In Imaging October 2012

Vol 4 l No. 4 l Pages 66

October 2012

IN IMAGING | OCTOBER 2012

EDITORIAL

What’s ‘In’ Imaging?

According to data with the WHO, globally, more than two billion people struggle to get access to the most basic forms of imaging. Thus imaging majors are focussing on products that are easy-to-use, point-of-care, hardy versions of existing systems which can be transported to rural care scenarios, not requiring highly trained personnel.

These criteria will be the hallmarks of many products to be launched at upcoming events like RSNA and IRIA. Carrying forward this trend in the latest issue of In Imaging, we feature 'Department Scan’: an in depth review of the radiology department and imaging facilities of a hospital/healthcare setting, on five key parameters which directly or indirectly impact both patient care and the hospital's bottom line. So also, in the ‘Tech Scan’ segment, our editorial team asked users of Sonosite's M-Turbo, positioned as a compact, portable point-of-care ultrasound system, to rate it on a scale of 15 (5 being the highest) on five key parameters. Both these segments strive to highlight the fact that without the right human software i.e. qualified radiologists , all the hi tech hardware is just a bunch of pricey wiring.

Its a sad reality that today these personnel need to be savvy about yet another field: medical law. Our Cover

IMAGING MAJORS ARE FOCUSSING ON PRODUCTS THAT CATER TO THE NEEDS OF PATIENTS IN RESOURCE-SCARCE LOCATIONS

Story, 'Probing legalities of ultrasound', highlights the medico-legal minefield that sonologists need to manoeuvre, and is a cautionary tale for any practitioner of this art.

The Spotlight section analyses ''Dr Velumani's 'PET' project': Nueclear Healthcare. With his flagship brand Thyrocare disrupting the market with Friday discounts on pathology tests ('50 tests @1300' went one ad) he is now gearing up to do the same in the nuclear medicine/cancer diagnostics space. Can he 'nuke' his naysayers once again?

Do write in and tell us who you'd like to see featured next in the 'Spotlight' as well other segments. We hope that our coverage of these movers and shakers highlights the many opportunities in radiology and imaging, both as a challenging profession for healthcare practitioners as well as a business opportunity. Besides a lack of doctors and nurses, India faces a dearth of radiographers. Only when we have adequate personnel qualified in the latest imaging techniques, can we reap its full potential as one of the most advanced diagnostic tools at our command today.

Viveka Roychowdhury viveka.r@expressindia.com

IMPRINTLINE

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4 IN IMAGING

OCTOBER 2012

CONTENT IN IMAGING | OCTOBER 2012 COVER

STORY

Probing legalities of Ultrasound An analysis on the field of diagnostic ultrasonography, ethical issues connected to this subject and the legal premise under which it is supposed to be practised PAGE 16

A Kohinoor indeed!

21

This new column in In Imaging, which endeavours to profile radiology set-ups at different hospitals across the country. PAGE 25

'Siemens will come up with better, faster and affordable solutions in clinical imaging' Bernd Montag, Global CEO, Healthcare Imaging & Therapy Systems Division, Siemens Healthcare discusses current imaging trends and factors driving the imaging market PAGE 32

29

USG in breast cancer: the old and the new Dr Arjun Poptani, Sr Radiologist, Rockland Hospital elaborates on the various usages of Ultrasound in the detection and diagnosis of breast cancers PAGE 36

34

‘I expect to see steady growth in the number of CT scanners in India’ Dr Lawrence Boxt, MD Cardiovascular Disease Physician, Diagnostic Radiologist in Bronx, New York, speaks on the concept of cardiac imaging which has been greatly expanded by the advances in CT technology PAGE 42

46

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NEWS

New MRI technique identifies early-stage coronary disease The techniques measures the wall thickness of the coronary arteries to identify the risk of CAD

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study is published online in the journal Radiology states that researchers are close to finding an imaging technique that can identify thickening of the coronary artery wall, an early stage of coronary heart disease (CAD).

Lead researcher Khaled Z AbdElmoniem, staff scientist in the Biomedical and Metabolic Imaging branch of NIH’s National Institute of Diabetes and Digestive and Kidney Diseases said, “Imaging the coronary arteries that supply the heart with blood is extremely difficult because they are very small and constantly in motion. Obtaining a reliable and accurate image of these vessels is very important because thickening of the vessel wall is an early indicator of atherosclerosis.”

“We currently have no reliable way to non-invasively image coronary artery disease in its early stages, when the disease can be treated with lifestyle changes and medications to lower cholesterol,” informed Dr Abd-Elmoniem.

The researchers used MRI to measure the wall thickness of the coronary arteries in 26 patients with at least one risk factor for CAD and 12 healthy control participants matched to patients by body mass index (BMI). The mean age of the patients, comprising 13 men and 13 women, was 48; healthy controls included three men and nine women (mean age 26).

8 IN IMAGING

To measure the coronary artery wall thickness, the researchers used both, a single-frame MRI scan and an MRI technique called timeresolved multi-frame acquisition, in which five continuous images are captured in order to increase the success rate of obtaining an image free of blurring. Using the timeresolved multi-frame acquisition method, the success rate for obtaining a usable image was 90 per cent versus a success rate of 76 per cent for the single-frame method.

Use of the time-resolved multi-frame technique also resulted in a greater ability to detect a significant difference between the wall thickness measurements of CAD patients and the healthy participants, as well as a smaller standard deviation, which is indicative of more precise measurements. “These results suggest that MRI may be used in the future to screen for individuals at risk for coronary artery disease and may be useful for monitoring the effects of therapies,” Dr Abd-Elmoniem said.

Dr Abd-Elmoniem also said that unlike blood tests which measure cholesterol and lipids in the blood, which can be indicators of atherosclerosis, the thickness of coronary artery walls is a direct measurement of early-stage CAD. He said additional studies are needed to validate this multi-frame MRI technique. ■ EH News Bureau

PGIMER to start paediatric radiology course

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ost graduate Institute of Medical Education and Research (PGIMER) is planning to introduce a fellowship programme on paediatric radiology by next year. Officials in the department of radio-diagnosis informed that the premier medical institute’s academic committee has already approved two seats for a paediatric radiology fellowship and the final approval is awaited from the PGI governing body.

“Paediatric radiology is a novel sub-specialty in the field of radiology for diagnosis and treatment of diseases in children. It is important to remember that children are not miniature adults and their ailments are different from grown up individuals. It is also very pertinent to keep the radiation dose during the imaging to as low as possible in order to reduce the risk of radiation to the paediatric patient population,” Dr N Khandelwal, head, department of Radio-diagnosis, PGIMER said.

The improvement of imaging modality and other technical advancements have widened the diagnostic range for paediatric radiologists, he added.

The recently held 10th annual conference of the Indian Society of Paediatric Radiology (ISPR) organised by PGIMER saw experts deliberating on the present status of paediatric radiology in India vis-a-vis the global scenario. The focus of the conference was on recent advances and innovations in technology and techniques related to paediatric radiology. ■ EH News Bureau OCTOBER 2012

NEWS

FDA nod for Philips and Celsion’s Phase II study of ThermoDox and MR-guided HIFU in bone cancer The companies expect to initiate a Phase II study in the later half of 2012

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oyal Philips Electronics and Celsion Corporation have received the US FDA clearance to initiate a clinical study supporting a joint development programme for Celsion’s ThermoDox combined with Philips' Sonalleve MR-guided high intensity focused ultrasound (MR-HIFU) technology for the palliation of painful metastases to the bone caused by lung, prostate or breast cancers. The companies expect to initiate a Phase II study in the second half of 2012.

ThermoDox combined with MRHIFU will be investigated for pain palliation in patients with bone metastasis. Cancer progresses to the bone in a majority of patients with late-stage breast, prostate or lung cancer, with estimates of between 300,000 to 500,000 cases annually in the US. Patients may experience excruciating and unrelenting pain, often treated with opiate drugs and non-steroidal anti-inflammatory drugs (NSAIDs) with only modest benefit. External beam radiation therapy is effective in palliating painful bone metastasis, but is limited by accumulating toxic effects to normal organs. Philips’ MR-HIFU system has the potential to precisely and non-invasively target lesions with acoustic energy, creating sufficient heat to activate ThermoDox and preferentially release high concentrations of doxorubicin in the targeted treatment area. Celsion is OCTOBER 2012

developing the combination of ThermoDox and MR-HIFU through a joint research agreement with Philips Healthcare, a division of Royal Philips Electronics. “The combination of Philips’ MR-HIFU system, a high-precision, heat-based therapy, and ThermoDox, a heattriggered oncolytic agent, holds great potential in that it gives us the ability to combine non-invasive thermal treatment with local delivery of high concentrations of potent, wellcharacterised anti-cancer drugs directly in a target area,” said Falko Busse, VP and GM, MR Therapy for Philips Healthcare. This multimodality approach could be transformative for the treatment of a number of cancers.

“Celsion is excited to evaluate ThermoDox in combination with MR-HIFU as a next generation, noninvasive treatment for a variety of cancers; a logical step to expand ThermoDox’s great potential in oncology. FDA’s clearance to clinically study the combination of ThermoDox and MR-HIFU is a cornerstone of this joint Celsion/ Philips effort,” said Michael H Tardugno, Celsion’s President and CEO. “As a recognised world leader in health care technology, Philips brings tremendous resources to this development pathway for ThermoDox, optimising its role in cutting edge medicine.” ■ EH News Bureau

Toshiba names CT Business Unit Senior Director Misra will devise strategies to enhance Toshiba’s visibility in the CT market

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oshiba America Medical Systems has named Satrajit Misra as its Senior Director, CT Business Unit.

Building on Toshiba’s success in the CT market, in this position, Misra will implement tactical and strategic marketing plans for Toshiba’s CT product line to enhance visibility for company and its products within the marketplace.

“Satrajit Misra’s deep knowledge of medical imaging and informatics is an ideal fit as we continue to partner with customers on integrated diagnostic solutions,” said Doug Ryan, Vice President, Marketing and Strategic Development, Toshiba. “His expertise will help Toshiba maintain its CT leadership position.” Toshiba Medical Systems is a leading worldwide provider of medical diagnostic imaging systems and comprehensive medical solutions, such as CT, X-ray and vascular, ultrasound, nuclear medicine and MRI systems, as well as information systems for medical institutions.

Prior to joining Toshiba, Misra has served as Senior Director and Head of Product Marketing for Nuclear Medicine at Philips Healthcare and was a Medical Systems Director of Business Management at Siemens.

EH News Bureau IN IMAGING 9

NEWS

Alliance Transfusion becomes Christie Medical Holdings' Indian distributor

New Automated Breast Volume Scanner at Jaslok KAMBLI, EH News Bureau

RAELENE

The companies have joined hands to distribute its award-winning VeinViewer vascular imaging devices

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hristie Medical Holdings, a US company has tied up with Alliance Transfusion as its distributor in India for the VeinViewer vascular imaging devices.

VeinViewer is a hand-held vein illuminator that uses harmless near-infrared light and other technologies to project a real-time digital vein image directly onto the surface of the skin.

VeinViewer displays vasculature and blood patterns up to 10 mm deep offers features like durability and portability to healthcare professionals.

The new model, VeinViewer Flex, first introduced in the US market in late 2011, will now be available in India as well. The VeinViewer vascular imaging device won the Medical Design Excellence Award (MDEA) in 2011 in New York, for medical design and innovation. The MDEA competition contributions and advances in the design of medical products. Entries are evaluated on the basis of the design and engineering features, including innovative use of materials, user-related functions that improve traditional medical practices and the ability of the product development team to overcome design and engineering challenges so 10 IN IMAGING

that the product meets its clinical objectives.

VeinViewer is the only directprojection vein illumination device clinically proven to improve peripheral vascular access while reducing the number of sticks and greatly improving patient satisfaction. Flex offers a customisable set of features through VeinViewer’s ASSESS imaging suite, as well as capabilities of digital real-time imaging via active vascular imaging navigation (AVIN).

VeinViewer provides a number of benefits to practitioners and patients, from easing the process during a paediatric blood draw to improving vascular access for a cancer patient. Patients and practitioners will see improvement in vascular access procedures, patient outcomes and cost savings. VeinViewer also increases successful vascular access, reduces pain and increases patient satisfaction. Among the benefits that practitioners can expect are improvements in patient throughput; a reduction in secondary procedures and treatment delays and an increase in referrals and revenue. ■ EH News Bureau

Mumbai’s Jaslok Hospital recently installed a Automated Breast Volume Scanner (ABVS) that helps acquire, analyse and report on detailed sonographic volumes of intricate breast anatomy and pathology. This system is known for its quick scanning process and early detection. Dr Chander Lulla, Consultant Radiologist, Jaslok Hospitals said, “1 in 22 Indian women are affected by breast cancer and the chances of survival are only 50 per cent as detection happens at a later stage. In this regard, the ABVS is going to help us detect breast cancers early."

The ABVS gives an overview of the breast like a geographic map and allows virtual scans. The ABVS system at Jaslok Hospital is the first one in the country so far. Dr (Col) RR Pulgaonkar, CEO, Jaslok Hospital, said, “We are happy to have acquired this scanner which provides a 3D detail of the whole breast relatively swiftly which was not possible before.

It will also benefit patients with minimal compression during examinations, allowing them to breathe comfortably making for a less stressful experience”.

Dr Mukund Joshi, Senior Radiologist, Jaslok Hospital, termed the ABVS as a "breakthrough technology." The ABVS is a relatively less painful diagnostic tool that mammography and allows a more detailed and clearer image thatn a conventional mammogram. ■ EH News Bureau OCTOBER 2012

NEWS

Piramal Imaging and IBA Molecular tie up for new imaging agent

New MRI method to reduce breast biopsies

Signed a global agreement for new F-18 Amyloid imaging agent called Florbetaben

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iramal Imaging SA (Piramal) and IBA Molecular have announced an agreement whereby IBA Molecular will manufacture and distribute 18F-Florbetaben, Piramal’s new diagnostic imaging agent, in the European and US markets. 18F-Florbetaben is a radiopharmaceutical currently in development for use with positron emission tomography (PET) for the detection of beta-Amyloid plaque deposition in the brain, a pathological feature associated with Alzheimer’s disease and other neurologic conditions.

Recently announced results from Phase III studies indicate that PET imaging with 18F-Florbetaben reliably detects beta-Amyloid in the brain with great accuracy and may have potential as an aid in the diagnosis and assessment of Alzheimer’s disease. The visual assessment procedure proposed for routine clinical practice demonstrated 100 per cent sensitivity and 92 per cent specificity with excellent inter-reader agreement (kappa=0.88). This pivotal trial was the first to overlay MRI and PET data to accurately match Florbetaben gray matter uptake with disease in six defined regions of the brain.

This was done to confirm that Florbetaben binds to beta-Amyloid on both a regional (brain sections) and subject (whole brain) level. This combination provided considerably OCTOBER 2012

more data points than any other beta-Amyloid tracer trial to date.

“We are committed to creating a strong global pharma business based on intellectual property.

18F-Florbetaben is our lead compound in the molecular imaging business, and we are confident that it has the potential to increase clinicians’ accuracy and confidence,” said Ajay Piramal, Chairman, Piramal Group.

“The 18F-Florbetaben distribution agreement with Piramal will allow us to provide, upon its approval, one of the most anticipated compounds in nuclear medicine to our network of customers. We have seen data from the global phase III results of 18F-Florbetaben, and recognise the significant potential of this compound. We are looking forward to joining forces with the Piramal team in their worldwide launch of the product,” said Renaud Dehareng, CEO of IBA Molecular.

Piramal recently acquired the intellectual property (including patents, trademarks and knowhow), worldwide development, marketing and distribution rights of the lead compound 18F-Florbetaben as well as other clinical and pre-clinical assets of Bayer Healthcare’s molecular imaging business to form its imaging subsidiary, Piramal Imaging SA. ■ EH News Bureau

iffusion-weighted imaging (DWI), an MRI technique that calculates the apparent diffusion coefficient (ADC)—a measure of how water moves through tissue is being touted as a promising tool for distinguishing between benign and malignant breast lesions. Water diffusion measurements with MRI could decrease false-positive breast cancer results and reduce preventable biopsies, according to a new study published online in the journal Radiology.

Researchers said the technique also could improve patient management by differentiating high-risk lesions requiring additional workup from other nonmalignant subtypes. The science behind DWI is that normal breast tissue has a high ADC because water moves through it relatively freely, while most cancers have a lower ADC because their cells are more tightly packed and restrict water motion. However, significant overlap exists between the ADC values of non-malignant lesions and breast malignancies, and little is known about the ADC values of specific subtypes of non-malignant lesions.

“DWI only adds a couple of minutes to the MRI exam and does not require additional contrast or any extra hardware,” said Dr Savannah C Partridge, research associate professor at the University of Washington, Seattle Cancer Care Alliance. The research team is planning a multi-centre trial to validate the findings and determine how to best to incorporate ADC measures into clinical breast MRI interpretations. ■ EH News Bureau IN IMAGING 11

NEWS

Study: Ultrasound waves can boost skin’s permeability to drugs It was also found that ultrasound waves of different frequencies can uniformly boost permeability across a region of skin more rapidly than using a single beam of ultrasound waves

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IT engineers have found a way to improve the permeability of skin to drugs using ultrasound waves, thereby making transdermal drug delivery more efficient. The researchers are expecting this technology to pave the way for noninvasive drug delivery or needle-free vaccinations.

“This could be used for topical drugs such as steroids — cortisol, for example — systemic drugs and proteins such as insulin, as well as antigens for vaccination, among many other things,” says Carl Schoellhammer, an MIT graduate student in chemical engineering and one of the lead authors of a recent paper on the new system.

Ultrasound — sound waves with frequencies greater than the upper limit of human hearing — can increase skin permeability by lightly wearing away the top layer of the skin, an effect that is transient and pain-free. The research team published a paper in the Journal of Controlled Release wherein they found that applying two separate beams of ultrasound waves — one of low frequency and one of high frequency — can uniformly boost permeability across a region of skin more rapidly than using a single beam of ultrasound waves.

In the new study, the MIT team found that combining high and low frequencies offers better results. The high-frequency ultrasound waves

12 IN IMAGING

generate additional bubbles, which are popped by the low-frequency waves. The high-frequency ultrasound waves also limit the lateral movement of the bubbles, keeping them contained in the desired treatment area and creating more uniform abrasion, Schoellhammer says.

The researchers tested their new approach using pig skin and found that it boosted permeability much more than a single-frequency system.

First, they delivered the ultrasound waves, then applied either glucose or inulin (a carbohydrate) to the treated skin. Glucose was absorbed10 times better, and inulin four times better.

“We think we can increase the enhancement of delivery even more by tweaking a few other things,” Schoellhammer says.

NONINVASIVE DRUG DELIVERY

Such a system could be used to deliver any type of drug that is currently given by capsule, potentially increasing the dosage that can be administered. It could also be used to deliver drugs for skin conditions such as acne or psoriasis, or to enhance the activity of transdermal patches already in use, such as nicotine patches.

Such devices also hold potential for administering vaccines, according to the researchers. It has already been shown that injections into the skin can induce the type of immune

response necessary for immunisation, so vaccination by skin patch could be a needle-free, pain-free way to deliver vaccines. This would be especially beneficial in developing countries, since the training required to administer such patches would be less intensive than that needed to give injections. The Blankschtein and Langer groups are now pursuing this line of research.

They are also working on a prototype for a handheld ultrasound device, and on ways to boost skin permeability even more. Safety tests in animals would be needed before human tests can begin. The US Food and Drug Administration has previously approved single-frequency ultrasound transdermal systems based on Langer and Blankschtein’s work, so the researchers are hopeful that the improved system will also pass the safety tests.

The research was funded by the National Institutes of Health. Senior authors of the paper are Daniel Blankschtein, the Herman P Meissner ’29 Professor of Chemical Engineering at MIT, and Robert Langer, the David H. Koch Institute Professor at MIT. Other authors include Baris Polat, one of the lead authors and a former doctoral student in the Blankschtein and Langer groups, and Douglas Hart, a professor of mechanical engineering at MIT. ■ EH News Bureau OCTOBER 2012

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NEWS

1st US FDA approval for breast ultrasound imaging system

Molecular imaging could improve surgery outcomes

Device designed to help healthcare providers detect smaller tumours in women with dense breast tissue

SACHIN JAGDALE, EH News Bureau

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he US Food and Drug Administration (US FDA) has approved the first ultrasound device for use in combination with a standard mammography in women with dense breast tissue who have a negative mammogram and no symptoms of breast cancer.

Called the somo-v Automated Breast Ultrasound System (ABUS), it can automatically scan the entire breast in about one minute to produce several images for review.

As part of the approval process, the FDA reviewed results from a clinical study in which board-certified radiologists were asked to review mammograms alone or in conjunction with somo-v ABUS images for 200 women with dense breasts and negative mammograms.

Biopsies were performed on masses detected with the somo-v ABUS to determine if they were cancer. The results show a statistically significant increase in breast cancer detection when ABUS images were reviewed in conjunction with mammograms, as compared to mammograms alone.

“A physician may recommend OCTOBER 2012

It is expected to minimise errors by protecting vital tissues from inadvertent damage during surgery

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additional screening using ultrasound, for women with dense breast tissue and a negative mammogram,” said Alberto Gutierrez, Director of the Office of In Vitro Diagnostic Device Evaluation and Safety at FDA’s Centre for Devices and Radiological Health.

“The somo-v ABUS is a safe and effective breast ultrasound tool when such screening is recommended,” he added.

The somo-v ABUS is approved for use in women who have not had previous clinical breast intervention, such as a surgery or biopsy, since this might alter the appearance of breast tissue in an ultrasound image.

As part of the approval, FDA has required that the manufacturer provide thorough training for physicians and technologists using the ABUS device, and that the manufacturer provide each facility with a manual clearly defining system tests required for initial, periodic, and yearly quality control measures.

The somo-v ABUS is marketed by Sunnyvale, Calif.-based U-Systems Inc. ■

olecular imaging, particularly optical imaging has begun to get recognition in the field of image-guided surgery. This form of interoperative florescence imaging will minimise errors during surgery, protecting vital tissues like nerves from inadvertent damage during surgery. Dr Rao Papineni, an Indian origin scientist from Carestream Health Inc, US, has teamed up with a few research groups at Baylor College of Medicine; to identify and evaluate near-IR fluorescence bound plant lectin as a suitable candidate for a surgical nerve contrast molecular probe.

Papineni informs, “This particular lectin is originally from wheat. Dr Scott Wellnitz, a post-doc had screened several of these sugar binding plant lectins from lentils, legumes, and cereals during the process of identification.” Other investigators are Dr Steen Pedersen, Dr Pautler of Baylor College of Medicine and Dr Daniel Kim, a neurosurgeon at University of Texas.

Papineni suggested stringent assessment on toxicity issues and other sideeffects, before the suregeons used such a spray in clinics to distinguish nerve endings during surgical procedures.

These optical-image guided surgical techniques are expected to gives best outcome for the patients through protection of vital organs. ■

EH News Bureau

EH News Bureau IN IMAGING 15

C O V E R

S T O R Y

PROBING LEGALITIES OF ULTRASOUND M NEELAM KACHHAP examines the field of diagnostic ultrasonography, ethical issues connected to this subject and the legal premise under which it is supposed to be practised

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edico-legal cases are on the rise in India. Although all fields of medicine attract medico-legal attention, recently, the field of diagnostic sonography has been in the public-eye. The medico-legal limelight is focussed on ultrasonography and sonologists, thanks to the recent media attention and celebrity talk show on female foeticide. Sex determination and subsequent female foeticide is an inhumane as well as illegal act. However, the issue of sex determination is only one of the many legalities associated with ultrasonography since it has vast applications in diagnostic imaging.

From soft tissue imaging to treatment of lesions, today ultrasonography is used for a variety of purposes in medicine. Thus a sonologist could face the court, not only for violating The Pre-conception and Pre-natal Diagnostic Techniques (PC/PNDT) Act but also for a lot of reasons like missed diagnosis, invented lesions,

OCTOBER 2012

misreported lesions, etc.

IGNORANCE IS NOT BLISS India has witnessed rapid developments in healthcare practice, with newer technologies and interventions promising better outcomes for patients. Informed patients are expecting more from doctors, leading to increasing dissatisfaction on the patients' part. In these times, where medico-legal cases against doctors are witnessing a sharp rise, being abreast of the fast changing laws has become even more important. Despite this, there are many sonologists who are not acquainted with the legalities of ultrasonography. "Most sonologists are unaware of the categories of litigation arising out of medico-legal issues in ultrasonography," says Dr Madhavan Unni, Professor and Consultant Radiologist, Kerala Institute of Medical Sciences (KIMS), Kerala. Seconding this, Dr Priya Chudgar, Senior Consultant IN IMAGING 17

COVER STORY Radiologist, Kohinoor Hospital, Mumbai avers, "To err is human and radiologists are also human beings. It is not uncommon in radiology practice to miss a diagnosis." Ignorance of law is not a defence. One cannot stand in court and say, 'I was unaware of the law'. It is upto the individual doctors to keep abreast of the rapidly changing laws and indemnify themselves. Like medicine, law also has its own language which needs to be comprehended by the doctors to fully understand the impact.

MEDICAL NEGLIGENCE The most common complaint registered against a doctor is of medical negligence. But, does it apply to sonologists? Yes, it does! "A mistake committed by the sonologist during the course of his professional duty, could be considered as a 'Tortuous Act',” opines Diljeet Titus, Founder, law firm Titus & Co, New Delhi.

The laws governing medical negligence are, by far and large, a section of Law of Tort, in addition to Indian Contract Act. "Tort is a civil wrong, as opposed to a criminal wrong where a defendant breaches a duty to the plaintiff (complainant). Negligence may be defined as the “breach of a duty caused by the omission to do something which a reasonable man, guided by those considerations which ordinarily regulate the conduct of human affairs would do, or doing something which a prudent and reasonable man would not do”. The definition involves three constituents of negligence: a legal duty to exercise the due care; breach of the said duty; consequential damage," explains Sajid Mohamed, Partner, PDS & Associates, Mumbai. He adds that to be successful, the plaintiff must establish that the defendant (sonologist) owed a duty of certain care towards the patient, this duty was 18 IN IMAGING

Most sonologists are unaware of the categories of litigation arising out of medico-legal issues in ultrasonography

Documentation and archiving are extremely crucial for every radiology report, so also for sonography

Dr Madhavan Unni Professor and Consultant Radiologist, KIMS

Dr Priya Chudgar Senior Consultant Radiologist Kohinoor Hospital

breached, and this breach resulted in the immediate proximate damage to the patient directly or indirectly. At times one feels that the plaintiff has a difficult task to prove this, but in reality it is a doctor's own lack of proper documentation and non-observance of standard operating procedures (SOPs), which makes it easier for the plaintiff to establish negligence on the part of the doctor. Duty of care is established as soon as the patient walks into a doctor's clinic and submits him/herself to examination. A doctor-patient relationship thereby comes in to existence.

The Supreme Court in Laxman v.

Trimbak, held, “The duties which a doctor owes to his patient are clear. A person who holds himself out ready

to give medical advice and treatment impliedly undertakes that he is possessed of skill and knowledge for the purpose. Such a person, when consulted by a patient owes him certain duties viz., a duty of care in deciding whether to undertake the case, a duty of care in deciding what treatment to give or a duty of care in the administration of that treatment. A breach of any of those duties gives a right of action for negligence to the patient. The practitioner must bring to his task a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. Neither the very highest nor very low degree of care and competence judged in the light of the particular circumstances of each case is what the law requires.”

OCTOBER 2012

COVER STORY LEGALITIES IN ULTRASONOGRAPHY Other than negligence there are other legalities in ultrasonography such as missed diagnosis, invented lesions, and misreported lesions "Missed diagnosis in ultrasonography is a disease/lesion which could not be interpreted properly, and reported appropriately by the sonographer, in spite of it being there and is obvious when another sonographer does the ultrasound scan with reasonable skill and care within reasonable time from the first scan," informs Dr Unni.

"Radiologic errors are of two types: cognitive, in which an abnormality is seen but its nature is misinterpreted, and perceptual or the ‘miss’, in which a radiologic abnormality is simply not seen by the radiologist on initial interpretation. The perceptual variety accounts for approximately 80 per cent of all radiologic errors. Because radiologic errors are common, and allegations that a diagnostic error has been committed account for 70 per cent of all medical malpractice lawsuits filed against radiologists, it is no wonder that radiologists are being forced into the courtroom as defendants in malpractice actions with disconcertingly high frequency," elaborates Dr Chudgar.

"The Supreme Court of India, in Jacob Mathew v. State of Punjab (2005) 6 SCC 1, held that, “A professional may be held liable for negligence on one of the two findings: either he was not possessed of the requisite skill which he professed to have possessed, or, he did not exercise, with reasonable competence in the given case, the skill which he did possess.

The standard to be applied for judging, whether the person charged has been negligent or not, would be that of an ordinary competent person exercising ordinary skill in that profession. It is not possible for every professional to OCTOBER 2012

A mistake committed by the sonologist during the course of his professional duty, could be considered as a 'Tortuous Act’

The legal relationship of the sonologist to the technician (sonographer) is governed by the law of agency

Diljeet Titus Founder, Titus & Co New Delhi

Sajid Mohamed Partner PDS & Associates

possess the highest level of expertise or skills in that branch which he practices.

A highly skilled professional may be possessed of better qualities, but that cannot be made the basis or the yardstick for judging the performance of the professional proceeded against on indictment of negligence. “Accordingly, we believe that ‘missed diagnosis’ could be equivalent to ‘medical negligence’ in the eyes of law if the test described above is proven. Examples of missed diagnosis are instances when an ultrasonologist fails to report an anomaly e.g. a twin pregnancy which is then subsequently picked by a second ultrasonography done by himself or by a peer or something that goes unnoticed and leads to a complicated clinical outcome. In such cases, a ultrasonologist has the right to adopt a

defence of "difficult foetal positioning", "scanty liquor", limitations of the machine etc., but the case will be judged on its own merit and an expert's testimony,” says Titus.

Invented lesions are instances where findings were reported when none existed. Misreported lesions are cases where the findings were not missed but incorrectly reported or interpreted.

DOES CONSENT MATTER IN ULTRASONOGRAPHY? The element of consent is a critical issue in medical treatment. In an article 'Consent and medical treatment: The legal paradigm in India', Dr Omprakash V Nandimath, Associate Professor, National Law School of India University, Bangalore, says that the patient has a legal right to autonomy IN IMAGING 19

COVER STORY and self determination enshrined within Article 21 of the Indian Constitution.

He can refuse treatment except in an emergency situation where consent is not needed. The consent obtained should be legally valid. A doctor who treats without valid consent will be liable under the tort and criminal laws.

The law presumes the doctor to be in a dominating position, hence the consent should be obtained after providing all the necessary information.

"This may perplex many sonologists who may wonder if they need to take an express consent even for a "routine" ultrasonography. However, they must appreciate that it is likely that a plaintiff will raise the lack of informed consent as a cause for legal action coupled with an action in negligence. The problem would be compounded when there is a gap in the understanding of an implied consent in the mind of doctor and the patient. Thus, it is always useful to have a clearly written consent outlining all terms and exceptions. In emergency procedures, when patients are unable to give consent, a physician may be excused from such discussion or obtaining consent. In case of minors, consent must be obtained from their lawful guardians,” adds Titus.

LEGAL RESPONSIBILITY IN GROUP PRACTICE Usually sonologists practising in a group or under an employee are also liable to the law. "The legal relationship of the sonologist to the technician (sonographer) is governed by the law of agency," says Mohamed. He adds, "The agent (sonographer) is a person who by a contractual relationship acts for, or under the control of, or by the direction of a principal (sonologist). In a private clinic, the sonographer will be the direct employee of the physician. It is extremely important that the physician never delegate his or her duties to the sonographer. It is the 20 IN IMAGING

physician's duty to give the diagnosis.

In a group practice, as far as possible, one should report on the procedure that one has performed. If the fiduciary relationship is in the capacity of partners in a group, then the responsibility will be jointly as well as severally."

However, Dr Chudgar paints a different picture. "In the current Indian setting of sonography practice, technicians do not play an important role, as most ultrasounds are performed by radiologists. However this may be an issue in group practice . It needs to be clarified beforehand with separate indemnity insurance and thus prime responsibility is on the signing person," she admits.

SIGNIFICANCE OF DOCUMENTATION Documentation is the holy grail of medico-legal issues. It is of utmost importance to either incriminate or release the sonologist from any kind of legality. Therefore, it is very important to maintain proper documentation.

"Ultrasound report is a scientific professional opinion. It has to be written, documented and signed with extreme care. It should not be taken as a document for legal purpose, by a layman or person unable to understand its technical limitations," warns Dr Unni. Dr Chudgar agrees, "Documentation and archiving are extremely crucial for every radiology report, so as for sonography. It works as best evidence for medico legal issues. If patient is uncooperative or body habits make it difficult for complete evaluation, it is necessary to mention in reports. Many times some organs are partially obscured by bowel gas or not optimally evaluated due to patient related l imitations, note of same can be made in report. In case any doubt, differential diagnosis can be given or clinical/pathological correlation can be recommended. It is important to

understand that radiological tests are adjunct to clinical diagnosis and not final authority. Every modality has its limitations, for e.g. bowel pathologies are not always detected on ultrasonography. Clinicians need to be aware of such issues. Also radiologists should take complete responsibility of their reports. It is important to check every report and sign it personally. These precautions will surely reduce errors."

Providing the legal aspect Titus says, "The documentation process and sign-posting are of crucial importance in the medical field. With regards to report writing, vague and meaningless reporting must be avoided.”

Mohammed adds, “Law holds sonologist responsible for lapses in their own conduct, irrespective of any liability that might be imposed on other physicians. Clinicians often receive reports which are described with wide variation and there is lack of uniformity in the terminologies used.” “National associations of ultrasonologists should formulate a lexicon of terminologies and definitions to provide standardised language in reporting images. A report must describe in its body a complete description of all abnormalities - that is everything seen by the eyes - but in the conclusion should discuss only those findings that are important to arrive at the inference. When rendering radiology reports, radiologists should refrain from hedging, defined as the making of calculatedly noncommittal or ambiguous statements,” he advises.

Every sonologist should understand the sources of error in sonography and the elements of negligence that form the basis of litigation. Errors happen; what is important is to learn to accept them with honest, humble and communicative approach and to be alert.

Frequent errors need to be uncovered and highlighted, in order to prevent repetition of the same mistakes.■ mneelam.kachhap@expressindia.com OCTOBER 2012

SPOTLIGHT

DR VELUMANI'S ‘PET’ PROJECT After proving his mettle with Thyrocare, Dr Velumani’s new endeavour is to make PET scans affordable and accessible to the masses. Lakshmipriya Nair looks into his game plan for achieving this goal; and the role of his Nueclear Healthcare in doing so

M

any questioned his move, when Dr A Velumani, a scientist at Mumbai’s Bhabha Atomic Research Centre ( BARC ) left his plum government job and a secure future to set up his own pathology lab for thyroid testing as the first step to fulfill hi s dream of “serving 50 per cent of the world’s population for 50 per cent of their diagnostic needs at 50 per cent of the cost.” His business model, that comprised centralised testing laboratories offering the usual thyroid test at half the market price and trusting on the volumes of the tests taken to raise the bottom numbers, raised even more scepticism and doubt.

Yet a decade and half later, Thyrocare, a venture which was born in a 150 sq ft garage with an investment of Rs one lakh, has grown to become one of the largest thyroid testing facilities in the world. Today, it is a nation-wide networked diagnostic laboratory with 20,000 service centres across 1,000 cities across India and covering over 100,000 doc-

OCTOBER 2012

tors through 600 franchisees.

Accredited by National Accreditation Board for Testing and Calibration Laboratories (NABL) and also the College of American Pathologists (CAP), it has the capacity to conduct over 100,000 investigations per day in its current facilities based in Navi Mumbai which sprawls over 2,00,000 sq ft.

Recently, Norwest Venture Partners, who picked up a 10 per cent stake in Thyrocare valued it at Rs 1,200 crore or $220 million, double the value of the firm in 2010, when CX Partners invested Rs 188 crore valuing it at Rs 550 crore. Thus, as far as the profitability of the venture is concerned, the numbers speak for themselves.

Thyrocare proved Dr Velumani’s business acumen, established him as a successful entrepreneur and demonstrated that marching to a different drummer can sometimes be a very good idea. Apart from these personal triumphs, he also managed to prove a point on an issue

of national importance. While the world continued its debate on affordability vs quality in healthcare, Dr Velumani, through his Thyrocare venture, very effectively demonstrated that balancing both effectively and yet having a sound bottom line is by no means an impossible task.

VENTURING INTO NEW TERRAIN As an extension of his dream, Dr Velumani has now trained his focus on a new challenge, a new venture – offering low cost treatment to cancer patients. He has set up a new company, Nueclear Healthcare Ltd (NHL) to help him ‘provide a low cost and high quality diagnostic solution to cancer patients throughout the country.’

THE NUECLEAR STORY As the name itself suggests, Dr Velumani has chosen nuclear medicine as the medium to fulfill this aim.

He claims that though nuclear medicine has a lot of potential, it remains largely untapped. He points out that despite the presence of around 2000 cancer centres across the country, there are only 60-70 PET/CT scanners installed and they operate way below their actual capacity i.e

IN IMAGING 21

SPOTLIGHT 4-5 scans per day or sometime even per week while the capacity is about 20-30 scans per day. He blames the high costs of PET/CT scans, which can go as high as Rs 25,000 to Rs 40,000 per scan for this scenario. He and opines that PET scanning - a promising technology - is not being put to optimum use since it is unaffordable to a large chunk of the masses. NHL has been formed to get this obstacle out of the way by applying Dr Velumani’s motto of ‘Take less to get more”.

His game plan is more or less similar to the one he adopted while building up Thyrocare. He plans to offer PET/CT scans at around Rs 10, 000 each (as opposed to the current market price of Rs 25,000 per scan) by setting up a network of medical cyclotrons in 16 major cities across the country within a period of five years. He believes that this, in turn, would lead to wider usage of this technology and also contribute towards lowering the costs of cancer treatment to a certain extent. Thus, his plan is to make nuclear medicine more accessible to the masses by reducing the cost of PET scans, while earning a profit for himself. He claims, “Ten years from today, PET will be a strong industry. I am getting a foothold in it now itself.”

SUCCESS SAGA IN THE MAKING OR A FOOLHARDY VENTURE? Dr Velumani’s plans for Nueclear are king-size but will he be able to pull it off? A question that exists in the minds of almost everyone who is connected to the industry. Quite legitimate too, since there are some formidable challenges that stand in his path towards achieving his goal.

To name a few: Untested waters: First and foremost, the field is quite new to him.

22 IN IMAGING

OCTOBER 2012

SPOTLIGHT He has been into in vitro diagnostics (thyroid testing) and the dynamics of in vivo (PET scanning) could be quite different. Moreover, he is aiming to achieve a goal which no one else in the country has even attempted to do.

Hence, Dr Velumani has set forth on an uncharted journey without any set guidelines about the do's and don’ts, which makes it an extremely risky endeavour, at least as far as the financials are concerned.

Huge initial costs: The expense of setting up a PET/CT scanner, arranging for the supply of essential radiopharmaceuticals and transporting it to the scanning centres are very high, which accounts for the high cost of the scans. So, the question that arises is how will he manage to lower the costs of the PET/CT scans, something that the rest of players have not been able to do effectively until now?

Strict regulations: Dr Velumani will have to wade through several levels of bureaucracy, and strive for compliance with the strict safety regulations laid down by the Atomic Energy Regulatory Board (AERB) before he will be allowed to set up his centres and cyclotrons.

Low demand: Dr Velumani intends that each of his PET scanners should conduct around 25-30 scans each day.

However, there are people who claim that the kind of market demand that Dr Velumani is envisaging simply does not exist. Hence, he might find himself facing a situation where the demand is less than supply, which will cause him to incur huge losses.

DR VELUMANI:: GUNG-HO ON GROWTH However, while the world continues to speculate about NHL and its success, the man behind the endeavour has no qualms on any count.

Completely clear about his chosen path, he is quite sure that his venture OCTOBER 2012

GE Healthcare would provide 20 advanced PET/CT imaging systems and 12 PET Trace Medical Cyclotrons for NHL would succeed and help him in achieving his objectives. Moreover, he also has an answer to all the major concerns raised by the detractors.

Addressing the concern that he is new to the field of in vivo diagnostics, Dr Velumani says that he is quite ready to live and learn. He is of the view that enthusiasm and willingness to learn is more important than experience when it comes to achieving something.

He has an answer for the cost concerns as well. He accepts that PET scanners come costly but also states that if they are bought in bulk, as he intends to do, then it is definitely pos-

sible to cut down the price by a good margin. Suiting his words to action, the entrepreneur has struck a lucrative bargain with leading healthcare equipment player, GE Healthcare— they would provide 20 advanced PET/CT imaging systems and 12 PET Trace Medical Cyclotrons for NHL— on the grounds that anything purchased in volumes should come at a reasonable price. Thus, he has found a way to lower hardware costs.

Coming to the issue of radiopharmaceuticals as well as the isotopes needed for the scans, Dr Velumani informs that he intends to produce them in-house, which would help him in saving a substantial amount of money. Stating that the reason behind the high costs of radiopharmaceuticals is their short life span, he informs that their effectiveness gets halved after each 110 minutes. Hence if the scanning centres are far away from where the cyclotron is located, by the time these radiopharmaceuticals and isotopes get used, huge amounts are needed to serve the purpose, which in turn leads to escalating costs. He has decided to counter this problem by setting up the cyclotrons which would produce these reagents at an easy distance from the molecular imaging centres. He informs that his PET scanning centres would be located within a 300 km radius from each cyclotron that he plans to set up across the country, thereby creating clusters of molecular imaging centres around the cyclotrons. He reasons that as the transportation distances would be less, the effectiveness of the isotopes would be more and hence would require lesser amounts to be used, thereby causing a decrease in the cost per scan. Not to forget the amount saved in the transportation itself.

The process of putting all the approvals from AERB in place is also IN IMAGING 23

SPOTLIGHT on. While admitting that it is a timeconsuming affair, Dr Velumani is confident about getting it all together sooner or later. He plans to commence the whole enterprise with two machines in Mumbai and then Hyderabad. Both are likely to be operational by the end of December 2012; thereby marking the beginning of the first phase of his campaign for NHL; wherein he intends to set up cyclotrons and PET scanning centres in six major cities i.e. Mumbai, Delhi, Kolkata, Hyderabad, Coimbatore and Bangalore.

He also doesn't share the view of the cynics who claim that 30 PET scans per day at each centre is a pipe-dream. On the contrary he says, “Molecular imaging and nuclear medicine are at a nascent stage presently, however it has tremendous potential.

The problem is that no one is creating a market, all are intent on only consuming the existing one.” He believes that when the medical fraternity and patients see that it is possible to get PET scans at affordable rates, many more would opt for it, thereby increasing demand. “No one has lost business if they have priced their products low,” he states.

CREATING A WIN-WIN SITUATION Elucidating further about his hub-and-spoke business model, he claims that it has three major benefits: higher efficiency, resource optimisation, and proximity to cyclotrons.

Dr Velumani also claims that his model offers a win-win situation to everyone involved, i.e. patients, doctors and scanning centres. Once his centres are in place, private practitioners would not have to send patients to big hospitals for PET scans, thereby standing the risk of losing them to huge hospital chains.

So, while the patient benefits in terms 24 IN IMAGING

I know that by the end of five years, I will have a Rs 100 crore turnover with 50 per cent profitability of affordability and quality, doctors get to retain their patients and the centres get more business and thus more profit.

Dr Velumani intends to adopt the franchisee model in the second phase of his growth plans for NHL. Here, anyone who has the space and the manpower to set up a scanning centre would be given the requisite machines and the isotopes by his company. In return, the centre would have to do a certain number of tests i.e. 20,000 scans in five years and offer 'X' amount per scan to NHL. CONQUERING NEW PEAKS Thus, Dr Velumani has huge plans for his new venture. He says, “I know

that by the end of five years, I will have a Rs 100 crore turnover with 50 per cent profitability.” The fact that his path is rocky and the destination lofty, only adds to its allure. While only time will tell whether he will succeed or fail in this venture, one would want to root for his success for the sheer confidence and conviction he has for his dream. To all detractors who consider his plans far fetched and crazy, it might be better to remember the famous American entrepreneur, Steve Jobs's words “The ones who are crazy enough to think that they can change the world, are the ones who do.” ■ lakshmipriya.nair@expressindia.com OCTOBER 2012

DEPARTMENT SCAN

A Kohinoor indeed!

With this issue, we introduce DEPARTMENT SCAN , a new column in In Imaging, which endeavours to profile radiology set-ups at different hospitals across the country.

Lakshmipriya Nair gives a synopsis of the radiology department at Kohinoor Hospital, Mumbai Radiology, which began as a subspeciality in medicine in the early 1900s, with the advent of X-ray, has emerged as a major diagnostic and treatment speciality in its own right, today. Advancements in technology, the growing knowledge about its applications, increasing disease burden, all have been instrumental in furthering the progress of radiology and its role in the medical scenario.

It has come a long way from the time when X-ray was introduced and moved to several more effective and new imaging modalities like ultrasound and magnetic resonance imaging, PET scanning, computed radiology and digital radiology.

Thus, it has undeniably become an integral part of healthcare diagnostics and delivery and this is evidenced by the fact that there is a fullfledged radiology department in almost all the major multi-speciality hospitals today. So, In Imaging, the specialist magazine from 'The Indian Express' group, which chronicles all the major developments and happenings radiology, brings its readers a new segment – an overview of the OCTOBER 2012

departments of radiology across different hospitals in the country. We intend to look at five aspects of the radiology departments, i.e. infrastructure, costing, technology, personnel and safety. The objective of the whole endeavour is to offer learning lessons in radiology and its management with different hospitals serving as case-in-point.

The first chapter of this series begins with the department of radiology at Kohinoor Hospital, a 150-bed multi-speciality hospital in Mumbai.

Established in 2009, it is spread over an area of approximately two lakh sq ft, five floors and two basements.

Apart from a team of qualified and skilled personnel, hi-tech infrastructure and several medical specialities, this hospital also boasts of being the first Platinum LEED-certified Green hospital in the country.

Kohinoor Hospital has a functional radiology department right from the time it began operations in 2009.

Since then it provides comprehensive radiology services to out-patients as well indoor patients. Besides this, the imaging services offered are impor-

tant to the hospital from the revenuegeneration perspective as well.

INFRASTRUCTURE The infrastructure of the radiology department is of paramount importance since without proper planning, designing, pre-requisite equipment and technology, radiology as a speciality cannot make an impact to healthcare delivery.

Kohinoor Hospital’s radiology department is situated on the ground floor and planned in such a way that it is very easily accessible from the casualty department. Explaining the rationale behind this layout, Dr Priya Chudgar, Senior Consultant at Kohinoor Hospital informs that since it is the casualty department which more often than not needs to use the radiology department on an emergency basis, it is better to have both departments at easily accessible locations from each other. She also informs that to a great extent, the department’s layout depends on the way processes in the department are aligned and take place. The major functional areas of the radiology department at Kohinoor Hospital are: ● Reception and Waiting area ● Change room (for patients) ● X-ray rooms ● Processing room (Dark room) ● Mammography room IN IMAGING 25

DEPARTMENT SCAN ● ● ● ● ● ●

Ultrasonography room MRI room with console room CT room with console room Storage space Report preparation area Radiologist’s office

INVESTMENT AND RETURNS While Kohinoor Hospital’s radiology department has been operational from the day the hospital began functioning, Dr Chudgar informs that the estimate cost of setting up a radiology department is approximately Rs 6-7 crores for a unit catering to 300-400 patients. Dr Chudgar reveals that the radiology department is highly capital-intensive and hence needs very high maintenance as well to keep it functioning smoothly. “Our department has not reached break even for the investment in the last two years.

But it is growing by leaps and bounds, and soon it should be making great profits,” informs Dr Chudgar. She also discloses that a well-established radiology department can be an excellent source of indirect income, by bringing more patients, since clinicians feel safe to admit their patients in a hospital which has well established radiology services.

EQUIPMENT & TECHNOLOGY The success and effectiveness of a radiology department is dependent on the equipment and technology it uses on a daily basis. If put to good use, they can be instrumental in helping to reduce time, effort and errors in a big way. Kohinoor’s radiology department boasts of a 500 MA X-ray Unit and a 100 MA Portable XRay unit from Siemens (one for routine test and one for fluroscopy); an USG instrument and a Colour Doppler from GE Healthcare as well as a CT scanner and a MRI machine 26 IN IMAGING

from Siemens. These machines have been chosen for the variety of features that they offer since they help in enhancing the services for the benefit of the patients.

The department is also equipped with PACS, where images of all modalities can be archived for future use. It also enables viewing of images at multiple stations, without any delay. This system is integrated with HMIS, hence it is very easy to trace patient data from the system.

Thus, technology has been deployed effectively at Kohinoor Hospital’s radiology department to enhance the efficiency and effectiveness of its operations.

PERSONNEL Any department's true strength is the people who run it. The radiology department is no exception. It requires highly skilled personnel round-the-clock as the services of this department may be required in emergency. Kohinoor's radiology department has around 8-10 people working in shifts. Instead of a single department head, the department has a couple of senior radiologists, a couple of junior radiologists, technicians, nursing assistants, a receptionist and an attendant. However, the total manpower strength for a department catering 300-400 patients is approximately 18-20 personnel. Addressing this short staffing issue, Dr Chudgar explains that the hospital is gradually enhancing and building its radiology team.

However, she assures that the functioning of the department is very effectively managed by the existing staff since they work in eight-hour shifts and the staff are always present to handle any emergence situation.

Moreover, she also points out that the senior radiologists, even when they are off-duty are accessible and

can be consulted about any case through their very effective PACS system.

SAFETY Last, but definitely not the least are the safety measures incorporated at the radiology department. They are crucial since, if not properly handled, both the patients and the staff can be at risk. There are several approvals that are needed, many radiation protection measures have to be enforced, compliance with AERB regulations have to adhered etc.

Kohinoor Hospital’s safety measures for the radiology department includes the following: Protective measures ● Radiographers use 0.5 mm lead aprons while conducting portable and Fluroscopy examination. Each unit has a sufficient number of lead aprons. ● 0.5 to 1.5 mm lead protective barriers (shielding) are present at all the xray units, which helps to stop scatter radation. ● 0.5 mm lead thyroid and 0.5 mm lead gonald sheilds are used by the radiology, Cathlab and OT staff during Fluroscopy examination. ● 0.5 mm lead glass in CT Scan/CathLab console ● All the radiation source areas consists of 2.0 mm lead lined doors to prevent radiation from moving beyond the consoles. ● The consoles have 230 mm thick brick walls and the units are located in such a way that that the primary rays would be kept away from the public ● The average ceiling height of all the radiology rooms are 11 feet as per AERB norms ● Lead gloves and goggles are used by the technicians and radiographers while working with the equipment.

OCTOBER 2012

DEPARTMENT SCAN Suitable warnings A suitable warning signal in the form of a red light has been provided at a conspicuous place outside the X-ray rooms and it is kept “ON” when the units are in use to warn and prevent other patients and people, who are not connected with the particular examination, from entering the room. An appropriate warning placard has been posted outside the X-ray rooms. ● Notice in the local language is displayed at a conspicuous place in the X-ray department, wherein every female patient is asked to inform the radiographer or radiologist whether she is likely to be pregnant. Examination of women known to be pregnant are given special consideration.

Adherence with the PNDT Act ● It is an Act “to provide for the prohibition of sex selection, before or after conception, and for regulation of prenatal diagnostic techniques for the purposes of detecting genetic abnormalities or metabolic disorders or chromosomal abnormalities or certain congenital malformations or sex-linked disorders and for the prevention of their misuse for sex determination leading to female foeticide; and, for matters connected therewith or incidental there to.” ● The Kohinoor Hospital is registered under the PC/PNDT act which forbids pre-natal ultrasound for sexdetermination. A poster has been placed outside the ultrasound room stating the same and also discloses the fine and punshment for such an offence. ● Every patient is given a form 'F' to be filled with the signs of both the sonologist as well as the patient. ● All records, charts, forms, reports, consent letters and other documents are maintained under this ●

28 IN IMAGING

Act and the rules are preserved for a period of two years or for such period as may be prescribed, ● All such records, at all reasonable times, will be made available for inspection of the appropriate authority or to any other person authorised by the appropriate authority on his behalf Thus, a host of safety measures have been put into place at Kohinoor for the protection of the patients as well as the staff involved in the operations at the radiology department.

CONCLUSION Overall, the hospital has made a concerted to put together a good radiology set-up which would help to serve a variety of purposes. While there is always scope for improvement, for e.g. in the number of staff, a couple more advanced equipment etc, one has to admit that the current radiology department at Kohinoor Hospital quite adequate and self-sufficient. ■ lakshmipriya.nair@expressindia.com OCTOBER 2012

TECH SCAN

PICTURE PERFECT Sonosite's M-turbo ultrasound system has been known for its durability and picture quality. Raelene Kambli presents a retrospect view of its users

It’s been more than 100 years since radiology was introduced in the medical field. Since then, the landscape of this sphere has been ever changing.

Riding on the various advancements in technology, today the field of radiology has evolved from being purely diagnostic devices to interventional technologies. New contrast agents in X ray, MRI and ultrasound enable physicians to make accurate diagnoses and plan therapies with greater precision. The introduction of computer technology in radiology has changed the way radiologist and physicians view X-ray, CT and MRI reports. Digitalisation in radiology has further opened up new avenues for nuclear medicine. All this and more makes technology the driving force for radiology.

Therefore, ‘In Imaging', the specialised magazine that tracks the latest developments and happenings in the field of radiology presents a new segment- ‘Tech Scan'. This section would offer user reviews of popular imaging products available in the market.

Today, imaging systems are designed keeping in mind the user's requirements. In this review article we intend to highlight five important qualities such as technology used, image quality delivery, durability, user-friendliness and cost effectiveness of the product.

This month we sought user reviews of a popular portable ultrasound system - the M-Turbo. This system was introduced in the Indian market by Sonosite Inc, a name well-known in providing advance ultrasound systems.

OCTOBER 2012

This system was designed with an intention to overcome the challenges of conventional ultrasound systems which were bulkier in size and had too many applications, in turn making their handling quite difficult for physicians. The M-Turbo ultrasound system is used for abdominal, nerve, vascular, cardiac, venous access, pelvic, and superficial imaging. This ultrasound system offers striking image quality with sharp contrast resolution and clear tissue delineation to the physicians. These features helps them to visualise details, improving their ability to differentiate structures, vessels and pathology. The system can be used in applications such as anaesthesia, critical care, cardiology, cardiovascular disease management, emergency medicine, pain management, musculoskeletal, OB/Gyn, radiology, vascular, surgery, shared services andwomen’s health.

UNIQUE FEATURES According to Sonosite, the M-Turbo ultrasound system is designed to provide point-of-care diagnosis, keeping in mind the user's need for durability, high image quality and quick scanning process. The system offers an advanced set of features with a wide array of connectivity options that seamlessly connects physicians to hospital information networks and their own computers. Compared to Sonosite's earlier system, the M-Turbo has a 16-fold increase in processing power. The device also generates

remarkable improvements in image quality by simultaneously running multiple advanced algorithms.

Moreover, SonoADAPT Tissue Optimisation within the system eliminates complicated manipulation of multiple controls. SonoHD Imaging Technology reduces speckle noise and other image artifacts while preserving and sharpening tissue information and SonoMB Multi-beam Imaging increases resolution of small structures and enhancing border delineation. On the other hand, having ColorHD Technology enhances colour performance, sensitivity and frame rates for more diagnostic information.

The uses of this portable system are as follows: ● Drop tested – 3 feet/91.4 cm ● Fluid-resistant user interface for patient safety ● Quick boot-up time ● Easy operation ● Capture quality video clips up to 60 seconds long ● Battery-powered operation for true mobility ● PC- and Mac-friendly for effortless data management with 2 highspeed USB 2.0 ports ● Weighs 3.4 kg/7.5 lbs with battery ● Increased application flexibility with optional Triple Transducer Connect After understanding the unique features and benefits of the M-Turbo ultrasound system, we spoke to some users of the product who believe that IN IMAGING 29

TECH SCAN images and fully coloured pictures. If these criteria are take care of, then the M-Turbo will fulfill all requirements of people like me”. When asked about the cost effectivity and the ROI, he says, “The system costs around Rs 15 lakh but is very cost effective. One can easily get ROI in a short span of time.”

While Dr Arora is much impressed with the picture quality, Dr Surinder M.Sharma, Vice Chairman, OrthoAnaesthesia, Medanta – The Medicity, Gurgaon, speaks of the user-friendliness and the ability of the product to

this system has been quite useful during their medical procedures and in times of emergency.

Dr Deep Arora, Additional Director, Dept of Anaesthesiology and Pain Management, Fortis Memorial Research Institute, Gurgaon is of the opinion that the M-Turbo mostly fulfills his requirements of high resolution images and hassle free imaging. He stresses on the high quality images that one receives with the help of the MTurbo machine. He says, “I come from an anaesthesia background and I nor-

ultrasound technology is the difficulty to visualise images in certain areas.

What he requires is a ultrasound system that has few probes and can provide for visual visibility. The M-Turbo system fulfills these requirements.

When asked what is the most impressive feature of the M-Turbo, he replies, “Utility is the main feature of this ultrasound system. It can fit into an ICU set up and can be taken outside the hospital. Moreover, this system has improved picture quality and has a warranty between 0-5 years. I find this

User ratings Scale: 1-5 ( 5 being the highest) Name of the Doctor

Technology

Durability

Image quality

User-friendliness

Value for money

Dr Deep Arora

3.5

4

4

4

4

Dr Surinder M Sharma

5

5

4

5

4

Dr Sathish Chandra Govind

3

5

4.5

3.5

4

Dr Rajendra Goyal

4

5

4

4.5

5

mally use this system in the ICU. Since this is a portable system, it can be used in various scenarios. We can now provide for point-of-care delivery. What's unique about the product is that the system comes with different probes for setting high frequency and low frequency. High frequency is set for giving high resolution images while low frequency is used to capture images from deep within the body. Earlier, I was using another handheld ultrasound machine from Sonosite but the MTurbo gives 10 times higher resolution images than the previous one. Another aspect that I would like to point out is that the battery backup that we get along with this system makes it more reliable. The only drawback is that the system still does not provide for 3D OCTOBER 2012

provide accurate analysis. He states, “The M-Turbo is a light weight portable system that provides high quality images in comparison to the earlier one that we used. The system takes less time to boot, thereby reducing the time taken to complete the examination. It also has a good battery backup and what makes the system unique is that it has less buttons, making it a hassle free equipment. The most important feature of this product is that the system targets the organ very well, thereby giving an accurate picture and avoiding complications. Also it provides good ROI.” Dr Sathish Chandra Govind, Cardiologist and Head Echo Labs, Narayana Hrudayalaya Bangalore, feels that the biggest challenge of

system to be very durable”.

“A decent ultrasound system”, says Dr Rajendra Goyal, Sr Consultant and Head, Non Invasive Cardiology Dept., Bombay Hospital, Mumbai. He goes on to say, “As echocardiology is gaining importance, portable ultrasounds like these will also play an important role.

M-Turbo is extremely stable and has a good backup battery”.

FOOD FOR THOUGHT Overall, the users of M-Turbo system acknowledge the high picture quality, durability and user-friendliness of the product. However as with any other device, the system still has more scope for improvement. ■

raelene.kambli@expressindia.com IN IMAGING 31

INTERVIEW

'SIEMENS WILL COME UP WITH BETTER, FASTER AND AFFORDABLE SOLUTIONS IN CLINICAL IMAGING' BERND MONTAG, GLOBAL CEO, HEALTHCARE IMAGING & THERAPY SYSTEMS DIVISION, SIEMENS HEALTHCARE discusses current imaging trends, factors

driving the imaging market, Siemens Healthcare's plans for the Indian imaging market and more in an interaction with LAKSHMIPRIYA NAIR How has imaging in healthcare evolved over the years?

Let me just touch on three aspects: Quality, speed and accessibility. Talking about quality, earlier, clinical images were pictures of shady grey, thus very difficult to read. 3D imaging, functional imaging or visualising molecular information was unthinkable. Today, we are close to delivering a ‘digital copy’ of the patient, showing structures of less than one millimetre in high resolution and 3D. But I’m not only talking about reading images, we also offer equipment for image-guided therapies. For example, our angiography system, Artis zee enables surgeons to perform minimally-invasive interventions such as trans-catheter aortic valve implantation (TAVI) through image-guidance, replacing conventional invasive surgeries. In terms of speed, we are currently living a world, where our flagship CT Somatom Definition Flash is performing a heart scan in a split second. Ten years ago, we would not have even dared to dream of this.

Finally, accessibility has significantly 32 IN IMAGING

improved. Today, millions of people in the emerging markets like India have access to clinical imaging, which is also a result of more affordable imaging solutions. And this trend will continue, Siemens will come up with better, faster and more affordable solutions in clinical imaging.

What are the disease and patient trends shaping the imaging industry, in India and globally?

According to the United Nations, average life expectancy in India, during the 1950s, was less than 40 years.

By the year 2000, life expectancy had gone up to an average of 64 years. By the mid of this century, Indians will live more than 75 years. So you can say that within 100 years, average life expectancy in India will have almost doubled! This is pretty impressive and outstanding globally, even if the trend of living longer is of course a global one. This increase in life years comes with a change in disease patterns: With growing age the likelihood of chronic diseases in the area of cardiol-

ogy, oncology and neurology increases.

So the task for the imaging industry is to help doctors provide high quality diagnosis at the earliest possible stage, leading to efficient and effective therapies.

How has India's imaging market grown in the past decade?

Global market growth in the last couple of years was between three to five per cent per year and India’s was definitely higher.

Which of your division’s products are most attuned to India's healthcare needs?

We would not be the market leader in India, if most of our products were not suitable for the local market. For instance, our factory in Goa very successfully targets the special requirements of our Indian customers. In the high-end segment we see a great demand for our products. For example, we have sold Artis Zeego, a cath lab with the world’s first robotic C-arm.

Another example, which I just touched OCTOBER 2012

INTERVIEW on, is the world’s fastest CT scanner, Somatom Definition Flash, which has been installed at quite a few health institutes in India. Biggest growth of course takes place in the middle segment. Our MRI system, Magnetom Essenza, explicitly addresses this market and due to its great price-performance-ratio it is now the best selling MRI system in India. In the course of Siemens Healthcare’s two-year innovation and competitiveness programme, Agenda 2013, we explicitly target further innovation in the middle segment to increase accessibility for our products. Since the beginning of the Agenda 2013, we introduced a CT, an MRI, an X-ray and an ultrasound system that offer a very compelling balance between image quality and investment budget. We may see more of this at the RSNA congress.

Tell us the rationale behind the Siemens and HCG collaboration to set up a Centre of Excellence for cancer care. Any more such collaborations in the pipeline?

The idea behind this is to give some kind of an organisational framework to our collaboration with one of our leading customers in Asia. At the end of the day, Siemens Healthcare is translating customer requirements based on clinical needs into products and solutions.

The better we understand these requirements, the more successful we can be in this translation. We believe both sides are winning in such collaborations: Our customers give us ideas based on their clinical expertise, and we present our ideas based on our technical expertise on how clinical work-flows could be improved. So this is truly a win-win-win-situation: The customers win through our input, we win through customer input and most importantly, the patient wins! We have a number of Centres of Excellence around the globe.

OCTOBER 2012

What are the unique opportunities and challenges in Indian healthcare market vis-à-vis the global market?

Due to its sheer size, the Indian market is a challenge in itself. This applies of course to the number of people and to the fact that India is a continent. Besides, the diversity of the Indian market is quite unique. On one hand, you have high-class hospitals with the same requirements as any teaching hospital in the US or Germany. On the other hand, there is a vast and fast growing market for entry and mid-level products. We try to serve both markets with innovations that cater for quality, effectiveness and price-efficiency. We have more than 1,000 software developers in Bangalore, who contribute in achieving our business goals. I have just been there and was truly impressed by the quality and speed of our teams…

What are the learning lessons for India from the global market?

I believe there is no specific one or two specific lessons, India can learn from the global market. India certainly has great potential for the development of almost all industries. However, like most countries in the world, India too is facing the challenges of the current economic environment. The Indian Government is very ambitious to establish a modern healthcare system for its vast population. This is an effort that deserves the highest respect.

Siemens has deep roots in India and we would feel honoured to help India on its way to implement an efficient and effective healthcare system.

What are the immediate policies or steps to enhance access to affordable imaging solutions in India?

Government rules and laws are always the result of the specific circumstances in the respective country, so it’s difficult to tell as a foreigner, what

should be done. In general, what has proved to be efficient and effective is open competition and a predictable, stable, long-term business environment making it possible to plan and invest in business activities.

How can your division play a role in alleviating the concern of healthcare access in the country?

Just one year ago, our Siemens’ President and CEO, Peter Loescher proudly donated another Sanjeevan mobile clinic, this time to Medanta, one of India's largest speciality institutes located in Gurgaon. The previous one was donated to Smile Foundation in Madhepura, Bihar. Sanjeevan mobile clinic was an initiative started

by Siemens India to help improve the accessibility and affordability of healthcare services in the interiors of India. Apart from our corporate citizenship programme, we are fostering our R&D efforts to come up with highly innovative and at the same time more cost-efficient imaging equipment. Last year, we introduced our digital X-ray system Multix Select DR, which is about one third less at cost than its predecessor. And as I already said, we may see more in the line of accessible innovations at this year’s RSNA congress in the US. What are Siemens Healthcare Imaging & Therapy Systems Division’s future plans for India?

The direction for our business in India is clear north. We are ready to grow! We are very confident that we can do this with our unique offering in the high-end segment and we will develop more and more products for the fast growing mid-level market. Talking about partnerships I can only say: I am open for discussions – any time! ■ lakshmipriya.nair@expressindia.com IN IMAGING 33

INDUSTRY SPEAK

ROOTING FOR REFURBISHED CT SCANNER MACHINES

W

e all need to agree with the fact that any X-ray generating machine, no matter small or big, old or new, makes for a radiation risk if it is not maintained or monitored for radiation safety.

But at the same time, we cannot agree with the propaganda that all the radiation hazards are mainly caused by imported, used X-ray tubes and CT machines brought from US, Europe or Japan to India, and conveniently forget that there are thousands of old X-ray equipment which are more than 10years old, both in government sector and private hospitals in India, which are neither monitored nor maintained due to various reasons.

We should not forget that many of these high end equipment like CT scanners are not fully manufactured in India till date and the cost of new medical equipment are extremely high, making it very unreasonable to charge the patients for these high end services .

There is a very acute shortage of qualified personnel for making quality assurance and test reports in this field.

Very often the diagnostic medical centres and hospitals have to wait for several months to get approvals, and also bear the brunt of certain officials who are hand in glove with agents to demand bribes and favours for providing licenses.

Under such prevailing circumstances, Atomic Energy Regulation Board (AERB) has authorised and issued licenses to qualified and trained personnel to do Q/A tests for X-ray

34 IN IMAGING

Som Panicker Vice President, Sanrad Medical Systems

SOM PANICKER, VICE PRESIDENT, SANRAD MEDICAL SYSTEMS ELUCIDATES ON THE ADVANTAGES OF USING REFURBISHED EQUIPMENT AND ADDRESSES THE MEANS TO REDUCE RADIATION RISKS IN THESE MACHINES

equipment which is a great relief to the medical centres and frees the system from the monopolistic attitude of the state DRS officials .

As a qualified person working with diagnostic imaging equipment for many years, I would like to highlight few important aspects that justify the import of refurbished or used CT scanners in India. They are as follows: 1. Government of India permits import of any used medical equipment with residual life of more than eight years.

2. Medical equipment do not have an expiry date and these equipment can be used as long as it is serviced and maintained efficiently to produce good quality images and performance within specifications 3. Due to very high costs of new and imported medical equipment, the costeffective but used medical equipment are the only feasible solution to provide high-end diagnostic services at low costs in remote and rural areas of the country.

4. X-rays are produced by secondary emission. Their use is very effectively controlled by electronic circuits and mechanical devices which limit the spread and scatter of X-rays. As these X-ray tubes get older, the radiation emitted keeps reducing and ultimately the tubes get fused after which they need to be replaced.

5. AERB is a regulatory body which provides training, testing and inspection for all types of radiation equipment at site. They also approve sites for installation of equipment and guide the doctors and hospitals on the specific use OCTOBER 2012

INDUSTRY SPEAK of such equipment.

6. Unlike radiation produced from nuclear isotopes and other materials used in nuclear medicine as well as cancer treatment equipment like Gamma camera, Linear Accelerator, Cobalt Therapy etc, X-ray radiation is much safer and less harmful when used for diagnosis under controlled situations.

7. X-rays are the main source of diagnostic medical imaging of patients, and the effective use of these equipment (old or new) by trained professionals are safe and harmless to the patients when used as per the allowed radiation limits and dosage.

8. The use of latest technology in developed nations has become a trend, and most of them replace equipment within a span of four to five years. The cost of such upgrade to technologically advanced equipment do not hinder their services to patients, as most of the patients are covered by medical insurances or government policies.

9. As these replaced equipment have a large percentage of residual life left over, it is wise to make good use of it in other countries where they lack such facilities greatly, hence these imported used equipment play a great role in the development of rural clinics and medical centres. They also facilitate rapid growth of high-end medical services by providing economical solutions to the needy patients.

10. Indian engineers use their skills and intellectual ability to make excellent use of these medical equipment for safe and effective patient diagnosis therapy, saving a lot of foreign exchange for the nation. They also provide alternative solutions to the dictum of some vendors who overcharge the OCTOBER 2012

Toshiba CT scanner customers and make huge profits from services and sales of new medical equipment.

11. Average life expectancy of good medical equipment is approximately 15 years with proper service and maintenance conducted at regular intervals. All X-ray equipment are calibrated at regular intervals to ensure production of good quality diagnostic images.

12. Even in countries like US, Japan, Korea etc. the use of second hand medical equipment are permitted and is considered as a viable alternative to new equipment. Most of the high-end medical equipment have CE/FDA/TUV certification thus proving to be safer for use in medical diagnosis.

13. Radiation hazards are caused only due to misuse or abuse of equipment and not because it new or old or imported. To ensure that good quality diagnostic images are produced, all X-ray based medical equipment need to undergo similar tests and periodic maintenance, irrespective of

whether it is a used machine, a brand new one, locally manufactured or imported.

14. Finally, we should work towards encouraging local manufacturing of high-end medical equipment like CT, MRI etc by offering tax cuts, incentives, subsidies etc. It is our government’s lack of policy, and illogical as well as difficult tax structures that make investments in medical equipment manufacturing an unattractive idea. China has gone a long way ahead in this arena and we should learn from their manufacturer-friendly policies. It is better to encourage more investors to start manufacturing these high-end medical equipment in India, thereby reducing the overall cost of such equipment. It would also create an alternative to expensive imports from US, Europe and other foreign countries. â–

The author can be reached at sompanicker@yahoo.com IN IMAGING 35

IMAGING TECHNIQUES

USG IN BREAST CANCER: THE OLD AND THE NEW

T

he traditional role of ultrasound in imaging of the breast is to further evaluate masses or asymmetries and to help differentiate a solid mass from a cyst. In breast cancer, it has been used as a diagnostic follow-up to an abnormal screening mammogram. The addition of ultrasonography to mammography increases sensitivity for small cancers but decreases specificity. Ultrasound (US) is also used to provide guidance for biopsies and other interventions. It is the first line of imaging in a woman who is pregnant or less than 30 years old with focal breast symptoms or findings, where both the sensitivity of ultrasound and negative predictive value for malignancy were 100 per cent. US of the axilla also detects suspicious lymph node metastasis, especially in the obese.

Results of a recent clinical trial from American Radiology Services Inc, conducted at the John Hopkins Institute and published in JAMA 2008, showed that addition of US to mammographic screening of the breast will yield an additional 1.1 to 7.2 cancers per 1000 high-risk women. However, this study also reported a higher incidence of false positives leading to more number of biopsies/cytology in the screened population.

The use of US to guide core needle biopsies (CNBs) from a breast lesion for diagnosis of nonpalpable lesions is faster and better tolerated by some patients than stereotactic mammography. The use of US requires that the lesion can be well visualised by ultrasound and confidence that the 36 IN IMAGING

Dr Arjun Poptani Sr Radiologist, Rockland Hospital

DR ARJUN POPTANI, SR RADIOLOGIST, ROCKLAND HOSPITAL ELABORATES ON THE VARIOUS USAGES OF ULTRASOUND IN THE DETECTION AND DIAGNOSIS OF BREAST CANCERS

ultrasound finding and mammographic finding represent the same thing. With USguided core needle biopsy, passage of the needle through the lesion can be directly visualised and confirmed; as a result, fewer samples (usually three to five) are needed to provide diagnostic material. If the lesion is better visualised mammographically and is difficult to reproduce reliably on US, then stereotactic guidance is the preferred method.

More recent uses of US in the management spectrum of breast cancer have been in the area of interventions during neoadjuvant chemotherapy and breast conservation surgeries. For patients who have large or locally advanced tumours for which neoadjuvant (induction) chemotherapy is considered, careful anatomic localisation is critical to ensure that the surgeon can localise the area of tumor after neoadjuvant therapy. Typically, the lesion is measured both clinically and through ultrasonograpy, reported in terms of size, the "o'clock" location on the breast surface, and the distance of the lesion from the nipple. The use of radio-opaque clips placed at the time of biopsy to localise the primary tumour in case there is a complete clinical and radiographic response to induction therapy can also be tried under sonographic guidance.

Ultrasound is useful in evaluating the local extent of breast cancer and can identify additional tumour in the same breast thereby altering surgical management (mastectomy verses breast conservation) in up to 18 per cent of women.

Ultrasound is appropriate in evaluating implants in a woman with contradictions to MRI or where MRI is not available. It can OCTOBER 2012

IMAGING TECHNIQUES

Pseudonodular hypoechoic lesion compatible with a microcystic mass on B-mode sonography. The colour elastogram shows homogeneous elasticity in the entire lesion (score 1). Cytologic diagnosis: fibrocystic changes

be used to check the integrity of a silicone implant capsule. Leak of silicone to the surrounding breast tissue causes a typical "snowstorm" appearance. Similarly, intracapsular rupture can be diagnosed on OCTOBER 2012

ultrasound by a characteristic "stepladder" appearance.

NEWER MODALITIES OF USG Real Time Tissue elastography: Conventional uses of mammography

for breast screening over the years have put forth some interesting caveats. For example, in Japan where the average age of diagnosis of breast cancer is a woman in her 40s, the specificity of mammography as a single tool of screening is unacceptably less, because the breast tissue is quite dense in this age group. Also, the global trend of breast cancer diagnosis is at present towards a younger population of women, who are mostly in their 30s, where simply getting a mammogram done won’t be sufficient as a screening tool. All this has created a need for a tool which can add to, and increase the specificity of mammography, and if necessary which can also be used as a standalone modality of screening or diagnosis.

Elastography was described at the beginning of the 1990s by Ophir et al.

In 1997, Garra et al published the first clinical study showing the potential of elastography in the detection and characterisation of breast lesions.

But it was only after 2004 that it became possible to use this technique simultaneously with conventional sonography, thanks to new equipment with probes that allowed both real-time B-mode sonographic and elastographic studies.

Ultrasonography works as an essential tool in diagnosing breast cancer, especially in women with dense breasts and in detecting small cancers of the breast. In recent years, real-time tissue elastography has come up in a big way as an auxillary tool in the evaluation of cancer of the breast. This method uses colour evaluation of the degree and distribution of tissue strain, induced by tissue compression with an ultrasound device. Compared with conventional B-mode sonography, it scores a lot higher in specificity, so much so that it might replace histological proof of some breast lesions in the near future. It can also IN IMAGING 37

IMAGING TECHNIQUES be useful in the preoperative assessment of the margins in breast cancer. Further development of ultrasound elastography is expected.

Method: Real time elastography visualises the degree and distribution of strain induced by light compression in a real-time manner when artificial light compression is applied to breast tissue. Results are noted when soft tissue receives greater strain, while stiff tissue receives less (Shiina et al., 2002).

The images are classified into five patterns (Itoh et al., 2006, Tsukuba Elastography Score, Itoh, 2007).

Interpretation: Scores from one to three showing green images of strain with and without tense blue images are judged to be benign.

Scores four and five showing blue images are diagnosed as malignant.

Score 1. Strain in the entire hypoechoic area Score 2. Strain not seen in part of the hypoechoic area Score 3. Strain only in the peripheral areas and not at the center of the hypoechoic area.

Score 4. No strain in the entire hypoechoic area; and Score 5. No strain either in the hypoechoic or surrounding areas.

PREOPERATIVE ASSESSMENT OF MARGINS IN BREAST CANCER With increasing awareness and use of breast conservation surgery, evaluation of the margins of excision of a lesion has become one of the important parameters of management. A precise grasp of the degree of invasion into the breast tissue and the presence and degree of the extensive intraductal component is important to assess margins of excision. As a tool for preoperative assessment of the extent of cancer, 3D MR mam38 IN IMAGING

Comparison of ultrasound imaging techniques for breast lesions Sensitivity (%)

Specificity (%)

Accuracy (%)

Sonography*

90

91.8

91.1

Elastographyâ€

77.5

100

91.1

* Conventional B-mode sonography: category 4 and over, diagnosed as malignant. †Real-time tissue elastogrpahy: score 4 and over, diagnosed as malignant

mography which utilises MRI is superior to mammography or ultrasound (Esserman et al., 1999; Nakamura et al., 2002). On the other hand, to achieve negative margins in the operating room, the usefulness of ultra-

sound with its easy portability and improvements in technology is well known (Henry-Tillman et al., 2001).

Furthermore, ultrasound is superior in specificity but inferior to MRI in sensitivity (Tamaki et al., 2002).

OCTOBER 2012

IMAGING TECHNIQUES Considering the above facts, application of ultrasound elastography to assess the extent can be considered in both pre and intraoperative setting.

Well-circumscribed solid nodule with small intranodular cystic areas compatible with fibroadenoma on B-mode sonography. On the color elastogram, a mosaic pattern is shown (score 2). Cytologic diagnosis: fibroadenoma.

Poorly defined solid nodular image with a posterior acoustic shadow and irregular echogenic halo compatible with carcinoma on B-mode sonography. The color elastogram shows stiffness in the entire lesion and an area of the surrounding tissue (pattern 5). Histopathologic diagnosis: invasive ductal carcinoma.

Solid nodule with indistinct margins and a sonographic suspicion of malignancy (BIRADS 4). The color elastogram shows stiffness in the entire lesion with homogeneous red distribution, representing maximum hardness (score 4). Histopathologic diagnosis: invasive ductal carcinoma.

OCTOBER 2012

ULTRASOUND TOMOGRAPHY A recent study from Karmanos Cancer Institute, Detroit, US by Duric et al describes the construction and use of a prototype tomographic scanner and reports on the feasibility of implementing tomographic theory in practice and the potential of US tomography in diagnostic imaging.

Method: Data were collected with the prototype by scanning two types of phantoms and a cadaveric breast.

A specialised suite of algorithms was developed and utilised to construct images of reflectivity and sound speed from the phantom data.

Results: The basic results can be summarised as follows. (i)A fast, clinically relevant US tomography scanner can be built using existing technology. (ii)The spatial resolution, deduced from images of reflectivity, is 0.4 mm. The demonstrated 10 cm depth-of-field is superior to that of conventional ultrasound and the image contrast is improved through the reduction of speckle noise and overall lowering of the noise floor. (iii)Images of acoustic properties such as sound speed suggest that it is possible to measure variations in the sound speed of five m/s. An apparent correlation with x-ray attenuation suggests that the sound speed can be used to discriminate between various types of soft tissue. (iv)Ultrasound tomography has the potential to improve diagnostic imaging in relation to breast cancer detection. â– IN IMAGING 39

CT FEST 2012

CT FEST 2012: AN EVENT TO LOOK FORWARD TO CT Fest, in this year's edition focuses on the various aspects of neck, chest (interstitium), and cardiac CT

O

rganised by MSBIRIA, CT Fest is an exclusive quality educational event focussed on CT Imaging. This year, CT Fest 2012 is being held at The Grand Hyatt in Mumbai from October 26-28, 2012.

After focussing on chest and abdominal imaging in its last edition, this year's theme at CT Fest 2012 is neck, chest (interstitium), and cardiac CT. Individual sessions have been dedicated to sections on neck, cardiac, interstitium and paediatric chest, with short 'Anatomy Flashback' sessions to tune the delegates about the practical aspects of CT anatomy of these sections, as well as the orbit, PNS and the temporal bone.

Coupled with this, poster presentations and 'Spotlight Section' (a popular segment at Ultrafest 2012), where five top abstracts sent by delegates will be presented by the delegates themselves in the main hall. They would be judged by the international speakers and given prizes.

Heading the list of international speakers is Dr Lawrence Boxt, a virtual treasure house of information on cardiac CT and Dr Sujal Desai who has

40 IN IMAGING

The scientific programme is filled with an array of lectures to cover almost all aspects of neck, chest and cardiac imaging done a lot of research in lung abnormalities especially interstitial lung disease (ILD). Alongside a star list of other international speakers, the

scientific programme is chock-ablock with a wonderful array of lectures to cover almost all aspects of neck, chest and cardiac imaging.

T20-Top 20 cases conducted by two speakers everyday at the end of the day, and a cardiac workshop by Dr Boxt will complete the proceedings on Day 3, that culminates at lunchtime on Sunday.

Thus with a whole range of interactive activities and sessions awaiting the delegates at the event, it is likely to be bigger and better this time. â–

OCTOBER 2012

INTERVIEW IN

‘THE FOCUS OF THIS YEAR'S CT FEST IS ON NECK, CHEST AND CARDIAC IMAGING’

CT FEST 2012 is just around the corner. Raelene Kambli catches up with Dr Sanjeev Mani, Organising Secretary, CT Fest 2012 to know more about the highlights of the event What is your rationale behind conducting a scientific programme dedicated to CT? How has it evolved and grown over the years?

As you know, CT is one of the greatest scientific inventions of the 20th century, and even today its use and protocols are ever changing, based on new studies and ideas. The aim of CT FEST is to educate radiologists and students in India about the changes that take place worldwide in the field of CT. By inviting internationally acclaimed speakers to India, we wish to expose the students to newer protocols and studies which will help them inculcate these protocols in their routine practice. This, in turn, will eventually improve diagnostics and healthcare.

How have you geared up for CT Fest 2012? What preparations have been underway?

We have moved our venue to Grand Hyatt, Mumbai for this event.

All delegates and speakers will be staying at this venue itself.

OCTOBER 2012

What will be the focus of CT Fest 2012? Which topics would be covered under the scientific programme?

The focus on this year's CT is on neck, chest and cardiac imaging. All topics in these sections will be covered in this year's programme, with a special emphasis on cardiac CT. Dr Lawrence Boxt who is an expert and pionerer of cardiac CT and MR imaging will be addressing the delegates on many topics such as cardiac anatomy variations, stent and plaque evaluation and emergency cardiac CT. Who are the national and international speakers at the event?

The international speakers are Dr Lawrence Boxt, Dr Sujal Desai, Dr Moulay Meziane, Dr Kshitij Mankad.

The national faculty includes Dr Sanjay Vaid.

What are the new additions to look for at CT Fest 2012?

This year's event will have a 'Rising Stars' programme in which youngsters selected on the basis of

their submitted abstracts and posters will be given a chance to present their material in the hall. These students will be judged by the international speakers.

Is there an exhibition along with the scientific programme? If yes, any specific launches scheduled?

Most of the top CT and software companies are participating in this event. Sanrad, who is India's premium company in CT, is our platinum sponsor for this event.

What is your message for the exhibitors and the participants expected at CT fest 2012?

We expect almost 400 participants for this event, and have created new sections such as ‘Rising Stars’ programme, ‘T20’, and a ‘Department Head-To-Head’ contest. We request all radiologists and residents to participate in this event, and we, the organisers would like to make this an event to remember. ■ raelene.kambli@expressindia.com

IN IMAGING 41

CT FEST 2012

‘I EXPECT TO SEE STEADY GROWTH IN THE NUMBER OF CT SCANNERS IN INDIA’

In recent times, the concept of cardiac imaging has been greatly expanded by the advances in CT technology. Raelene Kambli tracks its evolution and understands its scope in the Indian context, in an exclusive interaction with Dr Lawrence Boxt, MD Cardiovascular Disease Physician, Diagnostic Radiologist in Bronx, New York How did cardiac CT begin? How do you see the technology evolving ?

Cardiac CT (CCTA) as we practice it now, really began after 1999-2000, with the commercial introduction of 64-detector scanners. In a dramatic advance over recent, kindred technology (i.e., 4-, 8-, 16-detector scanners), the 64-detector scanner produced isotropic voxels. That is, the imaging elements obtained from a scan are cubes; equal length on all sides. Thus, digital imagery of the epicardial coronary arteries reconstructed from these volume elements is of adequate spatial resolution to be artifact-free, and thus reliable for detection and quantitation of coronary artery calcium and the detection of significant coronary stenosis. Prior to 2001, the electron beam CT (EBCT) scanner developed at The University of California should have “revolutionised” cardiac imaging. It produced cine cardiac examinations of adequate quality for evaluation of myocardial wall thickening and valvular function. However, it was limited 42 IN IMAGING

in spatial resolution, and thus unable to visualise the epicardial coronary arteries. Also, CCTA became commercially available in the early 1980’s, when magnetic resonance imaging was becoming commercially available.

Radiology Department Chairmen were uncomfortable supporting two new and expensive technologies at the same time. EBCT was seen as a cardiac imaging device, and Radiology Chairmen didn’t want to fight with Chiefs of Cardiology.

Radiology went headlong into MRI, and the EBCT virtually evaporated.

As to the future; the spread of multidetector CT technology, and the growth of 16- and 64-detector scanners, was associated with a dramatic increase in the number of CT scans, and the cumulative patient radiation exposure from multiple scanning. An uproar over patient radiation dose and risk of developing new cancer provided a moment of clarity for the CT and CCTA communities. In a remarkable change of industrial philosophy, there began another “revolu-

tion” in CT technology. Conscious attention to dose lowering methods and technologies have lowered the CCTA dose by nearly an order of magnitude. This is the first area of change we will see in the near and intermediate future. We will continue to see advances in tube and detector materials, and continued lowering of patient radiation exposure. The second area of change will come in the arena of computer-based image processing and image distribution algorithms and the network technology to connect scanners with workstations and physicians. We are already seeing “afterhour” exams in the US sent to India for review, and vice versa. Advanced display technology will allow us to visualise cardiac abnormalities rather than infer their presence.

Furthermore, association of relevant databases will provide correlation with other tests, other clinical information, or other imaging studies.

Association of particular characteristics of coronary arterial plaque with specific genetic loci on the individOCTOBER 2012

CT FEST 2012 ual’s genome will open new areas of clinical intervention based on the morphologic appearance of coronary plaque.

When is the prognostic value of CCTA best utilised?

CCTA is increasingly used as a clinical tool to visualise the coronary artery lumen and to identify coronary stenosis. That is, the foremost current use for CCTA is to exclude significant coronary artery disease, and avoid bringing the patient to the catheterisation laboratory for the performance of a diagnostic coronary catheterisation. The predictive power of coronary calcium quantitation, with regard to both future cardiovascular events and overall mortality has been well established. Given the significant contribution of underlying genetic mechanisms for the development of coronary atherosclerosis, and the high prevalence of asymptomatic individuals among those with coronary stenosis, the prognostic value of CCTA lies in the evaluation of asymptomatic or minimally symptomatic individuals with low or intermediate risk of coronary heart disease. These patients can be risk stratified, and directed toward aggressive risk lowering management in face of the presence of coronary calcium and mild-to-moderate arterial stenosis.

The results of several prospective, multi-centre trials has demonstrated that hospital costs are lowered and patient length of stay shortened when CCTA is performed in low-tointermediate risk, emergency department patients complaining of recent onset of chest pain, but without a known history of coronary heart disease. In these series, individuals in whom no significant coronary artery disease was demonstrated have a near zero cardiac event rate after emergency department discharge.

OCTOBER 2012

What are the benefits of cardiac CT? What are the risks involved?

The diagnostic benefits of CCTA are offset by the existing risks and potential risks of intravenous contrast administration for the opacification of the coronary arterial lumen, and the radiation exposure necessary to produce the tomographic imagery itself.

Intravenous iodinated contrast administration always carries a potential risk of an adverse effect on the patient, and should only be used in circumstances where the benefit of its administration is greater than the risk of that administration in a particular patient. Although acute ‘allergic’ (anaphylactoid or idiosyncratic) contrast reaction is rare, it is the most fre-

utilised with varying degree of success.

The diagnostic benefit of CCTA is offset by the potentially increased risk of the radiation exposure of the exam itself, as well as the patient’s cumulative radiation burden that the exam contributes to. The theoretical risk posed to a patient by the examination lies in the random interaction between radiation and cellular molecules resulting in sufficient damage to result in development of a malignancy years after performance of the exam. Although any radiation exposure carries with it the potential risk of development of a malignancy, radiogenic health effects have been demonstrated in humans, through

The prognostic value of CCTA lies in the evaluation of asymptomatic or minimally symptomatic individuals with low or intermediate risk of coronary heart disease

quent form of contrast reaction, and may, very rarely have severe, occasionally fatal complications. These reactions are five times more common in patients with asthma, four-to-six times more common in patients with a history of previous contrast reaction, and increasingly in patients with cardiovascular and renal disease, and those receiving beta-blockers.

Non-anaphylactoid reactions may be associated with transient alteration of circulatory homeostasis. They are less commonly seen when non-ionic versus ionic contrast is administered, with low versus high iodine concentration, and in upon intravenous versus intra-arterial injection. Various pre-medication protocols may be

epidemiological studies, only at doses exceeding 5-10 rem delivered at high dose rates. Below this dose, estimation of adverse health effects remain speculative, and there is no consensus as to whether the effects observed in Japanese individuals (i.e., survivors of the Hiroshima and Nagasaki bombings) exposed to whole-body acute exposure to primarily high levels of radiation can be extrapolated to the partial-body exposures at much lower levels of radiation delivered to patients undergoing medical diagnostic procedures. A prudent approach to performing CCTA recognises the possibility that there is indeed no threshold below which radiation cannot cause malignancy, and that the risk of malignancy increases linearly with IN IMAGING 43

CT FEST 2012 radiation dose. Therefore, examination planning and performance should revolve around limiting examination in patients at greatest risk, as well as limiting radiation exposure during examination in all patients.

How accurate is multislice CT angiography (CTA) as compared with standard angiography performed in the catheterisation lab?

Cardiac CTA does not provide the same degree of image quality or diagnostic accuracy as is achieved by conventional coronary arteriography.

Nevertheless, sensitivity and specificity rates for stenosis detection are high when expert operators perform and interpret the examinations. Metaanalysis of comparisons made between CCTA and conventional coronary arteriography has demonstrated high sensitivity (96-99 per cent) and specificity (93-94 per cent) for the CCTA detection of individuals with at least one coronary stenosis. Large multicentre trials comparing CCTA with conventional coronary arteriography have demonstrated high sensitivity (75-95 per cent) and specificity (77-93 per cent) when evaluating pervessel accuracy for detection of coronary stenosis. When per-patient accuracy is evaluated, higher sensitivity (85-99 per cent) but lower specificity (64-90 per cent) is found in CCTA examinations. However, in both metaanalyses and multicentre trials, the constant findings of moderate positive predictive value and very high negative predictive values are found. Thus, the true value of CCTA lies in its power to exclude significant coronary heart disease, rather than in its accuracy to quantitate per cent coronary artery stenosis determination. Most individuals with coronary heart disease exhibit coronary calcification.

CCTA is exquisitely sensitive to the presence of such calcification, which 44 IN IMAGING

is reflected in the high accuracy of CCTA to detect the presence of coronary heart disease. However, the physics and engineering of CT technology results in significant “blooming� artifact in the region of such calcified lesions, severely limiting the ability of cardiac CTA to actually quantitate the severity of such stenosis, an important attribute of conventional coronary arteriography.

What is its potential and its comparison vs conventional coronary angiography?

The potential value of CCTA, as compared with conventional coronary arteriography lies in both the accuracy of the CT technology and the evolving

CCTA is extraordinarily accurate as a tool for the exclusion of significant coronary artery stenosis

role of the catheterisation laboratory, the traditional location for the performance of conventional coronary arteriography. Thirty years ago, the paradigm for the management of patients with coronary heart disease was for an individual with chest pain to have a coronary arteriogram. If significant (>70 per cent) stenosis was identified, then the patient was sent for surgical revascularisation. In the vast majority of patients, revascularisation was associated with relief of pain.

Individuals with normal coronary arteries, or those with less than significant stenosis were managed medically.

With the development of percutaneous angioplasty, and subsequently intracoronary stent placement, revasculari-

sation moved from the operating theatre to the catheterisation laboratory.

Outcomes after percutaneous revascularisation were similar to those obtained surgically; pain was relieved.

However, all individuals who underwent either surgical or percutaneous revascularisation all eventually died of their coronary heart disease. In other words, revascularisation improved symptoms, but (with the exception of left main coronary stenosis) had little effect on outcome. Revascularisation plays an important role in the management of individuals with coronary heart disease. However, it does not treat the underlying atherosclerotic process, and is thus a temporising methodology. With the increasing role for percutaneous revascularisation, we have created an increased demand for access to catheterisation laboratories, and strain on their utilisation. Here is where CCTA will make great inroads in patient management. CCTA is extraordinarily accurate as a tool for the exclusion of significant coronary artery stenosis. Thus, directing patients with low- or intermediate risk of coronary heart disease to the CT scanner (i.e., away from the catherisation laboratory) lowers the burden on the cath lab, shortening door-to-balloon time, and thus increasing clinical efficacy. Furthermore (and this will become much more important when we begin to understand and utilise the vast stores of genomic data we can now obtain from an individual patient), CCTA allows us to characterise the less than significant coronary stenosis, providing a means of identifying individuals with early, or less diffuse coronary heart disease.

These individuals would benefit the most by early and aggressive medical intervention, and, as we have found in patients in whom their serum cholesterol levels have been lowered, have improved outcome.

OCTOBER 2012

CT FEST 2012 Is there a patient selection criteria for this? Who are the patients that can best benefit from CCTA? Currently, CCTA is proposed as a first line diagnostic tool in the context of low- and intermediate-risk individuals with chest pain but no documented history of coronary heart disease. In large institutions with very active cardiology services, catheterisation laboratory availability may be limited from time-to-time, thus bringing pressure to bear on lowering and loosening rigorous criteria for patient selection. As mentioned above, however, the strong association of coronary calcium with coronary stenosis limits the power of CCTA to characterise less-than-significant coronary lesions.

Institutions with large CCTA services have garnered great experience, and may move selected patients waiting for a catheterisation appointment to the CT scanner.

The patient who benefits most from CCTA examination is a middleaged man with chest pain, with some, but not many cardiac risk factors (low Framingham or TIMI score), and no documented history of coronary heart disease. The clinician taking care of this individual will send the patient for catheterisation if significant stenosis or an acute coronary syndrome is suspected. On the other hand, CCTA can exclude coronary heart disease in such a patient, giving both the patient and physician reassurance that no acute event is occurring.

Furthermore, in these lower risk individuals, characterisation of individual coronary arterial plaque (which cannot be obtained by conventional coronary arteriography) may provide the basis for tailored medical management of their abnormal cholesterol metabolism.

OCTOBER 2012

What is the growth rate of this segment in India and what would be the estimated size of the market, five years from now?

Most CT scanners are installed in the United States, Europe, and Japan. The number of CT scanners at an institution, as well as the number of scans performed continues to increase (certainly in the US, and presumably in the other markets).

Non-64 detector scanners continue to be sold in these markets because of the continued high CT utilisation, and their significant advantage over older (1-to-4-detector) scanners for non-cardiac use. However, nearly 40 per cent of CT scanners installed in the US in 2010 were 16-detector scanners.

India is a rapidly growing, emerging market for CT scanners; scanner

CCTA is a valuable diagnostic problem solver. There is a great deal of CCTA performed in India today

sales and installations will follow an increasing population, domestic economic growth, and increasing healthcare spending, including new hospital construction. There is no reason to expect the demand for high technology to wane. Rapid expansion will be met with installation of conventional (<64-detector) and refurbished CT scanners, as well as the expansion of the 64-detector market.

Approximately one-third of all new scanners in India are 64-detector devices; only about four per cent are “mega-scanners” (i.e., 128-256+ detectors). If I could predict the

Indian market in 5-10 years, I would expect to see steady growth in the number of scanners and in their utilisation. I would also expect to see growth in the >128-detector market, as older scanners become out of service and are replaced.

Tell us about your association with CT Fest 2012? What will be your area of focus while speaking at the CT Fest 2012?

This is my first time to India, much less speaking at CT Fest 2012.

Actually, Dr Sanjeev Mani contacted me two years ago, inviting me to speak at the 2011 meeting, but I had a previous engagement, and couldn’t come. I implored him to please remember me for the 2012 meeting, which he did. I intend to discuss the utility of CCTA to diagnose not only coronary, but other common, and less common forms of acquired valvular and myocardial heart disease. CCTA is a valuable diagnostic problem solver, and will continue to help elucidate normal and pathologic anatomy and function in patients with difficult to interpret echo-cardiograms and electrocardiograms, in a manner analogous to cardiac MRI. I will also point out the value of CCTA for the evaluation of adult patients with congenital heart disease. This growing population (there are now more adult patients than paediatric patients with congenital heart disease) is well-served by the speed, convenience, and accuracy of cardiac CTA. There is a great deal of cardiac CTA performed in India today, and the attendees at the meeting will reflect a broad spectrum of awareness, experience, and utilisation of the technology. I hope to teach a little, reinforce a lot, and learn from my audience. ■

raelene.kambli@expressindia.com IN IMAGING 45

INTERVIEW

‘CT FEST 2012 WILL INCREASE DIAGNOSTIC CAPABILITY OF THE DOCTORS PRESENT'

Raelene Kambli speaks to Dr Jignesh Thakker, All India Secretary, IRIA on common threats in the field of CT imaging and how CT Fest 2012 will increase the diagnostic capabilities of its attendees What have been the main developments and major milestones for you over the last few years in CT technology?

Lately, the CT technology has advanced a great deal. Fine tuning of technology is of immense help in terms of time and treatment.

What are the most common threats faced by radiologists with regard to CT technology and what are the measures that need to be taken to overcome those threats?

As such there is no threat to CT technology according to me, as it keeps on improving day by day. Yes, the threat in terms of lot of unscrupulous people posing as suppliers. They dupe doctors for which we have to be careful and have to verify their credentials of companies personally without trusting any one; especially, the cheap deals which they offer.

Atomic Energy Regulatory Board (AERB), along with the government is planning several measures to overcome this problem and I am sure that they will do a decent job. If IRIA needs to be involved in this we are 46 IN IMAGING

always there for them. In fact, in one of the meetings, our representative from IRIA also was present to give positive inputs.

Tell us about your association with CT Fest ?

CT Fest was started following the tremendous success of the Ultrafest series. Dr Sanjeev Mani, Dr Shailendra Singh, and I, along with our entire team of Maharashtra State Branch of Indian Radiological and Imaging Association (MSBIRIA) thought that the official body of IRIA must conduct a focussed, specialityoriented CME for our colleagues so that they can benefit from the experts of various countries. We are proud that we pulled it off but not without support of Ratish Nair from Sanrad and our esteemed colleagues- Dr Loniker Pramod, Dr Paresh Parekh, Dr Bimal Sahani, Dr Aniruddha Kulkarni and Dr Suresh Saboo.

How did CT Fest do last year? What are your expectations from the event this year?

Last year, CT Fest did a brilliant job

even beyond our expectations. This year, the bar of standard has been raised further. This year, we have excellent speakers of international repute. Let’s wait for the event which I am sure will do its best.

Which are the highlights to look for at CT Fest 2012? Which are the orations during CT Fest 2012 that interests you?

This time the emphasis is on the fight between the department for ‘Best Department’ trophy. We have increased ‘Rising Stars’ orations where best five papers will get a chance to speak live in front of the entire audience, apart from quizzes and interesting case study reports.

How will CT Fest 2012 be of benefit to the attendees ?

The standard of the speakers, chances given to youngsters for showcasing their talent and gaining knowledge will benefit one and all. This will increase the diagnostic capability of the doctors present at the event. ■ raelene.kambli@expressindia.com OCTOBER 2012

CT FEST 2012

'CT BUSINESS IS EXPECTED TO RISE MORE THAN RS 600 CRORE, THIS YEAR'

Sanrad, an organisation that specialises in offering affordable medical imaging equipment, in association with MSBIRIA, is organising the CT Fest 2012, Ratish Nair, CEO of Sanrad tells Express Healthcare why they chose to patronise CT Fest, the highlights to look forward for at this year's event and their expectations from it What has made you (Sanrad) lend your support to CT Fest 2012?

Sanrad feels privileged to be associated with quality education programmes for radiologists in India. CT Fest 2012 is a well organised programme, with reputed speakers coming from abroad to share their knowledge and experience in the field of CT scan diagnosis. In an effort to make this programme a great success, SANRAD has associated with MSBIRIA, who have taken the initiative to conduct such a premium educational programme in India.

Apart from sales and service of CT scanners at affordable costs to customers, we feel that there is a necessity for advanced educational programmes on the latest technology advancements from the world market, interacting with international luminaries in the radiology field gives confidence and imparts knowledge to our radiologists in India.

OCTOBER 2012

On the technology front, what are significant developments in the CT modality at large? How is the CT market growing in India?

In general, Indian healthcare industry is making great progress and medical equipment industry has advanced tremendously. CT scanners, with advanced application features like 3D imaging of the heart, brain perfusion, 3D scan of bone joints, blood flow imaging and angiographs, dental scans, endoscopic studies etc., are being used for whole body scans

per cent over the previous year, the approximate value of CT business in the previous year was Rs 450 crores and this year it is expected to rise more than Rs 600 crore.

Currently, what are Sanrad's offerings to its users in the CT segment. Are you introducing any new variants?

Presently, Sanrad is offering refurbished Toshiba CT scanners, from the basic sub second single slice to high-end 16-slice with car-

This year, at CT Fest, new additions like â&#x20AC;&#x153;Rising Starsâ&#x20AC;? will give an opportunity for young talents in radiology to provide accurate information to the physicians and surgeons for improved diagnosis and treatment of patients. The CT scanner market in India shows a positive growth of 20

diac software. Sanrad also offer new MRI scanners, both permanent magnet 0.3T/0.45T and 1.5T superconducting helium-less technology systems. Sanrad has plans to introduce IN IMAGING 47

CT FEST 2012

64-slice cardiac CT scanners during April 2013. All Sanrad equipment are sold with full warranty and superior technical service backup with 95 per cent up-time.

cussed at length. Other reputed speakers like, Dr Sujal Desai, Dr Moulay Meziane and Dr Kshitij Mankad will be speaking on interesting radiology topics.

What are the highlights to look for at CT Fest 2012 this year?

This year the main focus of CT Fest 2012 is on Neck, Chest and Cardiac Imaging. Eminent speakers like Dr Lawrance Boxt will be rendering a lecture on Cardiac CT with emphasis on special areas like car-

How is it going to be different from its previous editions?

This year, new additions like “Rising Stars” will give an opportunity for young talents in radiology.

It is a programme in which youngsters, selected on the basis of their submitted abstracts and posters will

CT Fest 2012 is a well organised programme, with reputed speakers coming from abroad to share their knowledge and experience in the field of CT scan diagnosis diac anatomy variation, stent and plaque evaluation, emergency cardiac CT scans, which will be dis48 IN IMAGING

be given a chance to present their material in the main hall. These students will be judged by the panel of

international speakers.

Are there any products and technologies slated to be launched at CT Fest 2012?

There is a good participation of the trade in this event and they are displaying some of the latest hardware, accessories and softwares for CT scanners. We plan to display images from our high-end CT scanner and latest MRI equipment at the show.

What are your expectations from the CT Fest event this year?

We expect a large number of delegates to attend CT Fest 2012 this year, approximately 500 people.

With such large participation; we expect good publicity and promotion for our company and products. This year, we are expecting lot of delegates from neighbouring countries and this will help us expand and establish business links with overseas customers. ■ OCTOBER 2012

EVENTS LISTING Breast Imaging and Interventions programme Date: November 2-4, 2012 Venue: GRT grand, T Nagar, Chennai Organiser: Chennai Breast Centre Topics: Mammography, breast ultrasound, breast MRI and interventions including us guided FNAC, core biosy, cysts / abscess aspiration,/ and wire localisations

Lucknow Ultrasound Course 2012

Speakers: Selvi Radhakrishna, Jill Wong, Sasi Govindarajulu, Dr Suresh, Dr Ravikanth, Dr Sumodh, Dr Deepa Chegu Contact: Selvi Radhakrishna, 47, South Beach Avenue, MRC Nagar, Chennai 600028 Tel: 09445913665, 044-24610831 Email: selvi.biip2012@gmail.com

To tie up with

Date: November 3-4, 2012 Venue: Hotel Clarks, Avadh

for Media Partnerships Contact tushar.kanchan@expressindia.com

Organiser: LUC 2012 Topics: Obstetrics Ultrasound (Fetus as Individual) Ultrasound in high risk pregnancy Fetal anomaly & Birth defects Speakers: Prof Bouffard Antonio Henry ford teaching Hospital, Detroit USA Contact: Prof P K Srivastava / Prof Yashodhara Pradeep Tel: 9335904794

CTFEST 2012 Dates: October 26-28, 2012 Venue: Grand Hyatt, Mumbai Organiser: MSBIRIA Topic: Neck, Chest & Cardiac CT Speakers: Dr Lawrence Boxt, Dr Sujal Desai, Dr Kshiti Mankad, Dr Moulay Meziane, Dr Sanjay Vaid Contact: ctfestindia@gmail.com Tel: 022-26463666 Email: ctfestindia@gmail.com

OCTOBER 2012

Date: December 1, 2012 Venue: Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore Organiser: Indian Association of Cardiac Imaging (IACI) and Sri Sathya Sai Academy for Radiology Education (SACRED) Topic: Modalities: CT and MRI; Organ system: Cardiac Speakers: Dr Elizabeth Joseph, Bhavin Jankharia, Hemant Telkar, Narendra Bodhey, Rajesh Kannan, Vijaya Bhaskar Nori, Gurpreet S Gulati, Mahesh Bannur, Sriram Rajan, Srikant Sola, and Sanjaya Viswamitra Contact: DV Chandrasekhar, Sr, Manager, Imaging Services, SSSIHMS, Whitefeild, SSSIHMS, EPIP Area, Whitefield, Bangalore - 560066 Tel: 9448172384 Email: dv@sssihms.org.in

Email: usgerf@gmail.com Website: www.yashdeepultrasound.in

Cardiac CT and MRI

Website: https://docs.google.com/ spreadsheet/viewform? formkey=dElBZWxwVzk2NE xva1FoS0ZiWFItYlE6MA IN IMAGING 49

PRE EVENT

'PATIENTS FIRST' AT RSNA 2012 RSNA 2012 with its theme of 'Patients First' has a lot of sessions, presentations, exhibitions and activities in store for the delegates expected to come from across the world

T

he Radiological Society of North America (RSNA), an international society of radiologists, medical physicists and other medical professionals with more than 50,000 members across the globe, hosts the largest medical meeting in the world, drawing 60,000 attendees annually.

This year, the 98th Scientific Assembly & Annual Meeting of the Radiological Society of North America, will be held from November 25 – 30, at the McCormick Place, Chicago, US. The theme for RSNA 2012 is “Patients First”.

From lectures and special sessions focussed on the speciality's hottest topics to presentations of cutting-edge research and the latest in radiology informatics, learning opportunities in every sub-speciality would be in abundance at RSNA 2012. Science, education programmes are expected to raise the bar at RSNA 2012. New research, evolving techniques and technology, expert updates on healthcare policy and the latest in patient-tailored care are included on the rich roster of offerings this year. Along with an overall up-tick in abstract submissions, RSNA’s science and education committee chairs reported stronger international participation, an increase in technology-driven sessions and a steady focus on keeping “Patients First.”

50 IN IMAGING

RSNA 2012 attendees can choose from a wide range of education exhibits and scientific sessions, refresher courses, self-assessment modules (SAMs), applied science, integrated science and practice sessions and workshops encompassing every sub-speciality. George S Bisset III, MD, is the President of RSNA 2012, Houston, Texas. Honorary Membership in RSNA will be presented for significant achievements in the field of radiology to Giovanni G Cerri of São Paulo, Brazil; Mukund S Joshi of Mumbai, India, and András Palkó of Szeged,Hungary.

In addition, RSNA will honour two individuals at the event for their contributions to research and education. A James Barkovich of San Francisco, for his outstanding work in research and Marilyn J Goske of Cincinnati for outstanding work in education. Other features at RSNA 2012 are: Brazil Presents: RSNA’s continuing series highlights discoveries, techniques and practical clinical applications from investigators in Brazil RSNA DxLive: A fast-paced expert-moderated sessions where participants test their knowledge against that of their colleagues using mobile devices.

Nuclear Medicine/MI Campus: Courses, exhibits and presentations featuring nuclear medicine/molecular imaging are housed together for focused study.

Mock Jury Trial: Witness the process of a medical malpractice trial in a case of overexposure to ionising radiation.

CIR Spanish Programme- Emergency Radiology: A series of presentations for the Spanish-speaking radiologic professional, with available English translation.

Resident & Fellow Symposium: This programme will help trainees make informed decisions in their careers For Hospital Administrators: The Hospital Administrators Symposium addresses compliance and coding, radiology reimbursements and anticipated technology advances Radiologist Assistants Symposium: Four interactive refresher courses on Sunday designed to meet the educational needs of radiologist assistants (RA) as defined by ARRT. RSNA also publishes two top peer-reviewed journals: Radiology, the highest-impact scientific journal in the field, and RadioGraphics, the only journal dedicated to continuing education in radiology. ■ OCTOBER 2012

PRE EVENT

IRIA 2013: OFFICIAL MEETING GROUND FOR INDIAN RADIOLOGISTS It promises to be an event that will bring together distinguished international and national radiology experts

T

he Indian Radiology and Imaging Association (IRIA) is organising its 66th annual

conference from January 4-7, 2013 at Daly College, Indore, Madhya Pradesh. The event will be hosted by the Madhya Pradesh State Chapter of IRIA. The annual conference of IRIA has become the official meeting ground for the Indian radiologists to exchange their professional experiences, discuss the recent advances, know about the state-ofthe-art technology in radiology and imaging sciences and educate the young radiologists and residents.

IRIA has been growing continuously by integrating new developments and involving more and more radiologists, not only from India but from all over the world.

An excellent scientific and educational programme covering various fields of diagnostic imaging, interventional radiology and molecular imaging, is being prepared to meet the expectations of the visitors to IRIA 2013.

It promises to be an event that will bring together distinguished international and national experts from the radiology field, who will present their experience on topics covering all spectrums of radiology.

In this regard, a comprehensive scientific programme is also designed.

This event will be an opportunity OCTOBER 2012

Last year’s visitors being informed about IRIA 2013 for the participants of all sub-specialities to attain knowledge about cutting edge technology. In addition, this event will be an ideal forum for networking and building lasting relations with participants from different parts of the country.

●

● ● ●

HIGHLIGHTS OF THE SCIENTIFIC PROGRAMME: ● A galaxy of National and International faculty ● Accreditation by M.P. Medical Council and Royal College of Radiologists ● Symposia on Radiology Journalism

● ● ●

PG Teaching Course by American Institute for Radiologic Pathology, a programme by the American College of Radiology Pre-conference workshops Daily plenary sessions Orations, debate and image interpretation sessions by International faculty.

"Meet the Professor" sessions for residents and students ESR Presents, AOSR Presents, Case of the Day Posters, Exhibits, Competitive Scientific Papers ■

IN IMAGING 51

POST EVENT

â&#x20AC;&#x2DC;Radiation in Healthcare Summit 2012': Rooting for Nuclear power The 'Radiation in Healthcare Summit 2012' served as a great platform to showcase the power of nuclear energy and its myriad applications in medicine

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adiation in Healthcare Summit 2012' was recently held on 27th September 2012 at the Bombay Convention and Exhibition Centre, Mumbai.

Organised by UBM, the event was also supported by Department of Atomic Energy (DAE), the Board of Radiation and Isotope Technology (BRIT), The Society of Nuclear Medicine - India (SNMI), the Association of Medical Physicists of India (AMPI) and the Indian Association of Radiation Protection (IARP), premier agencies, working to promote the advancement of nuclear power and research in nuclear science and technology.

The Radiation in Healthcare Summit was co-located with India Nuclear Energy 2012, another event to showcase the rapidly growing civil nuclear energy sector. The Summit was an attempt to present the positive applications of nuclear

52 IN IMAGING

energy and radiation, as well as to burst several myths about the so called harmful effects of radiation.

The event also had an exhibition that showcased radiation-based equipment and services which are used for therapy and diagnosis in medical sciences.

The conference held at the summit covered several pertinent topics such

as 'Radiation in Cancer Treatment', 'Emerging trends in Clinical Nuclear Medicine diagnosis and treatment', 'R&D in Radiopharmaceuticals', 'Advances in Radiation therapy and Imaging' etc. Some of the prominent speakers at the event were Prof MRA Pillai, Head, Radiopharmaceuticals Division, Bhabha Atomic Research Centre & Professor, Homi Bhabha National Institute (HBNI); Dr. Birajlaxmi Das, Bhabha Atomic Research Centre; Dr PK Pradhan, President, Society of Nuclear Medicine, India; Dr SK Shrivastava, Prof & Head, Department of Radiation Oncology, Tata Memorial Centre etc.

All of these speakers elucidated on the various advantages offered by nuclear energy and gave a wealth of information on the various applications of nuclear energy in the field of medicine. Presentations which demonstrated that, if used in moderation, radiation has no lasting harmful effects offered several learning lessons and served as real eye-openers.

CEOs, MDs, Directors, senior management, senior doctors and consultants from the medical and health institutes, radiotherapists, oncologists, nuclear medicine practitioners, medical schools, medical researchers, scientists, instrumentation researchers, biotechnology researchers, genetic engineers, and medical professionals were among the audience who attended the event. â&#x2013; OCTOBER 2012

PRODUCT UPDATE

Carestream enhances its family of DRX imaging systems Introduces smaller, lighter console for its DRX-1 system to further reduce footprint

C

arestream has upgraded its CARESTREAM DRX-1 System with a new console that is much smaller and lighter. The console is 20 x 8 x 15 inches and weighs just 36 pounds.

This newly designed console minimises the footprint of the DRX-1 system, which allows facilities to convert existing X-ray rooms to digital radiography with Carestreamâ&#x20AC;&#x2122;s wireless, cassette-size DRX detector.

The new console fits into even the most crowded Xray room and is easy to move if needed. All wiring and power components are mounted inside the cover.

The company recently launched its new DRXRevolution Mobile X-ray System and introduced new capabilities and software features for its DRX-Evolution DR Suite that can help manage dose, improve image quality and enhance patient care, especially for critically ill or injured patients.

The DRX-Evolution is a modular DR room that utilises the wireless DRX detector and can be configured to fit each userâ&#x20AC;&#x2122;s budget, space and workflow needs.

The DRX family of imaging systems includes: DRXRevolution Mobile X-ray System, CARESTREAM DRX-1 System, CARESTREAM DRXMobile Retrofit Kit, CARESTREAM DRX-Evolution, CARESTREAM DRX-Transportable System; and CARESTREAM DRX-Ascend System.

A DRX detector can be easily transferred for use with any DRX system to allow facilities to maximise the functionality of each system. Each DRX system also employs the same user interface to increase staff productivity and reduce the need for training.

The flexibility and image quality offered by the DRX family of digital X-ray systems makes these solutions an ideal fit for general radiography exams including

OCTOBER 2012

orthopaedic, trauma and paediatric as well as other speciality care environments.

For more information contact Nilesh Dattatray Sanap Carestream Health India Tel: 022-67248816 Email: nilesh.sanap@carestream.com

IN IMAGING 53

PRODUCT UPDATE

Carestream ships 20,000 th Tabletop CR system These affordable digital CR systems deliver high-quality images in variety of patient care settings

C

arestream’s continuous investment in CR technology has enabled thousands of facilities across the globe to convert to high-quality digital imaging with CARESTREAM Vita CR and Point-of-Care systems. The company announced it has shipped its 20,000th tabletop CR system. These systems make it possible for small to midsize hospitals, clinics and practices to achieve the convenience and flexibility of digital images at an affordable price. CARESTREAM Vita CR systems perform general radiology and long-length exams and are also suit-

54 IN IMAGING

able for military, veterinary and other diverse imaging environments. Carestream’s Vita CR family includes the CARESTREAM Vita, and CARESTREAM Vita XE CR Systems. Throughput ranges from 44 to 63 plates per hour for 14 x 17 inch cassettes.

In addition to being reliable and easy to maintain, Vita CR systems can be set up quickly in the office or on the road. An intuitive interface minimises training time, default image preferences simplify selection and system software automatically corrects over and under exposures. ■ OCTOBER 2012

TRADE & TRENDS

â&#x20AC;&#x2DC;WE HAVE PLANS TO SET UP MANUFACTURING FACILITIES HERE IN FUTUREâ&#x20AC;&#x2122;

B Rajavel Subramanian, Regional Manager - India, South East Asia, Australia and Middle East for NeoRad, elucidates on the importance of the Indian market to his company and its future plans for India

NeoRad has ventured into the Indian Market in 2012. Tell us how important is the Indian radiology market for your overall global business?

We consider Indian radiology market for three reasons: Healthcare infrastructure is developing rapidly across India. The new inventions in the field of radiology are contributing a lot in the way of better diagnostics and imaging. Indian radiology market is adopting the latest technology at a very high pace. Every year modern equipment with high quality, high-end features and tools for faster diagnosis are getting introduced in this market. Therefore, this is certainly a market with a lot of opportunity for a technology-driven company like ours.

We also find growth in the tier II and tier III segments of the market and we have the right products to cater to these segments.

Official statistics shows that cancer killed 5,56,400 people across the country in 2010. The 30-69 age group accounted for 71 per cent (3,95,400) of the deaths. In 2010, OCTOBER 2012

cancer alone accounted for eight per cent of the 2.5 million total male deaths and 12 per cent of the 1.6 million total female deaths in this age group (30 to 69 years). Equipment like SimpliCT can detect cancer at an early stage and save millions of lives.

Our main focus is to tie-up with the government regional cancer centres for detecting cancer at the early stages.

As India has good, talented professionals, we plan it to be our hub for

training other Asian and South East Asian doctors. We have plans to set up manufacturing facilities here in future.

What are the specialised products that NeoRad will be offering its customers in India? Which segments of radiology does your company focus on?

We focus our activities in the field on interventional radiology and interventional oncology, fighting and diagnosing cancer by means of minimal invasive procedures.

IN IMAGING 55

TRADE & TRENDS and adequate training for doctors on using advance technologies.

I am planning to have Indian counterparts to work together on clinical studies, a joint R&D project for codeveloping products and creating a joint learning experience. This would pave the way for the Innovation Centre which is to be established in India.

In how many countries is Neorad present and what is the company's plan to set up its distribution channel in India?

We are present in all Scandinavian countries, across Europe and actively marking our presence in US and other emerging nations. We have direct presence in India with our own sales and service teams covering all its states. We are also working in building a network of over 15 channel partners across India, serving thousands of customers.

With the passage of time, we are increasing our footprints.

How has NeoRad grown over the years in the radiology segment worldwide?

Initially, our focus was the Scandinavian market. Now, we have a global operation and believe that our products may make a difference in the field of interventional oncology.

What is the uniqueness of the technology used for these products?

A very easy to use 3D navigation system using a laser to pinpoint the target. Usability is key in a hectic daily environment, where time is of essence.

What market opportunities and trends do you witness in Indian radiology market? How do you plan to tap it?

India currently has over 11,500 corporate hospitals and more than 14, 000 diagnostic centres. Diagnostics is poised to become a $900 million industry by 2013 with significant improvements occurring in the area of 56 IN IMAGING

early detection. The basic market requirement is to come up with more technology products at affordable prices, bearing in mind that usability is also an issue: the diagnostic equipment should be easy to use. I am sure SimpliCT is easy to use and affordable.

What are the obstacles that plague the Indian radiology market? How do you plan to overcome them?

According to me, there are no particular obstacles, for e.g. I can mention two areas on which I am focussing: to have PPPs with state governments to give quality treatments to rural public,

What are your strategies to get a quick foothold into the Indian market?

Developing key referral training centres and key opinion leaders as ambassadors will gives us a strong foothold.

What new product can we see from Neorad in the near future?

We're constantly evolving our products to increase our competiveness.

Among our focus areas within research is respiratory monitoring. The fact that the patientsâ&#x20AC;&#x2122; breathing makes both diagnosis and operations challenging makes us want to to develop a solution for it. â&#x2013; OCTOBER 2012

TRADE & TRENDS

‘INDIAN RADIOLOGY MARKET IS READY TO ADOPT NEW INNOVATIONS AND IS ADVANCING RAPIDLY’ Mirna Bassil, Marketing Manager, Emerging Markets—Middle East, Africa, Greater Russia, Turkey, India, French Overseas, Carestream Health speaks to Express Healthcare about the company's perspective on the Indian radiology market and its plans for India. Associated with Carestream Health for more than a decade, Bassil has in-depth knowledge of the Indian radiology market and its customers. Excerpts: How important is the Indian radiology market for Carestream?

How has Carestream Health been faring in this market?

India is one of the key markets for us. Ever since we forayed into the Indian market in 1991 we have always strived to make our latest technologies promptly available to the Indian customers. We have introduced a slew of innovative Xray imaging solutions in the Indian market and have developed a strong and loyal customer base.

With which products did you enter the Indian market?

When we entered the market, medical imaging was almost synonymous with analog x-ray system and film. X-ray imaging was reliant on X-ray films being developed in dark rooms with the help of chemiOCTOBER 2012

cals. That was the starting point. We were the first to introduce laser imaging technology for X-ray film printing, which was a step towards the digital technology in imaging.

With the laser film technology, customers can do away with dark room and hassle of developing film with chemicals. So it’s just laser printing.

This is one of our innovations that we brought to the industry. More recently, we’re proud to have also been pioneers in digital imaging technology, with our launch of the world’s first cassette-sized wireless digital radiography detector.

You have been associated with the Indian market for a long time now.

What can you tell us about your experience with this market?

Yes, my association with Carestream Health is a decade old

and since the last five years, I support India for various marketing initiatives.

India’s radiology professionals are very keen on image quality and are very knowledgeable in their field. We are very proud to have had the chance over the years to be close to the Indian radiology professionals cooperating with them on bringing to India the latest technologies, which help them improve both image quality and patient care.

We are especially proud of our educational programmes and activities, which we continue to implement in India in cooperation with India’s most known luminaries in the field.

When you compare the Indian market with the rest of the world, where would you rank the Indian radiology market?

IN IMAGING 57

TRADE & TRENDS Indian radiologists in general are very technology oriented and very knowledgeable. The Indian radiology market is ready to adopt new innovations and is advancing quite rapidly.

Indian experts believe that innovation does not happen in India, it is adopted from the West. So, what is your perspective on this line of thought?

I feel is that the response to new technologies and products is quite encouraging among the customers in India. Indian radiologists are open to learning and adopting new technologies. They regularly attend

Our effort is to stay as close as possible to the customers. We have direct presence in India with our own sales and service teams covering all the states of India. We have also a network of over 150 channel partners across India serving thousands of customers. With the passage of time, we are adding more feet on the ground. We bring all newly introduced X-ray imaging products to India without any time lag. Customerâ&#x20AC;&#x2122;s success and satisfaction are the centre of our focus always.

How do you focus on territories and products?

Indian radiologists are always looking forward to learning new things that they want to embrace and adopt trade shows and congresses in the world in order to remain up-to-date on the latest technology advancements. Many Indian radiologists make it a point to attend RSNA, which is the biggest radiology show in the world. At RSNA, Indian radiologists are seen keen on understanding the new developments in the field. So, my perspective is that Indian radiologists are always looking forward to learning new things that they want to embrace and adopt.

Coming back to Carestream's operations in India, what marketing strategies did you adopt when you entered the Indian market in 1991? How did you make your presence felt?

58 IN IMAGING

We try to be as close as possible to the end users, be it through personal connections or by way of our channel partners. We try to be present at various shows and conferences. We are well known in India for our various educational activities that we conduct for our customers to contribute towards the growth of the industry. We had an educational magazine that we are revamping this year. Also, we regularly conduct Digital Radiography seminars across India to share advanced radiology imaging techniques and solutions with our customers as well as organise training programmes for radiographers.

Indian hospitals are price sensitive and often talk about budget

constraint when they have to update technology. Is it difficult to market your DR products in such a market?

At Carestream, we understand the requirement of the customer and based on this, we develop our products. Going for a full room DR may be a costly proposition for many Indian customers, which is why we came up with a retrofit solution, Carestream DRX1 System. Keeping existing set up with the help of the retrofit solution, one can upgrade to DR at just one third the cost of full room DR. Afterwards, the customer can step by step upgrade to fullroom DR as and when he wishes to.

Through this DRX technology, we offer flexibility of transforming the existing analogue X-ray room into a DR within a day.

Do you think that Indian hospitals and imaging centres are really prepared to embrace digital radiology?

Yes, they are. We can gauge their interest when we meet them at radiology events in India, the US and Europe, which they attend to understand the significance and usage of latest technologies. That many hospitals are now going film-less also reflects the fact that doctors are keen on adopting new technologies.

Our latest digital imaging solutions have already been adopted by many sites in India and we are very excited by the response we have had so far for our digital solutions.

You must have come down to India with a special purpose. So is there a new project that you are working on?

We always have projects in the OCTOBER 2012

TRADE & TRENDS pipeline and it’s always a pleasure for me to be here. We have a new product that we want to launch soon. It’s our DR mobile system, part of the DRX family. This is a revolutionary DR mobile system, which is why we call it the ‘DRX Revolution’. It’s different from what we know of mobile systems and really raises the bar up with respect to what a customer should expect from a DR mobile system. We are positive that the Indian radiologists would appreciate it as much as our other products.

Some PPP models have been created to make radiology and imaging available to the rural sector. Is Carestream willing to

OCTOBER 2012

We bring all newly introduced X-ray imaging products to India without any time lag explore such an opportunity?

Yes, we are very keen on PPPs. Carestream Health has always focused on rural development in many parts of the world, most recently in China and Saudi Arabia.

We have a slew of mobile solutions, one of them being our CR mobile, the CR-Vita system. We are capable of linking rural diagnostic centres with main city hospitals.

We are running successful projects with our CR and PACS solutions in Saudi Arabia and China.

And hopefully, we shall implement something similar in India as well when and as needed, because we have the experience.

What are your plans for the Indian radiology market?

As India is one of our key markets and Indian radiologists are technology-savvy, we will continue to introduce new technologies and products in India, which answer our customers’ needs for image quality, productivity and better patient care. ■

IN IMAGING 59

TRADE & TRENDS

‘MYRIAN IS USED BY MORE THAN 2000 USERS EVERY DAY’

Patrick Mayette, Co Founder and General Manager of INTRASENSE gives out information about his company’s association with Modi Medicare, Myrian a multimodality workspace launched by his company, its various features and applications; as well as the changing dynamics of the Indian radiology market

Can you tell us about Intrasense and its association with Modi Medicare?

INTRASENSE has been closely working with the company Modi Medicare, and its CEO Jigish Modi, for more than two years. Modi Medicare’s expertise on our Myrian platform means high service quality for our Indian customers.

Tell us about Myrian and its applications for radiologists, surgeons and clinicians in their daily practice.

INTRASENSE develops a new generation of advanced software solutions for the review and analysis of medical images. Our Myrian platform is a full-fledged multimodality workspace with a user-friendly interface and features not only high level functions but also powerful protocols to optimise clinical workflows and boost productivity. A comprehensive set of original clinical modules are available as options for 60 IN IMAGING

liver, lung, colon, vessels, breast, heart, vessels and brain. The XLONCO module is the most advanced oncology follow-up application on the market.

What is the USP of Myrian?

Myrian is the first true multimodality workstation in the market with the capacity to combine, compare and process images from sever-

Myrian is the first true multimodality workstation in the market with the capacity to combine, compare and process images from several modalities simultaneously. Myrian also adapts itself to the exact needs of each user and hospital

These applications are a key asset for radiologists, surgeons, oncologists and specialists: ● They improve the efficiency of image reading and the accuracy of diagnosis ● They support surgery and therapy planning and assessment ● They allow the early and accurate evaluation of a treatment

al modalities simultaneously. This is essential to allow the comprehensive analysis of patient information, particularly in chronic diseases.

Myrian is also a very versatile and customisable platform that perfectly adapts itself to the exact needs of each user and each hospital. It seamlessly fits in the hospital information system (PACS, RIS, OCTOBER 2012

TRADE & TRENDS DEPENDING ON THE APPLICATION & IMAGING MODALITY THERE IS A FAMILY OF DIFFERENT MODULES SUCH AS: MYRIAN FAMILY: BASE PLATFORMS

SPECIALITY MODULES

PRO (Basic CR/DR Workstation) ADVANCED (Double oblique MPR/ MIP, CPR, etc.)

EXPERT (3D Workstation) EXPERT VL (3D With Volumetry W/s) XL-REGISTRATION (Elastic Registration) XL-4D NAVIGATOR

XP-LIVER XP-LUNG XP-LUNGNODULE XP-COLON XL-XP-2D/ 3D STITCHING XL ONCOLOGY (RECIST1.1) XP ORTHO

modalities) to enhance its capacity.

Its modularity allows step-by-step investment. It is available in workstations as well as in application server configuration.

How has been the overall market response to Myrian in the Indian market?

Indian market is a huge market and we have seen very good response on very specific needs as liver post-processing diagnosis at the beginning. With all the new equipment on CT and MRIs, India has overcome many high challenges and is now targetting very high-end modules such as Brain MR and Cardiac MR. Can you share with us some signif icant achievements over the last few years, global or in India?

Today, INTRASENSE serves over 500 customers including prestigious university hospitals in over 25 countries. Myrian is used by more than 2000 users every day. Our outstanding technology and our fast growth have allowed us to introduce the company on the NYSE Euronext market in February 2012. This is a key asset to accelerate the development of our platform and our presence in strategic markets OCTOBER 2012

XT CARDIAC MRI XT BRAIN MRI XP-VESSELS(CT/MRI) XT DENTAL XP-COLONCAD RADIOTHERAPY PLANNING XP-FUSION

We believe that India is a high potential market.

The high-level of medical education and massive investments in the healthcare infrastructure are strong drivers for growth

such as India.

We believe that India is a high potential market. The high-level of medical education and massive investments in the healthcare infrastructure are strong drivers for growth.

What are the opportunities and bottlenecks in the Indian radiolo gy market for your business?

Today, we can see a very large scope of opportunities, from equipping PACS companies with advanced visualisation software to answering to global tenders with server base software.

How are you poised for growth in the near future?

Our platform is very well accepted on the global market and regarded as a competitive alternative or

complement to modality vendorsâ&#x20AC;&#x2122; workstations as well as a smart way to enhance existing PACS installations. With three major product launches every year, we move fast to offer state-of-the-art technology to our users.

Myrian XL-ONCO for cancer therapy evaluation or Myrian XPLIVER for liver surgery planning are considered as the best solutions in their categories. On October 15, 2012, we will launch Myrian XP-BREAST, the most advanced breast MRI viewer on the market, with outstanding reading performance and smart clinical workflows and post-processing features.

Combined with high quality services, these solutions will continue to drive our global growth and market leadership as the most innovative visualisation software company. â&#x2013; IN IMAGING 61

RADIOLOGY SOFTWARE LIVER TRANSPLANT & SURGERY PLANNING

Advanced Liver Volumetry - A Complete Solution  Liver Transplant Planning  Liver Surgery Planning  Liver Volumetry  Tumor Volume Estimation and Vessel Analysis  Right Lobe and Left Lobe Evaluation  Liver Segmental Analysis Couinaud 8-Segments Volumes  Liver Hepatic Drainage Analysis Congestion Volumes  Pre TACE / Post TACE Evaluation of Lesion Volumes  Pre RFA / Post RFA Evaluation of Lesion Volumes  Radio-Embolization Evaluation  LAI Liver Attenuation Index  Liver Hemochromatosis Evaluation  THAD and THID Volumes measurements

Liver Volumetry

Hepatic Drainage Territories

Couinaud Segments

Radio-Embolization Planning

MYRIAN® FAMILY OF MODULAR WORKSTATIONS: BASE PLATFORMS SPECIALITY CLINICAL MODULES o PRO (Basic CR/DR Workstation) XT- CARDIAC CT XT-CARDIAC MRI o ADVANCED (Double oblique MPR / XP-LUNG XP-LUNGNODULE MIP, CPR, etc.)

XT-BRAIN CT PERFUSION XT-BRAIN MRI o EXPERT (3D Workstation) XP-COLON XP-COLONCAD o EXPERT VL (3D With Volumetry) XP-ORTHO XT- DENTAL o XL-REGISTRATION (Elastic Registration) XL-2D/3D STITCHING XP-FUSION o XL-4D NAVIGATOR XP-LIVER XP-CT CTA sub XL-ONCOLOGY (RECIST 1.0, Modified RECIST 1.1, CHESON) For more details, please contact : JIGISH B MODI PH: 2506 5664, 98670 01110, email: modimedicare@gmail.com Skype: modi.medicare 4/102, DEEP SUNIL, GARODIANAGAR, GHATKOPAR(E),MUMBAI 400077.

NE

W!

Simplify sterile needle holder Adjustable for easy angling of needle Apply or remove with needle inserted Allows patient breathing Gauge range 12G - 25G FDA 510(k), CE mark

Place holder

CT needle intervention: The SimpliCTTM laser is set with the calculated needle angulation.

As long as the needle hub is within the laser light, the angulation is correct.

This allows easy positioning and greatly reduces the number of needle corrections and confirmation scans.

SimpliCTTM Pointing Laser aligned and set at correct angle.

Cone Beam CT needle intervention: Without laser: For any straight needle intervention the C-arm will have to be moved back and forth between entry point (bulls eye) view and progress view to verify the needle angulation and progress.

With laser Bi planar real time tracking of needle is possible. As long as the needle hub is within the laser light, the angulation is correct.

The C-arm stays in progress view.

Ready!

SimpliCTTM Pointing Laser aligned and set at correct angle with C-arm in progress view position.

Secure Needle

Patient study confirms dose savings without increasing procedure time.1

1) Laser guidance in combination with needle path planning reduces fluoroscopy time and patient radiation dose in cone-beam CT needle interventions M.Kroes1, S.J.Braak2, M.J van Strijen2, W.Busse1, Y.L. Hoogeveen1, F. de Lange1, L. Schultze Kool1; 1 Radiology, Radboud University Nijmegen, Netherlands;2 Radiology, St. Antonius Hospital, Niuwegein, Netherlands (SIR 2012, abstract No. 68)

FDA 510(k), CE mark

SimpliCTTM works with any CT scanner. No integration necessary.

System is mounted on standard ceiling suspension units and could be up and running in minutes.

1000â&#x20AC;&#x2122;s of patients treated using SimpliCTTM laser guidance.

Adjustable in any position

Contact: Mr. Rajavel Subramanian Phone: +91 (944) 28 511 48 Regional Manager - INDIA , South East Asia & Middle East Email: rajavel.subramanian@neorad.no NeoRad AS www.neorad.com

Copyright Š 2012, NeoRad AS

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