients at risk of developing a CAUTI,” said Brian Pedlar, CEO of Covalon. “With up to 25% of the patients hospitalized in the United States catheterized and annually over 500,000 patients with indwelling catheters developing an infection, we believe the opportunity for Covalon’s SilverCoat Foley to make a strong clinical impact is

compelling.” A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. Among hospital acquired UTIs, approximately 75% are catheter associated, with the most important risk factor for developing CAUTI being prolonged use of the urinary catheter, as indicated in between 15%–25% of hospitalized patients. Image: The SilverCoat silicone Foley catheter (Photo courtesy of Covalon).

Bilirubin May Provide Protection Against Heart Attacks new study suggests that unconjugated bilirubin (UCB), an endogenous antioxidant, may protect the heart against ischemia reperfusion injury. Researchers at Griffith University (Nathan, Australia; www.griffith.edu.au) conducted a study in isolated Langendorff perfused hearts to test whether pre- or post-ischemic treatment with bilirubin ditaurate (BRT) improves post-ischemic functional outcomes and myocardial oxidative damage. The isolated, ex-vivo rat hearts were treated with 50 M of BRT for 30 minutes before or after zero-flow ischemia. Functional outcomes were monitored, with myocardial damage estimated from creatine kinase efflux, infarct size, and left ventricular lipid/protein oxidation. The results showed significant cardioprotection upon BRT treatment, with post-ischemic recoveries for left end-diastolic pressure and left ventricular developed pressure, (LVDP) significantly enhanced

in the treated groups; myocardial infarction (MI) was also significantly reduced with BRT treatment. According to the researchers, the significant reductions in infarct size and lipid and protein oxidation indicate a mechanism related to protection from oxidative damage and point toward the potential of this molecule as a post-MI treatment. The study was published in the January 2016 issue of the International Journal of Cardiology. “Inflammation is the main culprit of damage to the body, and is caused by over-active white blood cells that release free radicals. It appears our natural bilirubin can protect from these free radicals during chronic inflammatory diseases like cardiovascular disease, kidney disease, and diabetes,” said lead author Andrew Bulmer, MD. “We believe that this protection could be related to recently identified anti-oxidative property of the bilirubin molecule.” “The findings could have positive implications for reducing health risks and improving life ex-

pectancy as a result of increasing the bilirubin concentration in people who have low levels of the pigment in blood,” added Dr. Bulmar. “Not only is there a benefit in being able to use bilirubin as a biomarker for measuring people’s future risk of various chronic diseases, there is a very real possibility it could be used as a treatment after a heart attack to reduce damage to the heart and possibly improve survival.” Bilirubin is the yellow-pigmented breakdown product of heme catabolism, caused by the body’s clearance of aged red blood cells (RBCs), which contain hemoglobin. It is excreted in bile and urine, and elevated levels may indicate certain diseases. Bilirubin is responsible for the yellow color of bruises and the yellow discoloration in jaundice. It is also responsible for the brown color of feces, via its conversion to stercobilin, and the background straw-yellow color of urine via its breakdown product, urobilin. HospiMedica International April/2016

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BLOOD PRESSURE MONITOR

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Rigel Medical

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ZOLL

The VenTest 800 measures flow, pressure, temperature, and O2 concentrations bi-directionally, and is compatible with 13 gas standards and 7 gas types. The three-model range includes a standard analyzer for use with all standard ventilators, as well as anesthesia machines and spirometers.

The Oscar 2 with SphygmoCor Inside uses motion-tolerant technology to eliminate ambulation and noise artifacts that cause failed readings and the need for repeated studies. User-friendly software allows data to be exported directly to a computer database for analysis and interpretation.

The TGXP system consists of the Thermogard XP console and a multiballoon heat-exchange catheter. As cool or warm saline circulates through the catheter, it quickly cools or warms the patient as venous blood passes over the balloons, without infusing saline into the patient.

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Kangaroo Mother Care Improves Neonatal Outcomes new study demonstrates that kangaroo mother care (KMC) is associated with reduced mortality among infants of any birth weight or gestational age. Researchers at the Harvard School of Public Health (HSPH; Boston, MA, USA; www.hsph.harvard.edu) conducted a systematic review and meta-analysis of observational studies through April 2014 that examined the relationship between KMC and outcomes among infants of any birth weight or gestational age. Studies with fewer than ten participants, lack of a comparison group without KMC, and those not reporting a quantitative association were excluded. Two reviewers then extracted data from 124 studies that met criteria on risk of bias, KMC intervention, neonatal outcomes, and relative risk (RR). The researchers found that KMC correlated with 36% lower mortality among low birth weight newborns, compared with conventional care. KMC also correlated with reduced risks of neonatal sepsis, hypothermia, hypoglycemia, and hospital readmis-

sion, as well as with increased exclusive breastfeeding. KMC was also associated with lower mean respiratory rate and pain measures in newborns and with higher oxygen saturation, temperature, and head circumference growth. The study was published online on December 23, 2015, in Pediatrics. “KMC is protective against a wide variety of adverse neonatal outcomes and has not shown evidence of harm,” concluded lead author Ellen O. Boundy, ScD, and colleagues. “This safe, low-cost intervention has the potential to prevent many complications associated with preterm birth and may also provide benefits to full-term newborns.” KMC was introduced in 1978 by Edgar Rey Sanabria, MD, in Bogotá (Colombia) as an alternative to incubators for low birth weight infants. KMC has four components: early, continuous, and prolonged skin-to-skin contact (SSC) between the newborn and mother; exclusive breastfeeding; early discharge from the health facility; and close follow-up at home. It is thought to improve neonatal

outcomes by maintaining the infant’s temperature and other vital sign parameters through SSC and by providing the benefits of breastfeeding. These effects are considered beneficial for all newborns, but may be especially advantageous for preterm infants. Image: Kangaroo mother care has shown many positive benefits for infants of any birth weight or gestational age (Photo courtesy of babiesideas.net).

Nasal Spray Effective in Hypoglycemia Rescue n intranasal glucagon spray is as good as injectable glucagon for treating hypoglycemia in patients with type 1 diabetes, according to a new study. Researchers at the University of Pennsylvania (Philadelphia, PA, USA; www.upenn.edu), Yale University (New Haven, CT, USA; www.yale.edu), and other institutions conducted a randomized crossover non-inferiority study involving 75 adults volunteers with type 1 diabetes (mean age 33 years, with diabetes for a median of 18 years). Study participants underwent two glucagon-dosing visits, scheduled 1-4 weeks apart. In the first visit they were randomly assigned to receive either 3 mg of intranasal glucagon or 1 mg of intramuscular glucagon, with the other preparation given during the second visit in a crossover fashion. Each visit was conducted after an overnight fast, following which the investigators induced hypoglycemia by an infusion of insulin. Once glucose con-

centration dropped to less than 60 mg/dL, the insulin infusion was stopped. Five minutes later, the investigators administered the glucagon, and collected blood samples for glucose at regular intervals for 90 minutes. Insulin levels were measured upon administration of glucagon and 30 and 60 minutes afterward. The investigators also assessed hypoglycemic symptoms at baseline and at regular intervals. The results showed that success criteria were met in all the intramuscular and in all but one of the intranasal administrations; in the one initially unsuccessful intranasal case, success criteria were reached at 40 minutes instead of the pre-specified 30 minutes. The rise in glucose concentrations after intranasal glucagon lagged behind that of intramuscular by about 3 minutes. Symptoms of hypoglycemia were greater in the intranasal group for the first 45 minutes after administration but were similar after that, while plasma insulin levels were

similar in both groups. The study was published on December 17, 2015, in Diabetes Care. “A needle-free intranasal preparation is likely to be preferred due to its relative simplicity compared with injectable formulations, particularly since individuals who must administer rescue glucagon are usually not trained medical professionals,” said lead author Michael Rickels, MD, of the University of Pennsylvania. Glucagon is a peptide hormone produced naturally by alpha cells of the pancreas that raises the concentration of glucose in the bloodstream. Its effect is opposite that of insulin, which lowers the glucose concentration. As a result, glucagon and insulin are part of a feedback system that keeps blood glucose levels at a stable level. The intranasal glucagon used in the study came in a single-use device designed to shoot a dry powder up the nasal passages when a plunger is depressed. HospiMedica International April/2016

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Critical Care

Intelligent Dressing Colorimetrically Detects Wound Pathogens prototype hydrogel wound dressing emits a fluorescent light when coming in contact with prevalent pathogens found within wound biofilms. The dressing, developed by researchers at the University of Bath (United Kingdom; www.bath.ac.uk) and Queen Victoria Hospital (QVH; East Grinstead, United Kingdom; www.qvh.nhs.uk), is made of a hydrated agarose film in which vesicles containing the fluorescent dye were mixed with agarose and dispersed within the hydrogel matrix. Static and dynamic models of wound biofilm growth in clinical strains of Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Enterococcus faecalis, were then established on a nanoporous polycarbonate membrane. The dressing’s response to the different biofilms was then evaluated. The researchers found a clear fluorescent response within four hours of the initial inoculation of the biofilm, but for an established

biofilm produced by a pathogenic strain, the response was within minutes. The sensitivity of the dressing to the biofilms was dependent on the species and strain types of the bacterial pathogens involved, but a relatively higher response was observed in strains considered good biofilm formers. There was also a clear distinction in the levels of dressing response, wherein dressings that were tested on bacteria grown in biofilm or in planktonic cultures responded differently, suggesting that the level of expression of virulence factors is dependent on the growth mode. The researchers also demonstrated the efficacy of the wound dressing in an ex vivo porcine skin model of burn wound infection. The study was published in the October 22, 2015, issue of ACS Applied Materials & Interfaces. “All wounds have some bacteria; whilst they are kept in check by immune clearance this is not a problem, but when bacteria start to form

biofilms and critically colonize the wound, pathogenic changes can result,” said senior author Toby Jenkins, PhD, and colleagues. “The early detection of wound infection in situ can dramatically improve patient care pathways and clinical outcomes. Our dressing will measure this critical colonization point.” A biofilm is any group of adherent microorganisms that are embedded within a self-produced matrix of extracellular polymeric substance

(EPS), a conglomeration generally composed of extracellular DNA, proteins, and polysaccharides, which is also referred to as slime. The microbial cells growing in a biofilm are physiologically distinct from planktonic cells of the same organism, which float or swim in a liquid medium. Image: The intelligent hydrogel wound dressing (Photo courtesy of the University of Bath).

App-Based System Monitors Pacemakers Remotely atients with a Medtronic (Dublin, Ireland; www. medtronic.com) pacemaker can now confirm functionality using their using their own smartphone or tablet. The MyCareLink Smart Monitor is comprised of a handheld pacemaker device reader and the MyCareLink Smart Monitor application, available for free on both Android and Apple platforms. The patient first places the reader over the location of the implanted pacemaker. Data is then extracted from the device – including from a cardiac resynchronization therapy pacemaker (CRT-P) – via Bluetooth. The reader sends this information to the Smart Monitor app, which relays it via cellular or Wi-Fi services to the Medtronic CareLink Network, where it is uploaded to their medical record. In addition to sending pacing information from their pacemakers to their physicians or clinics, patients using the MyCareLink Smart Monitor can also confirm the date of their most recent transmission of pacemaker information; create a personalized profile on the MyCareLink Connect Website; and receive email, text messages, or app notifications

HospiMedica International April/2016

to confirm their data transmissions. The app can only be used with a MyCareLink Smart Reader, which is prescribed by the patient’s doctor. “The use of smart technology continues to grow among people of all ages, and especially among people over 65, which is the age range of the majority of our pacemaker patients. Patients that are engaged with their disease, and engaged more fully, they have better outcomes,” said Darrell Johnson, general manager of the connected care business at Medtronic. “This is really a combination of giving patients the data to help them live on a daily basis with their cardiovascular disease as well as connect them to a healthcare system to prevent costly ER visits and hospital admissions.” “Remote monitoring of pacemakers and other cardiac devices is now the standard of care, as studies have established how it benefits patients – including faster diagnoses and increased survival – as well as how it helps physicians manage their pacemaker patients through increased efficiency and convenience,” said electrophysiologist George Crossley III, MD, of the Vanderbilt Heart and Vascular Institution (Nashville, TN, USA). LINKXPRESS COM

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Critical Care

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New Treatment Option for Alleviating Chronic Pain ovel spinal cord stimulation (SCS) system prioritizes convenience and comfort, helping patients shift focus from their chronic pain therapy toward their quality of life. The Proclaim Elite SCS System is designed to offer pain relief without disruptions, since it involves no external wires, wands, or recharging. With the aid of a programmer application, clinicians can adjust patient’s SCS therapy using an Apple (Cupertino, Ca, USA; www.apple.com) iPad mini digital device. In addition, patients can evaluate their SCS therapy using the proprietary Invisible Trial System, a discreet, app-based and wireless neuromodulation programming system that leverages Apple iPod touch mobile digital devices. The system improves patient convenience by removing the burden of regularly recharging the neuromodulation device, while an upgradable platform allows patients to access future SCS technology upgrades, such as new stimulation waveforms and software updates, without surgical device replacement. The system is also compatible with magnetic resonance imaging (MRI), which will allow patients to safely undergo head and extremity scans. The Proclaim Elite SCS System is a product of St. Jude Medical (SJM; St. Paul, MN, USA; www.sjm.com), and has been approved by the US Food and Drug Administration (FDA).

“The new St. Jude Medical Proclaim Elite system bridges the gap between today’s state-of-the-art therapies and tomorrow’s groundbreaking innovations for chronic pain,” said Allen Burton, MD, medical director of neuromodulation at St. Jude Medical. “The wireless platform is based on the latest Apple technologies, making it upgradeable to new therapies for the future. With a discreet, hassle-free trial system and a simple permanent implant procedure, this pioneering platform can improve both the patient’s chronic pain and overall therapy experience.” “In the last 10 years of SCS, we have seen advances in rechargeable technology, but less attention paid to therapy compliance and how patients interact with their device,” said Timothy Deer, MD, President and CEO of The Center for Pain Relief (Charleston, WV, USA). “Now with the Proclaim Elite SCS system we can offer appropriate patients an optimal low-maintenance experience while enabling access to future therapies without the need for additional surgeries.” SCS generates electrical pulses that mask or in-

terrupt pain signals as they travel to the brain, thus reducing pain sensation. Traditionally, SCS uses equally spaced electrical pulses to replace pain with a tingling sensation similar to paresthesia. SCS is used mostly in the treatment of failed back surgery syndrome, complex regional pain syndrome, and refractory pain due to ischemia. Image: The Proclaim Elite SCS system (Photo courtesy of St. Jude Medical).

Hypertension Treatment Beneficial Irrespective of Baseline BP reatment to lower blood pressure (BP) levels reduces the risk of major cardiovascular disease (CVD) events regardless of initial BP, according to a new study. Researcher at the University of Oxford (United Kingdom; www.oxford.ac.uk), the University of Sydney (Australia; sydney.edu.au), and other institutions affiliated with the George Institute for Global Health (Sydney, Australia; www.georgeinstitute.org) conducted a systematic review and metaanalysis of large-scale BP lowering trials published between Jan 1, 1966, and July 7, 2015. In all, a total of 123 studies with a minimum of 1,000 patient-years of follow-up were included, involving 613,815 participants. The results showed that every 10 mmHg reduction in systolic BP significantly reduced the risk of major CVD events, coronary heart disease (CHD), stroke, and heart failure. In trials with higher and lower mean baseline systolic BP, similar proportional risk reductions were observed, with an overall 13% reduction in allcause mortality; the effect on renal failure, however, was not significant. The researchers found no clear evi-

dence for variation in proportional risk reduction in major CVD based on baseline disease history, with the exception of diabetes and chronic kidney disease (CKD), which correlated with smaller risk reductions. From a disease management point of view, different classes of drugs to treat BP showed varying effects. For example, β-blockers were found to be inferior for the prevention of major CVD events, stroke, and renal failure, while calcium channel blockers were superior to other drugs for stroke prevention. The study was published on December 23, 2015, in the Lancet. “Blood pressure lowering significantly reduces vascular risk across various baseline levels and co-morbidities,” concluded lead author Dena Ettehad, MSc, of Oxford University, and colleagues of the George Institute for Global Health. “Our results provide strong support for lowering blood pressure to systolic blood pressures less than 130 mmHg and providing blood pressure lowering treatment to individuals with a history of cardiovascular disease, coronary heart disease, stroke, diabetes, heart failure, and chronic kidney disease.” HospiMedica International April/2016

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Critical Care

Revascularization Before Exercise Improves Walking in PAD Patients new study shows that endovascular revascularization followed by supervised exercise results in greater improvements among patients with peripheral artery disease (PAD) and intermittent claudication. Researchers at Erasmus University Medical Center (Erasmus MC; Rotterdam, The Netherlands; www.erasmusmc.nl), Elkerliek Hospital (Helmond, the Netherlands; www.elkerliek.nl), and other Dutch hospitals conducted a randomized clinical trial involving 212 patients who were allocated to ei-

Hospital Sepsis Program Lowers Death Rates and Costs novel sepsis detection and management program helps decrease intensive care unit (ICU) and inpatient death rates and costs, according to a new study. Researchers at Houston Methodist Hospital (HMH; Houston, TX, USA; www.houstonmethodist.org) implemented the sepsis program in 2008 to help with the early recognition of patients showing signs of possible infection. The interventions implemented consisted of four components: organizational commitment and databased leadership; development and integration of an early sepsis screening tool into the electronic health record (HER); creation of specific screening and response protocols; and education and training of nurses. The program called for daily screenings of patients on targeted units by bedside nurses, and nurse practitioners initiated definitive treatment as indicated. The results showed that by the third year of the sepsis program, 33% of inpatients were screened (56,190 screens in 9,718 unique patients), up from 10% in the first year. Inpatient sepsis-associated death rates decreased from 29.7% in the preimplementation period (2006–2008) to 21.1% after implementation (2009–2014). Death rates and hospital costs for Medicare beneficiaries also decreased from pre-implementation levels. According to the researchers, the main factors in the program’s success are a focus on all inpatients, not just patients in the ICU; the goal of identifying sepsis early, before it progresses to severe sepsis and septic shock; that nurses are the frontline implementers of screening and response protocols; the intensive simulation training that second-responder nurses undergo; and seamless integration of the screening tool into the hospital’s HER, supporting bedside patient care. The study was published in the November 2015 Issue of the Joint Commission Journal on Quality and Patient Safety. “Sepsis is a leading cause of death, but evidence suggests that early recognition and prompt intervention can save lives. In 2005 Houston Methodist Hospital prioritized sepsis detection and management in its ICU,” said lead author Stephen Jones, MD, MSHI. “In late 2007, because of marginal effects on sepsis death rates, the focus shifted to designing a program that would be readily used by nurses and ensure early recognition of patients showing signs suspicious for sepsis, as well as the institution of prompt, evidence-based interventions to diagnose and treat it.”

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ther endovascular revascularization plus supervised exercise (106 patients), or supervised exercise alone (106 patients); the patients were followed for up for 12 months. The primary end point was the difference in maximum treadmill walking distance at follow-up between the two groups. The results showed that combined endovascular revascularization and supervised exercise was associated with greater improvement in maximum walking distance (1,237 meter improvement), compared with the supervised exercise only group (955 meters), as well as in pain-free walking distance (1,120 meter versus 712 meter improvement, respectively). The combination therapy group also demonstrated significantly greater improvement in health-related quality-of-life (QoL) scores. The study was published in the November 10, 2015, issue of Journal of the American Medical Association (JAMA). “The present study reopens the debate for revas-

cularization in patients with claudication, in particular in terms of an approach using endovascular revascularization first,” concluded senior author Prof. Myriam Hunink, MD, PhD, of Erasmus MC, and colleagues. “By improving lower extremity blood flow, early percutaneous revascularization of the target lesion gives an impulse to patient mobility and quality of life in the short-term. This, in turn, facilitates subsequent exercising and allows the patient to profit from the long-term benefits of an additional supervised exercise program.” Intermittent claudication is the classic symptomatic form of PAD, affecting approximately 20–40 million people worldwide and increasing rapidly with the aging world population. Patients with claudication experience significant functional disability, often resulting in a sedentary lifestyle and reduced QoL. Supervised exercise is recommended as a firstline treatment.

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ULTRASOUND

PULMONARY IMAGING SEQUENCE

Agfa HealthCare

Mindray

Toshiba Medical Systems

The DR 600 is designed to provide high-quality images, while maximizing productivity and versatility. Key features of the fully automated system include a pre-programmed MUSICA workstation exam tree, automated MUSICA image processing, and seamless integration with RIS and PACS.

The Resona 7 enhances ultrasound image quality by zone acquisition and channel data processing. The gesture-based, multi-touch system improves clinical research with V Flow for vascular hemodynamic evaluation, and an intelligent plane acquisition from 3D dataset for fetal CNS diagnosis.

The Ultrashort Echo Time (UTE) allows clinicians to capture images in tissues that generally disappear too quickly for accurate MR imaging. The UTE is available on the Vantage Titan 3T MR system, and enables reliable imaging of anatomy such as the lungs.

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Clearance for CT Scanners For Low-Dose Lung Cancer Screening he US Food and Drug Administration (FDA) have approved the use of a leading imaging equipment provider’ CT scanners for lung cancer screening using standard low-dose lung protocols. The FDA approval for the use of Computed Tomography (CT) as a screening tool is a milestone for CT as a modality, making it available for the first time as a screening tool for a subset of high-risk asymptomatic patients, and could save the lives of patients by enabling earlier diagnosis of lung cancer. Siemens Healthcare (Erlangen, Germany; www.healthcare.siemens. com) now offers a comprehensive approach to low-dose lung cancer screening using its new and current installed base of CT scanners, with standard low-dose lung protocols. The FDA indication for low-dose lung cancer screening applies to the SOMATOM Force, SOMATOM Definition Flash, SOMATOM Definition

Edge, SOMATOM Definition AS/AS+, SOMATOM Perspective, SOMATOM Scope, and the SOMATOM Emotion 16 CT systems. Siemens CT systems feature Fully Assisting Scanner Technologies (FAST) planning to reduce user variability, optimize workflow and reproducibility, and set optimum range for scan settings avoiding cut-offs, or excessive radiation. The Combined Applications to Reduce Exposure (CARE) feature optimizes radiation dose in scan parameters making the clinical workflow more efficient. Other features help radiologist report dose and sharing findings in an interdisciplinary lung cancer team. Siemens has also launched a mobile imaging solution for lung cancer screening, the Mobile SOMATOM Scope CT system. The scanner is a self-powered mobile CT system using a diesel generator, and can begin scanning within minutes. The Mobile SOMATOM Scope CT also features a

high-speed wireless connection. David Pacitti, president, Siemens Healthcare North America, said, “Lung cancer screening represents one of the most significant opportunities to improve population health through earlier detection and improved follow-up opportunities for high-risk patients. That’s why

Siemens pursued the most expansive indication for lung cancer screening, bringing this valuable tool to all varieties of our current SOMATOM CT scanners.” Image: The SOMATOM Definition Edge computed tomography (CT) scanner (Photo courtesy of Siemens Healthcare).

Endoscopic Ultrasound Platform Unveiled n innovative ultrasound endoscopic imaging platform uses new ultrasound signal acquisition and detection technologies to provide high-resolution anatomical detail, image quality and display. The ARIETTA Endoscopic ultrasound platform was developed by Hitachi Medical Systems Europe (Zug, Switzerland; www.hitachi-medical-systems. eu) and Pentax Medical (Tokyo, Japan; www. pentaxmedical.com). Hitachi Medical also manufactures high-field Magnetic Resonance Imaging

(MRI) systems, multi-slice Computed Tomography (CT) scanners, and medical ultrasound systems. Hitachi Medical ultrasound expertise includes applications for radiology, obstetrics and gynecology, urology, internal medicine, cardiology, gastroenterology, and surgery. The ARIETTA platform uses the Pentax EUS ultrasound scopes, which are part of an extensive range of user-specific ultrasound transducers that Pentax Medical produces. The ARIETTA platform uses flexible advanced algorithms to enable precision control of the ultrasound

beam, and achieve the highest possible spatial resolution. The ultrasound-specific digital signal processors use advanced data processing techniques, and support a wide range of applications. The platform uses IPS-Pro LCD monitors, and highly sensitive CE-EUS scopes, and can provide Real-time Tissue Elastography (RTE), and contrast enhanced ultrasound images. The High Tissue Reduction Mode – TrC (Amplitude Modulation) provides highly sensitive contrast, depth penetration, reduction in movement artifacts, and uniform near field, and far field imaging. HospiMedica International April/2016

Image Analysis Technique Provides Enhanced Treatment Assessment for Liver Cancer study presented at the annual Radiological Society of North America (RSNA 2015) meeting in Chicago USA has shown that a novel MRI analysis technique can significantly speed up the assessment of the effectiveness of liver cancer treatment compared to existing methods. Hepatocellular Carcinoma (HCC) is the second most deadly cancer worldwide and treatment consists of an image-guided procedure called Transarterial Chemoembolization (TACE). During the procedure chemotherapeutic drugs are delivered to the tumor while at the same time the blood supply to the tumor is blocked. If a patient does not respond to TACE treatment the clinician needs treat them again, or change their therapy, as rapidly as possible. Infiltrative HCC is very difficult to treat after TACE with traditional methods because of the large number of lesions and their ill-defined borders. The researchers used a new approach developed together with Philips Research North America (Cambridge, MA, USA; www.research.philips.com/ locations/briarcliff.html), called the quantitative European Association for the Study of the Liver (qEASL) technique. The new 3D technology provides whole liver volumetric enhancement quantification on Magnetic Resonance Imaging (MRI) and enables a radiologist to segment and delineate an entire tumor in 15–20 seconds in a semi-automated process. The researchers assessed 68 liver cancer patients with infiltrative HCC, using the qEASL technique, before their first TACE procedure, and again one month after the procedure. The researchers measured treatment response, and predicted survival, and segmented the entire liver of the patients while identifying tumors. The researchers found that responders had an overall survival rate of around 21 months and a mean 57.8% decrease in enhancing volume. Non-responders had a survival rate of 6.8 months and a 19.1% increase enhancing volume on average. According to the researchers, the qEASL approach can also be used with modalities such as cone-beam Computed Tomography (CT), Multidetector CT (MDCT), and Single-Photon Emission Computed Tomography (SPECT), and has also been validated for benign brain, and uterine lesions, and might also be applicable for systemic therapy. Coauthor of the study, Julius Chapiro, MD, Yale University School of Medicine, said, “In clinical oncology, it is very challenging to assess tumor response to treatment. Up until now, we could measure the extent of tumor diameter or uptake with manual tools like the caliper on the screen, which are highly unreliable due to reader bias. The radiologist can segment the entire tumor with the assistance of the computer. It’s a work-flow efficient, semi-automated process that takes 15 to 20 seconds to segment and allows you to delineate the tumor in 3D. The findings show that quantitative tumor enhancement is possible with 3-D qEASL and can predict survival after TACE for infiltrative and multifocal HCC. qEASL is not a diagnostic tool but rather a means of comparing differences before and after treatment to identify non-responders. The earlier the non-responders are identified and treated, the better their outcomes.”

Image: Liver images from before and after treatment. The bottom right image shows that less cancer is visible after treatment (Photo courtesy of RSNA).

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PRODUCT NEWS PORTABLE ULTRASOUND

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PET/CT SYSTEM

RESPIRATORY IMAGING SYSTEM

FujiFilm SonoSite

Neusoft Medical Systems

PneumaCare

The SonoSite Edge II is designed with emergency medicine and critical care applications in mind, and features a design intended to enhance infection control management and efficient use of common controls. It offers a wide-angle display with a 33 percent increase in viewing angles.

The NeuSight PET/CT combines anatomic and functional imaging with qualified design and technology for tumor, brain and heart scanning. Key features include a large port and dual pillar bed to improve patient comfort, along with improved scan speed and accuracy for analysis.

The Thora-3DI is designed to show respiratory function in real time and divide that performance data into various regional assessments for comparison. The NIV system does not require any direct interaction with the patient, allowing them to be sitting, lying, conscious or unconscious.

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Antibody Cancer Marker Causes Tumors to Light Up novel marker attaches to a molecule on highly aggressive brain cancer, resulting in glioblastoma tumor tissue being easily identified in a positron emission tomography (PET) scanner. Developed by researchers at the University of Wisconsin (WISC; Madison, USA; www.wisc.edu) and the Third Military Medical University (Chongqing, China; www.tmmu. edu.cn), the antibody created is specific to a unique protein, called CD146, that is present on the surface of glioblastoma multiforme cancer cells; the antibody was joined to a copper isotope to create a radio-labeled anti-CD146 antibody (YY146). The researchers then implanted a human glioblastoma sample into a mouse and injected the antibodymarker combination into its blood, waiting for it to spread through the body. When the mouse was later placed into a PET scanner, the tumors with a high level of CD146 protein on the outside of their cells were easily iden-

tified. In comparison, signals from a genetically distinct variant of glioblastoma with low CD146 activity were much weaker. In their study, the researchers also explored the potential therapeutic effects of YY146 on cancer stem cell (CSC) and epithelialto-mesenchymal (ETM) properties of glioblastoma cells, demonstrating that it can mitigate aggressive U87MG phenotypes. The researchers also demonstrated that YY146 could be used to detect CD146 in cancer cell lines and human resected tumor tissues of multiple other origins, such as in gastric, ovarian, liver, and lung tissues. These findings, according to the researchers, indicate a broad applicability of the YY146 marker in solid tumors, including for diagnosis, stratification, and targeted therapy. The study was published on November 9,

2015, in Proceedings of the National Academy of Sciences of the United States of America (PNAS). “Most methods generate antibodies that recognize short fragments of the target protein, whereas our antibody recognizes the target in the biologically active form. So the antibodies can be readily used in living subjects, such as the animal models in this study and potentially in patients,” said senior author associate

professor of radiology Weibo Cai, PhD, of WISC. “If the technique proves out in further tests, it could be used to diagnose some strains of aggressive glioblastoma, and also to evaluate treatment progress or even to test potential drugs.” Image: A glioblastoma in a PET scanner with (left) and without (right) the YY146 marker (Photo courtesy of Weibo Cai, WISC).

fMRI Scans Can Predict Recurrence of Depressive Episodes new study shows that Functional Magnetic Resonance Imaging (fMRI) could help predict whether patients risk a recurrence of depressive episodes after recovery from a major depressive disorder. The study was carried out by researchers from King’s College London (London, UK; www.kcl.ac.uk) and The University of Manchester (Manchester, UK; www.manchester.ac.uk) and was published in the journal JAMA Psychiatry. In the study the researchers carried out fMRI scans on 64 patients, who were not on prescribed medication, and were in remission from major depressive disorder, to look for atypical connections in

the brain. The study participants’ brains were scanned while they experienced guilt or other selfblaming emotions, and were monitored regularly for symptoms over the following 14 months. By the end of the study 27 participants had a recurrence of the depression, while 37 participants remained in remission. Those participants with a recurrence of depression showed a higher level of connection between the anterior temporal lobe and the sub-genual region of the brain, in the fMRI scans. On the other hand those who remained in remission for a year and a control group of 39 people did not have the increased interconnectedness. The results of

the study enabled the researchers to accurately predict (75%, 48 out of 64 cases) who would have another depressive episode. Dr. Kathryn Adcock, head of neurosciences and mental health, MRC, said, “This exciting research has the potential to help identify those individuals who are more likely to suffer from recurrent episodes of depression and will therefore benefit most from long-term treatment and medication. This work could aid the discovery of new treatments for depression because clinical trials will be better able to focus on people with a more comparable disorder and experience.” HospiMedica International April/2016

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Medical Imaging

Total MRI Imaging Helps Detect Prostate Cancer new approach to magnetic resonance imaging (MRI) can assist in the detection of prostate cancer without using an invasive endorectal probe. Developed at Hospital San José Tec (Monterrey, Mexico; www.hsj.com.mx), the new approach replaces the standard endorectal MRI coil with a surface coil placed on the pelvis, like a collar. By using only external body coils, the technique offers more comfort to the patient, with a reliability that appears to be comparable to the invasive approach. The new approach is available due to the high element density of Siemens Healthcare (Erlangen, Germany; www. healthcare.siemens.com) total imaging matrix (TIM) technology, which provides excellent signal-

CT Angiograms Outperform Ergometrics in Detection of Blocked Arteries new study shows that noninvasive computerized tomography (CT) scanning of cardiac vessels is far better at spotting coronary artery disease (CAD) than commonly prescribed exercise stress tests. Researchers at Johns Hopkins University (JHU; Baltimore, MD, USA; www.jhu.edu), St. Luke’s International Hospital (Tokyo, Japan; http:// hospital.luke.ac.jp), and other institutions conducted a study to compare the accuracy of single-photon emission computed tomography (CT)–acquired myocardial perfusion imaging (SPECT-MPI) and coronary CT angiography (CTA) for the diagnosis of CAD in 391 symptomatic patients who were prospectively enrolled in 16 hospitals in eight countries, after clinical referral for cardiac catheterization. All the patients (ages 45–85) underwent noninvasive SPECT-MPI angiograms, followed by traditional CTA; within two months, each patient also underwent an exercise stress test. The results showed that sensitivity to identify CAD was greater for CTA than SPECT-MPI; the results were similar in patients without previous history of CAD. Noninvasive CTA accurately detected or ruled out artery blockages in 91% of the patients, compared with 69% for stress testing. The study was published online on October 14, 2015, in Circulation: Cardiovascular Imaging. “Results of the new study should help settle lingering doubts among physicians and the nearly 15 million Americans who seek medical attention each year for symptoms that signal a clogged artery, including chest pain, shortness of breath, and extreme fatigue,” said lead author Armin Zadeh, MD, PhD, MPH, associate professor of medicine at the JHU School of Medicine. Current guidelines from the American Heart Association (AHA; Dallas, TX, USA; www.heart.org) and the American College Cardiology (ACC) call for a stress tests in all patients who show signs of CAD to confirm the diagnosis and define the severity of the blockage. CT angiograms are generally reserved only for patients with borderline stress test results. However, according to the researchers, the much higher accuracy of CTA may be a better first-line test in people with symptoms suggestive of a blocked artery.

to-noise ratio (SNR). TIM represents a revolutionary addition to the traditional MRI process, using as many as 76 seamlessly integrated coil elements and 32 independent receiver channels to create a whole-body imaging matrix, supporting a total field of view of 205 cm. And while conventional metastases evaluation requires changing coils and repositioning the patient for each anatomical area of interest – head, thoracic, abdominal, pelvis, etc. – TIM simplifies the process and shortens examination times. Both the matrix coils and the patient need only be positioned once for all desired exams, as multiple channels allow a unique and almost unlimited scanning flexibility. “The shame experienced with a rectal examination of the prostate is particularly high in the Mexican and Latin American cultures. This holds true for a simple digital prostate exam as well as for more advanced diagnostic procedures like magnetic resonance imaging with the aid of a rectal probe,” said

Jorge Fernández de la Torre, MD, chief radiologist at Hospital San José Tec. “My mother died of cancer shortly after I started college. Watching her suffer really stirred up my emotions. I would like to save other people from a fate like hers.” The American Cancer Society (ACS) recommends that a discussion about screening should take place in men 50 years old who are at average risk of prostate cancer and are expected to live at least 10 more years; men aged 45 at high risk of developing prostate cancer, including African-Americans and men who have a first-degree relative diagnosed with prostate cancer at an early age (younger than age 65); and men aged 40 with more than one first-degree relative who had prostate cancer at an early age. Those screened should be tested with the prostate-specific antigen (PSA) blood test. A digital rectal exam (DRE) may also be done as a part of screening.

NE DES W IGN

HospiMedica International April/2016

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The MobileDaRt Evolution upgrades include a vibration-resistant solid-state drive, and a new energy-saving collimator with a bright irradiation field. Other upgrades include an LCD monitor with a wide viewing angle, and a 17 x 17-inch flat-panel display that boosts internal processing speed.

The MAGNETOM Amira 1.5T offers the potential to shorten many exams and enable many patients to undergo scans in routine applications. It features DotGO MRI exam software to simplify protocol management and offer the right operating sequence for each scan to suit requirements.

The RadPro Delinia 200 digital X-ray acquisition cart comes equipped with a computer, access point, touchscreen monitor, and detector holder. The user-friendly cart also offers users a choice of Canon CXDI-801C, CXDI-701C, or CXDI-401C wireless flat-panel DR detectors.

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Social Brain Functionally Impaired in Autism Spectrum Disorder novel imaging study shows that brain areas linked to social behavior are both underdeveloped and insufficiently networked in youths with high functioning autism spectrum disorder (ASD). Researchers the University of California Los Angeles (UCLA; USA; www.ucla.edu) conducted a study to investigate the neurobiological underpinnings of ASD. To do so, they used functional magnetic resonance imaging (fMRI) to assess resting cerebral blood flow (CBF) and functional connectivity (FC) of intrinsic brain networks in 17 youth with ASD and 22 matched typically developing children. The groups were matched by age (7 to 17 years old), gender, and IQ scores. The researchers utilized a novel MRI tool known as pseudo-continuous arterial spin labeling (ASL) perfusion with background suppression to magnetically label the water content of blood so that it could serve as a tracer to quantify brain blood flow. The re-

searchers also refined for the study an existing technology that assesses how well separate brain areas are functionally interconnected. Both techniques are noninvasive, requiring no injections of radioactive tracers. The results showed a pattern of altered resting perfusion in ASD children, including frontotemporal hyperperfusion and hypoperfusion in the dorsal anterior cingulate cortex. They also found increased local FC in the anterior module of the default mode network (DMN), accompanied by decreased CBF in the same area. Reduced long-range FC between anterior and posterior modules of the DMN in children with ASD was also demonstrated. These were associated with greater social impairments, as assessed with the social responsiveness scale (SRS) score. The study was published in the September 2015 online issue of Brain and Behavior. “The brain controls most of our behavior, and changes in how brain areas work and communicate

with each other can alter this behavior and lead to impairments associated with mental disorders,” said Kay Jann, PhD, a postdoctoral researcher in the UCLA department of neurology. “When you match physiologic changes in the brain with behavioral impairment, you can start to understand the biological mechanisms of this disorder, which may help improve diagnosis, and, in time, treatment.” “ASD might be caused by increased or decreased connectivity within specific neural networks that form the ‘social brain.’ This connectivity can be measured by the amount of blood flow and activity patterns between brain nodes, or neural networks,” added senior author associate Prof. Danny J. J. Wang, PhD. “One major brain network, the DMN, has become a focus of such research, because it is important for social and emotional processes, self-referential thought, and in ‘Theory of Mind,’ which is the ability to attribute mental states to one-self and to others.”

Metabolic PET Tracer Can Locate Brain Tumors and Improve Therapy Outcomes esearchers at the Stanford School of Medicine (Stanford, MD, USA; http://med. stanford.edu) have found a new way to visualize brain tumor tissue using Positron Emission Tomography (PET) imaging. Cancer cells divide rapidly, and require large stores of molecular building block to divide and grow. The Stanford team used this property of cancer cells, and developed a molecular tracer to track the activity of a key regulatory protein called pyruvate kinase M2 (PKM2) that helps control the metabolism of tumor cells. The tracer enabled the researchers to track the precise location of cancer cells in the brain. According to the researchers, the tracer could also help provide feedback about how a tumor is responding to therapy. Pyruvate kinase is a key regulator in the cellular process of metabolizing energy sources such as glucose. Cells can either convert energy into the co-enzyme Adenosine Triphosphate (ATP), or use the energy to generate amino acids and other cellular

building blocks. When pyruvate kinase exists as a dimer, a complex of two pyruvate kinase molecules, it favors the accumulation of amino acids. When the protein exists as four molecules bound together the cell generates more ATP. Cancer cells have higher levels of the dimer, and DASA molecules bind to the dimer. The researchers labeled DASA-23 molecules with a radioactive carbon molecule, and used PET scans observed how the DASA-23 molecules found, and bound to human glioblastoma cells, implanted in the brains of mice. The technique was able to highlight the brain cancer cells clearly among the normal, non-cancerous cells. The researchers expect the new [11C]DASA-23 tracer to be approved by the US Food and Drug Administration (FDA) for use in humans by Fall 2016. Sanjiv Sam Gambhir, MD, PhD, director Molecular Imaging at Stanford, senior author of the research, said, “Tumor cells do all kinds of things to survive and prosper in the body. One of the key

things they modify is a master switch that controls cell metabolism and allows the cell to make more of the building blocks necessary for cell division. But until now we’ve had no way to assess the presence or activity levels of the PKM2 protein involved in that switch. This is the first time we can noninvasively interrogate the biochemistry of a tumor with respect to this master switch PKM2. If we treat a tumor with a drug, we now see whether the cancer cells’ metabolic properties are changing. So we could know very quickly, possibly within a few days, whether the therapeutic approach is working. This new molecule, or tracer, works particularly well in the brain because normal brain cells have very low levels of PKM2 dimers. It’s possible, though, that this tracer could also be used in cancers in other tissues like the prostate, or to even learn more about how normal tissues adjust their metabolism during development or in response to varied environmental conditions.” HospiMedica International April/2016

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Medical Imaging

Twin Robotic X-Ray System Combines Care and Productivity he world’s first twin robotic X-ray scanner delivers a combination of high asset utilization, new clinical insights, and less patient positioning and transfers. The Siemens Healthcare (Erlangen, Germany; www.healthcare.siemens. com) Multitom Robotic Advanced Xray (Rax) offers radiology departments a comprehensive range of applications by integrating multiple X-ray capabilities in one room, thus improving asset utilization and saving on costs. Modalities include radiography, tomography, fluoroscopy, and angiography; multiclinical options, including trauma, orthopedic, intervention, pain management, and more; static, dynamic, and three-dimensional (3D) scanning; and multiple patient configurations. The two ceiling-mounted arms of the Multitom Rax can be moved into position automatically using robotic technology, and they can also be moved manually (servo motor supported) when required, such as for fine adjustment. One arm moves the X-ray tube and the large touchscreen control, while the other carries a 43

x 43 cm flat panel detector. Consequently, there is no need to reposition the patient or to change rooms for further imaging procedures, which makes examinations less painful and less time-consuming. Multitom Rax also offers Real 3D – the ability to perform X-ray examinations and diagnoses under natural weight-bearing conditions, such as in lying, sitting, and standing conditions, allowing comfortable patient positioning with an open design, while still maintaining low-dose protocols. Another comfort feature is that the scanner revolves around the patient utilizing an open, patient-centered design, resulting in less patient risks and pain due to fewer transfers and repositioning, especially important in pediatric, geriatric, bariatric, immobile, and trauma patients. The Siemens Multitom Robotic Advanced X-ray (Rax) also offers optional wireless, portable, detectors in two different sizes that can be positioned directly between a wheelchair or mattress and the patient’s back, which avoids the need to sit the pa-

Study: Accelerated Partial Breast Irradiation Can Treat Early-Stage Breast Cancer he results of a new prospective brachytherapy clinical study have been released. The randomized, multicenter phase III study evaluated 1,184 patients aged 40 years and older with a median age of 62, and compared treatment using Accelerated Partial Breast Irradiation (APBI) combined with interstitial multi-catheter brachytherapy to treatment using Whole Breast Irradiation (WBI). The study took place at 16 medical centers in six European countries – Austria, the Czech Republic, Germany, Hungary, Poland, Spain, and Switzerland. The study results were announced by the Groupe Européen de Curiethérapie – European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) and showed that overall survival, local and regional cancer control rates using APBI brachytherapy, after breast conserving surgery for those patients with early stage breast cancers, were equivalent to those using WBI. The researchers randomized the patients either to a standardized treatment arm (WBI, n=551), or an investigational treatment arm (APBI, n=633). Follow-up exams were

HospiMedica International April/2016

made for the patients every three months in the first 60 months, and then annually, with a median follow up of 6.6 years. Nine patients were treated with APBI, and five patients with WBI. All had a local recurrence after five years, equivalent to cumulative recurrence rates of 1.44% and 0.92% (p=0.42) respectively. Prof. Vratislav Strnad, MD, PhD, Department of Radiation Oncology, University Hospital, Erlangen, Germany, said, “GEC-ESTRO is the most comprehensive clinical study to date evaluating the efficacy of APBI brachytherapy alone versus traditional external whole breast irradiation. APBI brachytherapy is an attractive treatment approach with a high level of precision, versatility and flexibility. The benefits of APBI brachytherapy include an at least four-fold reduction in total radiation exposure to healthy surrounding tissue and nearby structures including the chest wall, heart, lungs or skin; preservation of future treatment options; and a notably shorter course of therapy – four or five days, compared to three or up to seven weeks for whole breast irradiation.”

Image: The Multitom Robotic Advanced X-ray (Rax) system (Photo courtesy of Siemens Healthcare)

tient up. Preprogrammed safety zones, an automatic stop in response to contact, and automatic control of the robotic arms that ensures that

they will always take the shortest and safest route to reach the next programmed position also improve safety.

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The AT4 is easy to use and ideal for single or bilateral orthopedic surgery and pain management. It operates from its own integral air supply, has built-in leak compensation facilities and automatic self-diagnostic checks on start up, which means it is calibrated every time it is turned on.

The ATS surgical table features a C-arm compatible table top with up to a 1,000 lb lift capacity. It is equipped with a 180-degree rotating tabletop to maximize patient imaging access, and can be adjusted to 24 inches from the floor to allow the surgeon better access for seated procedures.

The endoscopic (hysteroscopic) cannula is a single-use cannula for uterine observation pre- and post-surgery. Durable and water-resistant, it provides viewing of the entire uterine cavity, has a built-in optical system with suction tube, and connections for light source and dual monitors.

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Novel Thrombectomy Catheter Targets Deep Vein Thrombosis new thrombectomy catheter has been specifically designed to treat deep vein thrombosis (DVT) in large-diameter upper and lower peripheral veins. The AngioJet ZelanteDVT thrombectomy catheter is indicated for the disruption and removal of large venous clot burdens from iliofemoral and lower extremity veins greater than or equal to 6 mm in diameter, and upper extremity peripheral veins greater than or equal to 6 mm in diameter. The 8 F (2.7 mm) catheter is the largest and strongest thrombectomy catheter in the AngioJet portfolio, with four times the thrombus removal power of previous generation catheters, and is used in conjunction with the AngioJet Ultra Console. The 105 centimeters long thrombectomy catheter, which utilizes an over-the-wire guidewire and sheath for delivery, is torqueable and direction-

al, enabling rapid thrombus removal, and is also PowerPulse enabled for the infusion of physicianspecified fluids, including thrombolytic agents into the peripheral vascular system. The AngioJet ZelanteDVT thrombectomy catheter is a product of Boston Scientific (Natick, MA, USA; www.bostonscientific.com), and has been approved by the US Food and Drug Administration (FDA). “The new features of the ZelanteDVT catheter represent our focus on improving procedural efficiencies and reducing the economic burden associated with this challenging condition,” said Jeff Mirviss, peripheral interventions president at Boston Scientific. “With this addition to our AngioJet portfolio, we are further evolving the current suite of life-changing therapeutic options available to physicians and their patients with deep vein thrombosis.”

DVT commonly affects peripheral veins (such as the femoral vein, the popliteal vein, or the iliofemoral vein), and can occur without any symptoms. In many cases the affected extremity will be painful, swollen, red, and warm, and the superficial veins may be engorged. The most serious complication of a DVT is that the clot could dislodge and cause a pulmonary embolism (PE). DVT is a medical emergency and untreated lower extremity DVT has a 3% PE-related mortality rate. Image: The AngioJet ZelanteDVT thrombectomy catheter (Photo courtesy of Boston Scientific).

No Added Benefits for Full-Defrag Ablation for AF stepwise approach to ablation for persistent atrial fibrillation (AF) does not offer any benefits over pulmonary vein isolation (PVI) alone, according to a new study. Researchers at University Medical Center Hamburg-Eppendorf (UKE; Germany; www.uke.de), University Hospital Cologne (Germany; www. koelner-wissenschaftsrunde.de), and other institutions conducted a study involving 205 patients (151 men; mean age 61.7 years) who underwent de novo ablation for persistent AF. Subsequently, the patients were prospectively randomized to either PVI alone (78 patients), or full defragmentation ablation (75 patients), consisting of PVI, ablation of complex fractionated electrograms, and additional linear ablation lines. The remaining 52 patients were not randomized due to AF termination with the original PVI. The primary endpoint of the study was recurrence of any atrial tachycardia (AT) after a blanking

period of three months. The results showed that during the entire study, 241 ablations were performed. At 12 months, the incidence of AT was similar between recipients of PVI alone and those who underwent full defragmentation (8.2% versus 8.5%, respectively). Arrhythmia-free survival rates were also similar between groups, at 63.9% with PVI only and 57.7% with full defragmentation. The researchers also found, conversely, that despite the fact that the rate of major complications did not differ materially between groups, the full defragmentation arm suffered a 23.3% incidence of pericardial effusion with symptoms of pericarditis, compared with a much lower 5.3% incidence in their single-procedure counterparts. The study was published on December 22, 2015, in the Journal of the American College of Cardiology. “Pulmonary vein isolation should be the initial strategy in patients with persistent AF undergoing catheter ablation, because more extensive ablation

is associated with longer procedure duration, fluoroscopy, and radiofrequency exposure, without better rhythm control outcomes,” concluded lead author Julia Vogler, MD, of University Heart Center Hamburg, and colleagues. She added, however, that, “pulmonary vein isolation alone appears to be insufficient for treating persistent AF, with disappointing long-term results.” PVI is a catheter ablation technique developed to prevent focal triggers in the pulmonary veins from initiating episodes of AF. Although the procedure initially involved focal ablation with a catheter directly in the pulmonary veins, isolating the pulmonary veins by applying ablation energy at their junction with the left atrium is more effective. The PVI procedure is most suitable for patients whose recurring symptomatic episodes of AF have not been suppressed by anti-arrhythmic drugs, or who do not wish to take long-term anti-arrhythmic or anticoagulation medications. HospiMedica International April/2016

Mini-Sponge Wound Dressing Controls Hemorrhage syringe-like device injects a large number of tiny, rapidly expanding sponges into a wound cavity, quickly controlling bleeding when tourniquets are not an option. The XStat 30 device is a 30 mm diameter applicator shaped like a large syringe that holds 92 tablet-sized, mini-cellulose sponges that are coated with an absorbent hemostatic agent. Once injected into a bleeding wound, the compressed sponges expand when they come in contact with fluids, thus rapidly filling a volume substantially larger than that of their compressed state. Besides helping to provide hemostasis for up to four hours until surgery, the sponges also provide a surface on which blood clots can begin to form. The Xstat 30 is intended for use in patients at high risk for immediate, life-threatening and severe hemorrhagic shock and for use in non-compressible junctional wounds, such as the armpit or groin, or when definitive care at an emergency care facility cannot be reached within minutes. It is not indicated for use in the thorax, pleural cavity, mediastinum, abdomen, retroperitoneal space, sacral space, or in tissues above the clavicle. Since the

sponges are eventually removed, each has a tiny radiopaque marker that is visible on X-ray. The XStat 30 device, a product of RevMedx (Wilsonville, OR, USA; www.revmedx.com), will be marketed in packages of one or three applicators, each with a telescoping handle and a sealed valve tip; the telescoping mechanism allows the handle to be stored in a shortened state to maximize compactness. The number of sponges necessary to stop bleeding depends on the size and depth of the wound, with each applicator capable of absorbing about 570 mL blood, and with up to three applicators indicated for use on a given patient. “The majority of people with massive abdominal bleeding die before they reach the hospital,” said David King, MD, a trauma surgeon at Massachu-

Image: The XStat 30 device (Photo courtesy of RevMedX)

setts General Hospital (Boston, MA, USA). “Many of these deaths could be prevented if we were able to temporarily stabilize a patient long enough to reach a trauma center.”

Procedureless Gastric Balloon Promotes Weight Loss n innovative gastric balloon offers an alternative treatment option for overweight and obese individuals. The Elipse procedureless gastric balloon is a thin, flexible polymer film balloon that is delivered in a swallowable capsule, thus eliminating the need for surgery, endoscopy, or anesthesia. Once in position, it is filled with liquid through a thin delivery catheter, which is then detached by tugging. The gastric balloon remains in the stomach for four months, after which it automatically empties and is excreted naturally from the body. The Elipse will be offered by physicians in conjunction with a medically supervised diet and exercise program. The Elipse has undergone clinical studies in people with a body mass index (BMI) of 27-40 kg/m2. Study findings indicated an average weight loss of 10 kilograms, with participants losing 37% of their excess weight and eight centimeters off their waist circumference over the four-month treatment period. Participants also saw improvements in triglyceride and hemoglobin HbA1c levels, and all balloons were safely and naturally excreted. The Elipse procedureless gastric balloon is a product of Allurion Technologies (Wellesley, MA, USA; www.allurion.com), and has received the European Community CE marking of approval. “Excess weight often has a profound impact on health and quality of life, including work, relationships, and self-perception. But of nearly two billion overweight and obese adults worldwide, less than one percent have embraced currently available surgical and endoscopic options,” said Shantanu Gaur, MD, co-founder and chief scientific officer of Allurion Technologies. “Weight loss therapies that require surgery, endoscopy, or anesthesia are often too invasive and can be too expensive for people who might otherwise greatly benefit from them.”

HospiMedica International April/2016

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The BioMonitor 2 is intended for insertion under the skin of patients suffering from unexplained syncope, and to detect AF. It records all cardiac electrical events, with data transmitted directly to the physician, where they are given an accurate map of the heart’s activity on the computer screen.

The Blazer Open-Irrigated (OI) radiofrequency ablation catheter is designed for use in ablation procedures to restore a normal heart rhythm for patients in atrial flutter. It features Total Tip Cooling technology intended to cool the catheter tip consistently during the ablation procedure.

The spineEOS 3D planning software allows a surgeon to create a treatment plan to achieve improved sagittal alignment. The software takes into account the patient vertebrae shape and position in 3D. The expected surgical correction can be visualized and captured in a planning report.

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Optical System Illuminates Cardiac Ablation Procedures n optical tissue characterization system for use during cardiac ablation allows cardiologists to continuously “see” into heart tissue. The LuxCath system is intended for the treatment of all arrhythmias that require a cardiac ablation procedure, including atrial fibrillation (AF), atrial flutter, AV nodal reentrant tachycardia (AVNRT), and others. The optical technology is used to directly interrogate cardiac tissue with light prior to and during ablation in order to identify tissue contact, visualize lesions, and detect lesion gaps in real-time, all without using pressure sensors or ultrasound. The system delivers illumination and retrieves tissue fluorescence via an optical fiber with the intention of providing better tissue contact and lesion formation assessment during ablation to reduce procedure times, fluoroscopy times, arrhythmia recurrences, and costs. The LuxCath system is a product of LuxCath (Boston, MA, USA; www.luxcath.com) and can be utilized as a standalone catheter or as an embedded optical technology that can be integrated into an existing ablation catheter.

“The technology identified tissue contact and was easy to use in a wide variety of settings, and we were able to assess and monitor ablation lesions as they were being created. There were no complications,” said Vivek Reddy, MD, who led the first-in-man clinical trial in 11 arrhythmia patients at Homolka Hospital (Prague, Czech Republic) conducted during December 2015. “This is an exciting step forward in the world of ablation. Based on our experience, the technology platform is quite promising.” “We are thrilled with the performance of our optical tissue interrogation system for contact and lesion progression assessment,” said Omar Amirana, MD, CEO of LuxCath and senior vice president of its parent company, Allied Minds (Boston, MA, USA; www.alliedminds.com). “Given the potential to positively impact all ablation procedures, we are excited to advance the technology into the marketplace. This is an enormous milestone for the company.” AF occurs when the heart’s two upper chambers

beat erratically. In one form of the condition, paroxysmal AF, patients have bouts of erratic beats that begin spontaneously and usually last less than a week. AF and other arrhythmias can lead to serious adverse events such as thrombi travelling from the heart to obstruct arteries supplying the brain, causing stroke, or thrombi in other parts of the body, causing tissue damage. Image: The LuxCath optical tissue characterization system (Photo courtesy of LuxCath).

Bariatric Surgery Outcomes Affected by Vitamin D Status new study demonstrates a graded relationship between proxy measures of vitamin D (VitD) status and adverse outcomes following bariatric surgery. Researchers at Johns Hopkins University (JHU; Baltimore, MD, USA; www.jhu.edu) conducted a retrospective cohort study to investigate the association between adverse surgical outcomes following bariatric surgery when compared by season (Summer, Winter, and Fall/Spring), and latitude (Northern United States vs. Southern) as proxy measures of VitD status, based on the US nationwide inpatient sample (NIS). In all, 932,091 bariatric surgeries were identified (median age 43 years, 81.2% female, and 74.4% white), with most surgeries occurring in the North. The results showed that most adverse postop-

erative complications occurred in colder seasons with less sunshine. Adverse outcome rates ranged from wound infections (0.01%) to prolonged length of stay (LOS, 39.4%). Season was inversely associated with wound infection and dehiscence, and extended LOS was inversely correlated with season; the relationships held after adjustment for latitude. For example, around 16% of delayed wound healing cases occurred in summer, compared with 0.07% in winter. The study was published on December 14, 2015, in Obesity Science & Practice. “Sun exposure is critical in the synthesis of vitamin D, so the notion that people living in less sunny northern states may suffer from vitamin D deficiency is not surprising. What is remarkable is how closely sun exposure, vitamin D, and surgical out-

comes were linked,” said lead author nutritionist Leigh Peterson, PhD, MHS, of the JHU Centers for Bariatric Surgery. “The growing rates of obesity and increased popularity of bariatric surgeries mean that primary care clinicians and bariatric surgeons should consider screening their patients and correcting any confirmed vitamin D deficiency.” VitD is a group of fat-soluble secosteroids that the human body can synthesize with adequate sun exposure. VitD prevents rickets in children and osteomalacia in adults, and together with calcium, helps protect older adults from osteoporosis. It also affects neuromuscular function, inflammation, and the action of many genes that regulate the proliferation, differentiation and apoptosis of cells. Epidemiology has long used season and latitude as proxies for group VitD. HospiMedica International April/2016

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Surgical Techniques

Menopausal Status Should Guide Mammography Intervals new study suggests that menopause may be a more important indicator than age when determining breast cancer (BC) screening intervals. Researchers at the University of California Davis (UCD; USA; www.ucdavis.edu), the University of California, San Francisco (UCSF; USA; www.ucsf. edu), and other institutions conducted a prospective cohort study of 15,440 women (40–85 years of age) to compare the proportion of BC with less versus more favorable prognostic characteristics in women screening annually versus biennially by age, menopausal status, and postmenopausal hormone therapy (HT) use. The researchers defined less favorable prognostic characteristics as tumors that were stage IIB or higher, size greater than 15 mm, positive nodes, and any one or more of these characteristics.

The results showed that among 2,027 premenopausal women (13.1%), biennial screeners had a higher proportion of tumors with less favorable prognostic characteristic, compared to annual screeners. Among women taking postmenopausal HT, biennial screeners also tended to have tumors with less favorable prognostic characteristics than annual screeners, but differences were not statistically significant. Postmenopausal women not using HT had a higher proportion of invasive cancers if they were screened biennially than women who were screened annually. The study was published on October 20, 2015, in JAMA Oncology. “Our findings suggest that menopausal status may be more important than age when considering breast cancer screening intervals,” concluded lead author Diana Miglioretti, PhD, and colleagues. “If

screening guidelines were based on menopausal status rather than age, some women ages 40 to 54 years might be recommended for more frequent screening and others, less frequent screening.” The frequency at which women should receive screening mammography remains controversial in the United States. In 2009, the US Preventive Services Task Force (USPSTF; Rockville, MD, USA; www.uspreventiveservicestaskforce.org) updated breast cancer screening guidelines to recommend routine biennial mammography for women ages 50–74 years, based on evidence suggesting that the harms of more frequent screening outweigh the small estimated added benefit of annual screening. In contrast, the American Cancer Society (ACS) recommends annual screening for women 40 years of age and older.

Surgery May Be Best Treatment for Hashimoto’s Disease atients diagnosed with Hashimoto’s disease who underwent a complete thyroidectomy saw significant improvement in chronic fatigue symptoms, according to a new study. Researchers at Telemark Central Hospital (Porsgrunn, Norway; www.sthf.no) and University Hospital Stavanger (Norway; www.helsestavanger.no) conducted a randomized pilot study involving 97 consec-

utive Hashimoto patients who underwent complete thyroidectomy between 2004 and 2009. The researchers monitored anti-thyroidperoxidase (anti-TPO) levels preoperatively and up to 96 months after surgery, thyroxin supplement, and typical symptoms not ameliorated by thyroxin. They also registered symptoms by phone survey, with patients being asked to estimate changes in the severity of the autoimmune symp-

Silicone Gel Breast Implant Safety Remains Unclear new review of literature that examined health outcomes of silicone gel breast implants failed to provide clear evidence either for safety or harm. Researchers at the University of Texas Southwestern Medical Center (Dallas, TX, USA; www.utsouthwestern.edu) and Brown University (Providence, RI, USA; www.brown.edu) reviewed studies published through June 2015 to examine specific long-term health outcomes in women with silicone gel breast implants, including cancer development; connective tissue, rheumatologic, and autoimmune diseases; neurologic diseases; reproductive issues, including lactation; offspring issues; and mental health issues, included depression and suicide. In all, 32 longitudinal studies (in 58 publications) met eligibility criteria. The researchers then extracted data on participant and implant characteristics that compared women with and without breast implants and reported long-term health outcomes of interest. The researchers found possible associations with decreased risk for

HospiMedica International April/2016

primary breast and endometrial cancers and increased risks for lung cancer, rheumatoid arthritis, Sjögren syndrome, and Raynaud syndrome, but the evidence was frequently not specific to silicone gel implants, and studies were rarely adequately adjusted for potential confounders. The report was published on November 10, 2015, in Annals of Internal Medicine. “This project was conducted to provide background information for advice to be provided to the FDA regarding development of a silicone gel breast implant registry. While some databases may not have captured enough information, other studies might be worth reanalyzing to include more available confounders than before and with new methods,” added Dr. Balk. “We are hopeful that this study will serve as a guide to future researchers to improve analyses of currently available studies and of future studies.” Silicone gel breast implants were removed from the US market for cosmetic use in 1992 owing to safety concerns. They were reintroduced in 2006, with a call for improved surveillance of clinical outcomes.

toms before and after surgery. The results showed that post-procedure, anti-TPO levels normalized in a majority of patients, with serious exhaustion, pain, and stiffness in musculature and joints correlated to titers of anti-TPO. The percentage of those reporting severe fatigue was reduced from 84% at baseline to 34% at 18 months, with symptoms improved in more than 75% of patients after 36 months. The study was presented as a poster session at the International Thyroid Congress, held during October 2015 in Orlando (FL, USA). “Eighteen months after randomization, the surgical group reports significant improvement in health-related quality of life and chronic fatigue, almost comparable to the background population,” said lead author and study presenter Ivar Guldvog, MD, PhD, of Telemark Central Hospital.

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“The results stimulate the hypothesis that Hashimoto is a surgical condition; there is no other treatment alternative. We have now included all 150 patients planned for the randomized study, and we are in the middle of the follow up time observing that the antibodies are falling in all patients.” Hashimoto’s disease, also known as chronic lymphocytic thyroiditis, is an autoimmune condition in which the immune system attacks the thyroid gland, a part of the endocrine hormonal system. The resulting inflammation often leads to an underactive thyroid gland (hypothyroidism). Hashimoto’s disease is the most common cause of hypothyroidism in the United States, primarily affecting middle-aged women, but also can occur in men and women of any age, as well as children.

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PRODUCT NEWS NITINOL GUIDEWIRE

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SURGICAL IMAGING SYSTEM

OCT SYSTEM

Nipro Medical

Olympus Medical Systems

St. Jude Medical

The AQUALiner II guidewire enables the operator to navigate through complex lesions and deliver interventional devices such as balloons and stents. It is available in various lengths, ranging from 150cm to 260cm, with a regular or stiff-configured wire, and with a straight or angled tip.

The VISERA 4K UHD system delivers four times the resolution of HD with better light and wider color spectrum. The 55-inch display magnifies anatomical features to provide more visual information to the surgical team, helping surgeons operate with increased precision and confidence.

The Optis Mobile system couples optical coherence tomography and angiography coregistration with fractional flow reserve technology into one system. It gives patients an alternative to openheart surgery with the goal of improving outcomes, shortening stays, and reducing costs.

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Chemical Denervation Aids Dermal Fillers Last Longer new study suggests that combining hyaluronic acid (HA) dermal fillers with botulinum toxin could slow down their degradation process. Researchers at Ondokuz Mayis University (Samsun, Turkey; www.omu.edu.tr) designed a study in rabbits in which a small amount of HA filler was injected under the skin in front of each ear; the area was chosen because it corresponds to the forehead region in humans, a common area for dermal fillers. On one side, HA filler alone was used; on the other, HA filler was combined with botulinum neurotoxin-A (BoNT-A) to paralyze the muscle in that area. Two days later, magnetic resonance imaging (MRI) scans were performed to compare the amount of filler remaining on both sides. After three months, MRI scans were repeated. The results showed that the average initial volume of filler was 0.61 cm3 on both sides. At the end of three months, however, the average degraded volume of the filler-only side was 0.33 cm3, com-

pared to 0.19 cm3 on the combined HA- BoNTA side, a diminished degradation rate of 42%. The difference was visible as well as measurable, supporting the clinical experience that local BoNT-A injection provides longer-lasting outcomes in patients. The study was published in the January 2016 issue of Plastic and Reconstructive Surgery. “This study showed that HA filler application in combination with BoNT-A significantly decreases the degradation process and increases the remaining volume at the end of the paralyzed period,” concluded lead author İsmail Küçüker, MD, and colleagues of the department of plastic surgery. “The study provides objective evidence to support the use of this combination procedure in patients undergoing dermal filler treatments.” HA is an anionic, nonsulfated glycosaminoglycan distributed widely in connective, epithelial, and neural tissues. One of the chief components of the extracellular matrix (ECM), it contributes sig-

nificantly to cell proliferation and migration, and may also be involved in the progression of some malignant tumors. HA fillers are a popular treatment option for facial lines and wrinkles, but early degradation of fillers may limit how long their effects last. Image: Experimental evidence supports a simple technique for prolonging the effects of HA dermal fillers: using them together with botulinum toxin (Photo courtesy of the ASPS).

Stimulating Vagus Nerve Prevents Blood Loss Following Surgery timulating neural pathways is a potentially efficacious and safe way to prevent hemorrhagic complications following surgery and other invasive procedures, according to a new study. Developed by researchers at the Feinstein Institute for Medical Research (Manhasset, NY, USA; www.feinsteininstitute.org), the Neural Tourniquet is designed in the form of a wearable technology clipped to a patient’s ear, which will work by stimulating neural pathways leading to the spleen in order to activate the inflammatory reflex, thus allowing the brain to monitor and control systemic inflammatory mediators rapidly and directly. The stimulation of the efferent vagus nerve, for example, informs the brain of increases in systemic proinflammatory cytokine concentrations in the peritoneal cavity. The efferent vagus nerve signaling also reaches the spleen through the splenic nerve, which then increases acetylcholine release from cholineacetyl-

transferase-positiveT cells. The acetylcholine can then inhibit proinflammatory cytokine production by stimulating the 7 nicotinic acetylcholine receptor subunit, activating circulating platelets and priming the coagulation system. Studies have shown that stimulation for as little as 60 seconds can induce clotting 50% faster and reduce the volume of blood loss by 50%. Applications include reducing blood loss in the operating room (OR); slowing blood loss in trauma victims at accident scenes, and as a device to proactively curb blood loss in wounded soldiers on the battlefield. The Neural Tourniquet is being developed by the Feinstein Institute in conjunction with Battelle (Columbus, OH, USA; www.battelle.org), with data on the device being presented at the North American Neuromodulation Society (NANS) 19th annual meeting, held during December 2015 in Las Vegas (NV, USA). “Our main goal at the Feinstein is to improve the

health and wellbeing of people through scientific discovery,” said Christopher Czura, PhD, vice president of scientific affairs at the Feinstein Institute and co-inventor of the Neural Tourniquet. “We know that blood loss is a tremendous problem in a range of settings, and when we saw that our discoveries could change that, we knew we needed a partner to help bring that discovery to market. Battelle’s track record and approach make them a perfect partner.” Bioelectronic medicine involves screening for nerves that control a target organ, and then designing devices that control those nerves. The devices have the potential to deliver treatment specifically where it is required, versus a drug that is typically is distributed throughout the body and causes side effects. The list of possible diseases, conditions, and injuries that bioelectronic medicine could treat includes cancer, hypertension, diabetes, Alzheimer’s disease (AD), rheumatoid arthritis, organ transplantation, paralysis, and shock. HospiMedica International April/2016

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Surgical Techniques

Novel Suturing Device Facilitates Soft Tissue Closure new delivery device provides an intuitive solution to soft tissue closure compatible with a wide range of surgical procedures. The Lariat suture delivery device is intended for use in surgical applications where soft tissues need to be approximated and ligated. It is based on a pretied, common polyester suture loop to provide complete closure with no metal, clip, or implant left behind. The user-controlled remote delivery system can deliver the 40-mm suture loop through an access of 4.3 mm or greater, and is compatible with a wide range of anatomical shapes. One of the primary indications is for ligating the left atrial appendage (LAA) to treat atrial fibrillation (AF). The collapsible snare retains the suture loop until ready to deploy, opening or closing it as needed to confirm placement prior to suture release. Once in position, the Meltzer knot is tightened with the Tensure integrated suture-tightening system, reducing the risk of operator variability during closure. The low profile design also gives surgeons greater control in suture placement, and is designed to be compatible with open- chest, thoracotomy, or port access procedures. The Lariat suture delivery device is a product of SentreHEART (Redwood City,

CA, USA; www.sentreheart.com), and has received the European community CE marking of approval. “The Lariat surgical device solves many of the issues posed by current closure technologies in surgery,” said Russell Seiber, president and CEO of SentreHEART. “Improving the surgeon’s control, reducing operator variability, and minimizing technique dependence through a simple to deliver, repeatable, suture-based solution is more natural for cardiac surgeons and should lead to better outcomes.” “The Lariat surgical device is an elegant surgical closure solution, combining the best of all the current approaches into a single device,” said associate professor of cardiac surgery Krzysztof Bartus MD, PhD, of Jagiellonian University (Krakow, Poland). “The new device enables flexibility in my approach and access to close tissue where I want, with the additional confidence that it will remain closed. These are important characteristics when closing soft tissue such as the LLA.” The LAA is a small, ear-shaped sac in the muscle wall of the left atrium. In normal hearts, the heart contracts with each heartbeat, and the blood in the left atrium and LAA is squeezed out into the left

ventricle. When a patient has AF, the chaotic impulses do not give the atria time to contract, and blood collects and can form clots in the LAA and atria. The LAA is thought to be the source of more than 90% of stroke-causing blood clots that come from the heart in non-valvular AF patients. Image: The LARIAT surgical left atrial appendage suture delivery device (Photo courtesy of SentreHEART).

Study: Mechanical Heart Valves Superior to Biological Ones new study suggests that mechanical valve prostheses last longer and have a better survival record than biological valve prostheses. Researchers at Karolinska Institutet (Solna, Sweden; www.ki.se) and Karolinska University Hospital (Stockholm, Sweden; www.karolinska.se) conducted a study among 4,545 patients (50–69 years of age) who underwent aortic valve replacement (AVR) with bioprosthetic or mechanical valves in Sweden between 1997 and 2013; in all, 60% of the patients received mechanical valves and 40% received bioprostheses. The patients were distributed to 1,099 propensity score-matched patient pairs to investigate long-term all-cause mortality outcomes. The results showed that 16% of the mechanical valve group and 20% of the bioprosthetic group died during a mean follow-up period of 6.6 years. Long-term survival was higher in the mechanical than in the bioprosthetic group when evaluated at five, 10, and 15 years, with an overall hazard ration of 1.34. There was no difference in stroke outcomes, but patients who received bioprostheses had a higher risk of aortic valve reoperation and a lower risk of major bleeding. The study was published on November 12, 2015, in European Heart Journal. “Biological valve prostheses have been used more and more in young patients in recent years, partly because these patients don’t have to take blood thinners,” said lead author Natalie Glaser, MD, a PhD student at the Karolinska Institutet department of molecular medicine and surgery, and a physician at the Karolinska University Hospital department of cardiothoracic surgery. “Our

HospiMedica International April/2016

research shows that mechanical valve prostheses should be the preferred option for young patients.” “We show that patients who had received a mechanical prosthesis had better survival rates than those who had received a biological prosthesis,” added senior author cardiac surgeon Ulrik Sartipy, MD, of the Karolinska University Hospital department of cardiothoracic surgery. “Our results are important since the trend in Sweden and abroad in recent years has been towards a greater use of biological valve prostheses in relatively

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young patients, which has no backing in clinical therapy guidelines.” While mechanical valves are the longest lasting type of replacement valve, patients will usually require blood thinners to stop clots from forming, as they can lodge in valve flaps or hinges, which can cause malfunction or form emboli. Bioprosthetic tissue valves can last 10–20 years, but usually do not require long-term use of medication. On the other hand, in a young person a bioprosthetic valve will usually need replacement later in life.

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PRODUCT NEWS COLLABORATION PLATFORM

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IMAGING SOFTWARE

DOSIMETRY SOFTWARE

Carestream Health

EDDA Technology

Elekta

The Clinical Collaboration Platform uses clinical data across and outside the enterprise to break down walls between departments, sites and networks, and provide physicians with a single view of critical patient data. It allows for sharing data in ways that can reduce costs and improve care.

The IQQA-Guide provides RT 3D image guidance in the interventional suite for abdominal/thoracic biopsy, interventional procedures, and surgery. It uses a 3D map of anatomic representations from multimodality images, providing RT tracking and referencing to anatomic features of interest in 3D.

The iViewDose is designed to provide an efficient solution for the detection of radiotherapy errors. It prompts user intervention with a simple traffic light system, and increases clinical confidence by detecting dose errors during treatment, including those caused by changes in patient anatomy.

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Advanced Visualization Table Features Capacitive Touch Interface n enhanced 55-inch visualization table with state-of-the-art touch technology enables medical staff to smoothly navigate three dimensional (3D) images of actual patient cases. The next-generation Sectra (Linköping, Sweden; www.sectra.com) F15 visualization table with capacitive touch technology allows medical staff and students to gain enhanced understanding of the body’s anatomy and functions, the variation between individuals, and visually explore more unusual diseases. The 3D images are taken by modern computed tomography (CT) and magnetic resonance imaging (MRI) cameras. Users of the table can simply zoom in, rotate, or cut into the visualized body without using a scalpel, and can repeat virtual autopsies and dissections over and over. The table also serves as a terminal for the proprietary Sectra Education Portal, a concept for sharing patient cases and teaching content and knowledge with other universities that use the Sectra Table. Based on an enterprise image management platform, the tables is suitable for all training programs,

including anatomy training on virtual images of actual patient cases from other universities, in addition to the preinstalled training images that accompany the table. “The visualization table allows us to modernize and increase the quality of our teaching,” said Sandra Ceccatelli, MD, PhD, head of the department of neuroscience and in charge of anatomy teaching at the Karolinska Institutet (Solna, Sweden; www.ki.se). “The table opens up unique opportunities to convey basic knowledge about the body, offering a whole new way to teach anatomy to our students.” The visualization table was developed in cooperation between the Linköping University (Sweden; www.liu.se) Center for Medical Image Science and Visualization (CMIV), Visualiseringscenter C (Norrköping, Sweden; www.visualiseringscenter.se), and The Interactive Institute (TII; Stockholm, Sweden; www.tii.se). Image: The Sectra F15 visualization table (Photo courtesy of Sectra).

New Software Package Released for Compatibility Of MRI Scanners with Post-Processing Tools ew software that enhances the efficiency of the Magnetic Resonance Imaging (MRI) workflow, and clinical decision has been released. The release is part of a cooperation and co-marketing agreement between a software company and a major manufacturer of MRI scanners. The software upgrade is optional, and makes MRI scanners compatible with the post-processing software packages from the software vendor. Philips Healthcare is offering the SyntheticMR, SyntAc sequence software to customers. The SyntAc will enable most Philips MRI customers to use the SyMRI post-processing software packages. The

SyntheticMR, SyMRI software can use the data from one SyntAc scan and convert this into several image contrasts, even after the scan has taken place, without re-calling the patient for multiple scans. The need for only a single scan saves time and simplifies workflow. Another feature of the SyMRI software is automatic segmentation of brain tissue, with quantitative data and objective decision support. There are three versions of the SyMRI software. The SyMRI IMAGE package can optimize workflows and short scan times using a single MR quantification scan. The SyMRI NEURO package aids analysis and decision-making during brain imaging

for the follow-up in the development of neurodegenerative diseases, by adding quantitative data. The SyMRI Research Edition is intended for neuro imaging clinical research, and provides quantitative T1, T2 and PD maps (SyMaps) that can be stored and exported in other formats. Stefan Tell, CEO of SyntheticMR, said, “I am very pleased that customers using most Philips MRI scanners will now have access to SyMRI, expanding our software packages to a broader, global customer base and enabling them to explore new imaging strategies and efficient quantification capabilities.” HospiMedica International April/2016

New Cloud Ecosystem To Serve Healthcare Sector E Healthcare (GE; Little Chalfont, United Kingdom; www.gehealthcare.com) has unveiled a Health Cloud and apps that are designed exclusively to connect medical imaging with analytics. The GE cloud ecosystem will connect to more than 500,000 GE imaging machines, shifting image post-processing from on-site machines to the Cloud, where three-dimensional (3D) images can be viewed on multiple devices both inside and outside the hospital setting. Radiologists and clinicians will link with the ecosystem using cloud-based apps that can connect them in real time with imaging, data, analytics and insights, as well as with other clinicians, thus promoting collaboration across care pathways and multidisciplinary teams. Apps available will include Centricity Cloud Advanced Visualization, Centricity Multi-Disciplinary Team Virtual Meeting, Centricity Case Exchange, and Centricity Image Access. The apps will be delivered on a subscription basis, allowing hospitals and health systems an on-demand, flexible computing power that can be scaled up or down on a variable cost model that will allow them to control computing expenses. The cloud ecosystem will also include a software development toolkit (SDK), and its app store will host and promote new software solutions. “Healthcare devices are generating enormous amounts of data, and that data is expected to increase 50 fold by 2020. The GE Health Cloud can help unlock the value of this data quickly and seamlessly for better patient care,” said John Flannery, president of GE Healthcare. “The GE Health Cloud will help clinicians turn data into insights, and insights into tangible actions for decision-makers to drive better outcomes.” “Our new apps will bring incredible computing and mobility power to radiologists and clinicians,” said Jan De Witte, president of IT at GE Healthcare. “By enhancing radiologists’ speed and confidence through the apps, we can help improve their ability to collaborate with referring clinicians inside and outside the hospital.” The apps are being developed as part of a partnership with the University of Pittsburgh Medical Center (UPMC; PA, USA; www.upmc.com) in a joint venture known as Omnyx. The Health Cloud and apps will also be open for development by third parties, healthcare providers, and academic institutions, in a bid to attract independent software vendors (ISVs) to develop their apps in the new cloud ecosystem.

Image: Images from a GE Health Cloud 3-D visualization app using CT scan data (Photo courtesy of GE Healthcare). V

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PACS/RIS/EHR PLATFORM

DIAGNOSTIC DISPLAY

GE Healthcare

Konica Minolta Medical Imaging

NEC Display Solutions of America

The GE Health Cloud is designed to enable medical facilities to perform data analytics and other functions more efficiently in the cloud. Four key features of the GE Health Cloud include advanced visualization, virtual meetings, case exchanges, and image access portal.

The Exa platform includes a custom workflow design engine and performance dashboards. It allows each facility to design its own preferred imaging workflow with drag-and-drop tools. The entire process can be customized quickly and easily, with no prior IT or coding experience.

The MultiSync MD211G5 21-inch display is designed for tomosynthesis applications and full field digital mammography (FFDM). The 5MP monitor is also cleared for standard mammography, and offers out-of-the-box factory DICOM calibration and uniformity control for consistent imaging.

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Self-Service Kiosk Equips Patients to Share Medical Data n innovative prototype kiosk allows patients to share medical and radiology reports and output their medical images onto paper, radiographic film, or a USB device. The MyVue Center self-service kiosk is a point of care (POC) access device that allows patients to view and share their medical images and radiology reports from a variety of web-enabled devices, including laptops, tablets, mobile phones, or from any healthcare facility electronic medical record (EMR) portal. Patients can thus gain rapid, convenient access to medical exam information by utilizing a secure method of identification, and select the medical images or radiology reports they want to output. Facilities that already provide a MyVue Patient Portal service that install a MyVue Center can allow their patients to share access to their medical images and reports with physicians, friends, or family members from the kiosk using a unique and secure log-in access code generated by the patient portal that is emailed to each patient after their exam. Both the MyVue Patient Portal and the MyVue Center systems are products of Carestream Health (Rochester, NY, USA; www.carestream.com), and employ globally accepted security protocols to ensure patient privacy. The system is not available for commercial sale at this time.

Image: The MyVue Center self-service kiosk (Photo courtesy of Carestream Health).

Dell Announces Its First Purpose-Built Medical Monitor leading computer hardware manufacturer is showcasing its first monitor that was purpose-built for the healthcare environment, at the annual meeting of the Radiological Society of North America (RSNA 2015). The monitor is calibrated to the part 14 standard grayscale Digital Imaging and Communications in Medicine (DICOM) standard for accurate and consistent image display, is fully cleanable and consistent with infection reduction initiatives, and is sealed with an antireflective edge-to-edge front-covered glass. The Dell (Round Rock, TX, USA; www.dell.com) MR2416 Medical Review 24 Monitor has a fully sealed IP-32 rated design, a light-colored exterior,

and can withstand cleaning agents of up to 75% concentrated ethyl alcohol. The monitor features intelligent backlight stabilization control, 24 inches of diagonal viewing area and a resolution of 1920 x 1200 with an aspect ratio of 16:10, making it compatible with most image-enabled Electronic Medical or Healthcare Record (EMR/ EHR) applications. The monitor can be tilted between landscape and portrait orientations. The height, pivot, tilt, or swivel of the monitor can be adjusted up to 60 degrees left and right with consistent 178 x 178-degree viewability from almost any angle. The monitor specifications meet the IEC 60601-1 standard for medical design and safety. The monitor has an active screw-on cable clip within the housing, and

mechanical pop-up power and OSD buttons on its side. Downtime can be minimized using the manufacturerâ&#x20AC;&#x2122;s three-year Limited Hardware Warranty and Advanced Exchange Service. The monitor is not designed or intended for use in primary medical image interpretation or active patient monitoring. Bert Park, vice president and GM, Dell Global Software and Peripherals, said, â&#x20AC;&#x153;As the number-one monitor brand in the world, we want to bring our innovation and expertise in display technology to the healthcare field with a selection of medicalgrade Dell monitors. The MR2416 is the first in a line of products we will be introducing to enable healthcare customers to improve their efficiency and service quality. HospiMedica International April/2016

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Health IT

Virtual Reality Device Offers Potential for Diagnostic Imaging prototype of a high-resolution mobile Virtual Reality (VR) diagnostic imaging device for radiologists was presented at the annual Radiological Society of North America (RSNA 2015) meeting in Chicago (IL, USA). The researchers investigated whether VR visualization could be useful for diagnostic imaging without sacrificing the quality and stability of Digital Imaging and Communications in Medicine (DICOM) images. The researchers also tested the feasibility of remote diagnosis of complete Computed Tomography (CT) exams using a mobile VR system. The study of the prototype VR system, powered by a smartphone with an ultra-high-density 550 ppi display, was carried out by researchers from the Evangelismos Hospital (Athens, Greece; www. evaggelismos-hosp.gr). The researchers began by testing the system using CT images. Two radiologists, a consultant in the hospital, and a radiologist in another area of the hospital, reviewed 271 CT exams using remote VR. The two reports were compared using standardized reporting systems. The researchers assessed imaging quality of the VR

3D Printed Models of DICOM Images Critical For Medical Care he use of 3D printed models of DICOM images can change the way doctors are trained, and how they communicate with their patients. The research was presented at the annual meeting of the Radiological Society of North America (RSNA 2015). The research shows that despite the challenges that still need to be overcome before 3D models printing reaches its full potential in radiology, the impact of 3D printing could become the standard. According to Frank Rybicki, MD, PhD, professor, Department of Radiology, University of Ottawa Faculty of Medicine (uOttawa; Ottawa, Canada; http://med.uottawa.ca/en), radiologists need to invest the time to learn 3D model printing methods. Dr. Rybicki suggests that printing of medical models from Computed Tomography (CT) and Magnetic Resonance (MR) images should become part of radiology departments. Advanced imaging modalities and protocols need to be able to generate source DICOM images that can be used for 3D printing. Dr. Rybicki, said, “If we’re going to get reimbursement, we need a single reporting standard for 3D printing, and reimbursement will be a major hurdle. All payors know that we need 3D printing, and that it will eventually be reimbursed as the demand continues to swell. This will happen as we accumulate more data, and then develop guidelines regarding appropriate utilization. While there are many pressures to contain costs, data is beginning to show that the generation of 3D models is cost-effective for several applications, particularly when the model saves time in the operating room.”

HospiMedica International April/2016

system, compared to the hospital’s workstation, in the independent, double-blinded reports. The two radiologists showed agreement in 97.27% of the results. The remaining contradicting results also showed discrepancies between radiologists on the same monitor. The results showed that in most of the parameters evaluated by the researchers, there was good inter-observer agreement, and the use of the VR system did not affect image quality, or alter the diagnosis. Dr. Moustakas, radiologist at the Evangelismos Hospital, said, “Using the system is like being in front of a 175-inch mega screen while enabling visualization at 360 degrees. Once the DICOM images are downloaded, the user wears the device and can scroll through the images, viewing up to 56 at any time – all while being on the move. It is very easy to use. Once the files are downloaded it takes less than

a minute to wear the VR device and start viewing the CT images. The fact that it’s also mobile is crucial, because this technique can be used for remote diagnosis, avoiding the limitations of the relatively small displays of normal mobile devices. The main drawbacks until now were mobility and display resolution, but our system resolves both, but the potential advantages are boundless.” Image: The prototype virtual reality mobile diagnostic imaging device (Photo courtesy of RSNA).

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MRI APPLICATION

RECONSTRUCTION SOLUTION

RaySearch Laboratories

Siemens Healthcare

Toshiba Medical Systems

The RayStation5 features carbon ion treatment planning, an advanced form of radiation therapy, and Plan Explorer, a planning tool that allows clinics to maximize delivery efficiency and plan quality for every individual patient treatment. Other key features include unlimited patient data storage.

The Simultaneous Multi-Slice (SMS) EPI is designed to acquire imaging slices simultaneously rather than sequentially to reduce 2D acquisition times. It also integrates DTI and blood oxygen level-dependent (BOLD) imaging, benefiting surgical neurology cases through mapping.

The Forward projected model-based Iterative Reconstruction SoluTion (FIRST) improves image quality with noise reduction, while reducing dose. It cuts the time needed for model-based CT image reconstruction, helping providers make diagnoses and treatment decisions more effectively.

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Wireless Monitoring Facilitates Cardiac Patient Management new remote cardiac rhythm monitor incorporates complete mobile cardiac telemetry (MCT), Holter, and cellular event monitoring. The 3-1 TeleSense device is a comfortable to wear, simple to set up, and configurable device for the auto-detection of arrhythmia events and concomitant wireless transmission of three-channel electrocardiogram (ECG) data, thus allowing clinicians to more accurately correlate between patient symptoms and changes in the electrical conduction of the heart. A web-accessible platform supports detailed and actionable reporting through daily event reports, heart rate trends reports, and end-of-session reports; interim and summary statistics; and advanced administrative and clinical queries. The device can transmit up to 30 days of continuous ECG data across multiple cellular networks or by utilizing a patient’s own WiFi network. For clinicians unable to offer patients 24-hour monitoring coverage, an optional dedicated monitoring service provides active daily surveillance and reporting capabilities, as well as immediate access to raw data and completed reports from any Internet connected

computer. Optional electronic health record (EHR) integration enables reports to be easily viewed and e-signed by the physician prior to automated transmission. Brightly lit icons allow the patient to easily identify whether the device has sufficient power, whether leads are properly connected, if the device is recording, and the status of the WiFi or cellular connection. Patients can also quickly record and immediately transmit self-identified events via a large, easily accessible button on the front of the device, helping to address the continuous concern of patient compliance. The 3-1 TeleSense device is a product of ScottCare (Cleveland, OH, USA; www.scottcare.com). “We created TeleSense with the goal of providing clinicians with an easy-to-use, comprehensive monitoring device they could trust for diagnostic accuracy, technological reliability and improved pa-

tient compliance,” said Sneh Merchant, vice president of research and development at ScottCare. “They can depend on TeleSense to help them care for their cardiac event patients in a highly convenient and effective way.” Image: The 3-1 TeleSense remote cardiac rhythm monitor (Photo courtesy of ScottCare).

New Cardiovascular Image and Information Management System newly-introduced Cardiovascular Image and Information Management System (CVIS) is intended to improve interoperability, enhance collaboration, and centralize patient data from around the hospital. The system should help streamline workflows, and improve patient care, by allowing all clinicians to view the complete patient history, treatment, and therapy, preventing delay and unnecessary repetition of tests. The Royal Philips (Amsterdam, the Netherlands; www.philips.com) web-enabled IntelliSpace Cardiovascular CVIS provides tools that enable clinicians to access, analyze, and share car-

diovascular images and information freely. Existing Philips’ Xcelera customers can also upgrade to the new IntelliSpace Cardiovascular CVIS, which includes clinical applications such as IntelliSpace Portal, and IntelliSpace ECG, in one workspace. Improved interoperability, and centralized patient data, will help streamline workflows and improve care. CVIS is vendor agnostic, and can link users to advanced visualization tools, a third-party Picture Archiving and Communication System (PACS), or Electronic Medical Record (EMR). The system has a scalable design and built-in echocardiography reporting features to help cardiologists in the report-

ing workflow. The CVIS also includes built-in analytics tools that can compile data and provide searchable information for clinicians, researchers, and administrators. Iain Burns, CEO, Philips Canada, said, “At Philips we are committed to delivering innovations that can improve people’s lives. IntelliSpace Cardiovascular’s single integrated workspace produces a panoramic view of the patient’s care continuum across the entire cardiovascular service line enabling better care for cardiology patients. This new technology provides cardiologists with sophisticated tools for confident diagnosis and planning of patient cardiovascular care.” HospiMedica International April/2016

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Health IT

CVIS System Integrated with Post-Acquisition Ultrasound Image Management healthcare Information Technology vendor and an ultrasound-imaging manufacturer have integrated their Cardiovascular Information System (CVIS) and advanced 3-D/4-D ultrasound imaging and strain rate software to improve productivity and streamline the clinical workflow. The ultrasound image-processing tool can now be launched with a single mouse click, while viewing an ultrasound study in the CVIS. The clinical workflow of the two tools has been merged and can be operated from one workstation instead of two. This now enables a clinician to launch the 3D/4D tool, perform an analysis of the image and return the image back to the CVIS in one location. GE Healthcare’s (Chalfont St Giles, Buckinghamshire, UK; www3. gehealthcare.co.uk) EchoPAC ultrasound post-processing and reporting tool, and Digisonics’s (Houston, TX, USA; www.digisonics.com) CVIS solutions can now directly store and retrieve images acquired by GE Health-

care’s Vivid range of ultrasound scanners. The Digisonics CVIS solution is standards-based and vendorneutral, and can be used with all cardiovascular modalities. The CVIS combines a Picture Archive and Communications System (PACS) with a clinical database, for high-performance image review. The CVIS conforms to and exceeds US Health Insurance Portability and Accountability Act (HIPAA) requirements for a secure environment with electronic signature, and audit trail capabilities. The EchoPAC tool can be used to perform image processing, analysis, measurement, and annotation. The tool is also used Image: The standards-based, vendor-neutral Cardiovascular Information System to generate reports, and for com(CVIS) solution for all cardiovascular modalities (Photo courtesy of Digisonics). munications. The EchoPAC software is integrated into each application to our best-in-class suite the ultrasound system, expanding Vivid ultrasound system. of CVIS interfaces. With EchoPAC, productivity and leveraging the adErnest Jackson, chief technology users have the ability to post-process vanced quantitative and multidimenofficer Digisonics, said, “Digisonics is the original RAW data acquired on sional analysis provided.” very pleased to add the GE EchoPAC

4K Display Combines Wireless Mobility with Clarity n integrated cordless high definition (HD) display solution offers untethered mobility and flexibility for endoscopic surgery visualization. The ZeroWire MOBILE surgical display system is a self-powered, full HD solution that delivers video with complete freedom of movement, thanks to an embedded, integrated wireless transmitter and receiver unit built into an advanced Radiance Ultra display, which is mounted on a specially designed roll-stand. The dual-battery power source docks to a wall-mounted two- or four-bay battery charging system that provides hot-swap capability for extended operational requirements. The integrated Radiance Ultra surgical LED backlight display offers 4K (3840 x 2160) pixel resolution at a typical luminance of 900 cd/m2 at a color temperature of 6,500 K. The resulting clarity improves visualization in high ambient light environments by overcoming glare and reflection, while at the same time increasing usable contrast ratio, enhancing visualization of recessed anatomy. Proprietary MediMatch color calibration and a backlight stabilization system deliver superior image consistency that increases surgi-

HospiMedica International April/2016

cal team confidence. A seamless, edge-to-edge glass surface supports easy cleaning and infection control that enable faster operating room (OR) turnaround times and clinical efficiency. And since the ZeroWire MOBILE eliminates cables, a potential tripping hazard, it also helps enable greater procedure room efficiency through ease of movement and repositioning and reduces OR cleaning times. The ZeroWire MOBILE is a product of NDS Surgical Imaging (San Jose, CA, USA; www.ndssi.com). NDS also offers a suite of video processing products to simplify OR integration and streamline image management. ConductOR is a configurable audio and video routing solution, enabling the routing of virtually any medical imaging source to the surgeon’s field of view and beyond; ScaleOR is a video converter/scaler solution for endoscopy that connects equipment with incompatible signal input and output resolutions, ideal for upgrading clinical facilities to HD video; and ExpandOR is a medicalgrade video IP streaming technology that allows secure bi-directional HD video/audio streaming to multiple destinations simultaneously.

Hospital News I

Creative Emergency Department Eliminates X-Ray Room he new Crouse Hospital (Syracuse, NY, USA; www. crouse.org) emergency department (ED) will use portable digital radiography to provide rapid image access. The new ER will be built on top of Crouse’s new surgical suite building, adjacent to the existing ER, at a cost of USD 35 million, and will open in late 2017. It will include 46 treatment rooms on a clinical space larger than 4,700 m2, three times the size of the current ED, which was built in 1972. As part of the project, the existing ER will be converted to an urgent care space for patients with nonemergency illnesses and injuries, a service currently provided across the street at the PromptCare office. That office will be eliminated when the ER project is completed in 2018. Plans call for the ED to be equipped with a computerized tomography (CT) system, as well as a magnetic resonance imaging (MRI) system to be located in an adjacent

area. But trauma patients in need of X-ray exams on their chest, abdomen, arms, legs and other extremities will have them done at the point of care via two Carestream (Rochester, NY, USA; www.carestream. com) DRX-Revolution mobile X-ray systems that features a small footprint, exceptional maneuverability, excellent image quality, and wireless communication of X-ray exams. The images will thus be available for review by physicians in seconds. Those patients requiring cross-table, C-spine, or other complex X-ray exams will be transported to the hospital’s existing radiology department, as will bariatric patients. An additional benefit of the new arrangement is that since the hospital will not construct an ED X-ray room, not only will the waiting room will be larger but also will save over USD 250,000 in construction costs. “We purchased a Carestream DRX-Revolution Mobile X-ray System for our new ED because it is easy to

maneuver and enables technologists to quickly and easily capture highquality images of seriously ill or injured patients,” said Brad Hellwig, director of radiology at Crouse Hospital. “Physicians can view images in seconds and the system also has special software that enhances visualization of tubes and lines, which is especially important for urgent care patients.” Crouse Hospital is Central New York’s largest provider of maternity care services, delivering more than 4,200 babies annually, and is the

state-designated regional referral center for high-risk neonatal intensive care services. Crouse also operates two ambulatory surgery centers near the main hospital complex. Other specialties include a comprehensive diagnostic and interventional cardiac care; surgical services, including robotic surgery; orthopedics; stroke care; oncology; and a hospital-based chemical dependency treatment services. Image: The Crouse Hospital planned emergency department (Photo courtesy of Crouse Hospital).

UK’s NHS Receives Funding To Rebuild Hospital Finances he UK Department of Health (DH; London, UK; www. g o v. u k / g o v e r n m e n t / organisations/department-of-health) has announced a GBP 1.8 billion sustainability and transformation fund to provide the National Health Service (NHS; London; www.nhs.uk) with the resources it needs to achieve a financial balance for challenged hospitals and to focus on changing the way they provide high quality care for patients. The transformation fund, which will be allocated dependent on hospitals meeting a series of strict conditions, will give the NHS the time and space it needs to put transformation plans in place. The GBP 1.8 billion is part of a larger, GBP 3.8 billion frontloaded funding boost intended for 2016, which will help trusts reduce their deficits and allow them to focus on transforming services to deliver excellent care for patients every day of the week. The funding will be broken down into two parts. A proportion of the sum will be distributed to all

providers of emergency care, linked to demonstrating initial progress against conditions outlined by the DH and the setting of agreed control totals with NHS Improvement. A second element will be used to target providers, which can deliver additional efficiencies and improvements. According to the DH, Both elements of the fund will put trusts in a stronger financial position to make sure patients benefit from a worldclass NHS for decades to come. “This government is committed to the values of the NHS, which is why we are investing GBP 10 billion in its own plan for the future, including GBP 6 billion upfront by next year,” said UK Health Secretary Jeremy Hunt said. “We are offering trusts help to improve their financial position and transform services for patients based on that planned investment, subject to strict conditions. This will allow hospitals to focus their efforts on making the NHS a truly seven day service, offering the same excellent world class care every day of the week.” HospiMedica International April/2016

Industry News

Genesis HealthCare to Sell Home & Hospice Operations enesis HealthCare (Kennett Square, PA, USA; www. genesishcc.com) has signed an agreement to sell the majority of its home health and hospice operations to Compassus (Brentwood, TN, USA; http://compassus.com) for USD 84 million. The Genesis home health and hospice operations included in the deal are located in the states of California, Idaho, Montana, and New Mexico; remaining hospice operations in Arizona and Nevada will be closed. The agreement is part of an ongoing strategic move launched by Genesis to monetize non-strategic assets, including the home health and hospice businesses,

in order to repay debts. The strategy is expected to yield a cash flow income of USD 100–150 million, after tax. The home health and hospice operations became part of Genesis HealthCare following its February 2015 merger with Skilled Healthcare, which created one of the largest post-acute care providers in the United States. The buyer, Compassus, is comprised of a nationwide network of community-based post-acute care services primarily focused on hospice, palliative, and home health care. The company opened its first hospice in 1979, and following the deal will operate more than 165 programs in 30 states.

Global Electrosurgical Devices Sector to Continue Steady Growth he global electrosurgical devices market will exhibit a compound annual growth rate (CAGR) of 4.11%, reaching a volume of USD 5.56 billion by 2012. These are the latest findings of GlobalData (London, United Kingdom; www.globaldata.com), an international business intelligence provider. According to the marker report, electrosurgical generators and instruments have become indispensable tools in cutting, sealing, and coagulating tissue during a variety of open and laparoscopic procedures. The two major segments of the electrosurgical market are surgical generators, which include radiofrequency (RF), ultrasonic (US), electrocautery, and argon plasma (AP) equipment; and

the electrosurgical instruments sector, which includes monopolar, bipolar, ultrasonic, and argon-plasma coagulation (APC) instruments. The projected expansion, which will occur across ten major markets – the United States, France, Germany, Italy, Spain, the United Kingdom, China, India, Brazil, and Japan – will be driven by an increase in minimally invasive procedures, the growth of computer-assisted surgery, an aging population, and untapped potential in emerging markets. The expansion of computer-assisted surgery will also encourage market growth due to the increased adoption of specialized instruments used in robotic surgery, including electrosurgical devices.

Surgical Robotics Field Projected to Double by 2020 he global sales of surgical robotic systems are projected to reach USD 28.8 Billion by 2020. These are the latest findings of Allied Market Research (AMR; Portland, OR, USA; www.alliedmarketresearch.com), a full-service market research and business-consulting firm. According to AMR, increased adoption of advanced robotic surgery over conventional open surgery, a growing count of surgical procedures, and the rising incidence rates of gynecological, neurological, and urological disorders are the major factors that will boost market growth. As a result, the surgical robotic procedures market is estimated to grow at a compound annual growth rate (CAGR) of 4.9% during 2015–2020, fostering the growth of

HospiMedica International April/2016

the surgical robotics market. The gynecology application segment accounted for 28% share of the surgical robotic systems market share in 2014, maintaining its dominance. Orthopedic surgery, currently at 22%, is projected to be the fastest growing application segment during the forecast period. Systems and accessories jointly accounted for three-fourths of the market in 2014, and are forecast to maintain this trend, mainly due to rising adoption rates across Tier-1 hospitals and recurrent sales of accessories for these systems. System-related services are projected to be the fastest growing segment, owing to growing need for technical systems support, software upgrades, and product parts replacements.

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