In Imaging July 2012

IN IMAGING | JULY 2012

EDITORIAL

One man’s medicine, another man’s poison?

According to Mercom Capital Group, telemedicine companies bagged $19 million in three venture funded deals, the second highest fund flow in Q2 2012. Thus one of its branches, teleradiology, was a natural choice for our cover story in this issue, which traces the many twists and turns in its evolution. Telemedicine could play a major role in filling the accessibility gap in India’s healthcare system and hopefullly the 12th Five Year Plan will harness its reach and potential.

Like teleradiology, imaging practitioners continue to find new uses for existing technologies. For instance, a scan that is quite literally the last hope of patients with chronic liver disease, Fibroscan measures the ‘stiffness’ or ‘elasticity’ of the liver. At its heart, the Fibroscan is nothing but an ultrasound scan which creates waves and measures their speed. This gives an idea of the ‘stiffness’ of the liver, thus indicating the extent of liver fibrosis and enabling the doctor to plan treatment better.

But the same modality behind the Fibroscan, which offers hope for chronic liver disease patients, has come under fire for its role in sex

THE POTENTIAL OF A TECHNOLOGY HAS TURNED INTO A PAIN POINT, IRONICALLY BECAUSE AS PRACTITIONERS PUSH THE LIMITS OF TECHNOLOGY, WE WILL ALSO END UP CHALLENGING ETHICS

determination and hence increasing cases of female foeticide leading to skewed gender ratios. Imaging clinics have been raided, ultrasound machines have been seized, and now the authorities are planning to bring into force a law that will restrict the practice of radiologists.

The potential of a technology has turned into a pain point, ironically because as practitioners push the limits of technology, we will also end up challenging ethics. But resolving these ethical dilemmas calls for debate and discussion, not a knee jerk reaction and new laws.

There is strong opposition from the radiology fraternity. Their stance is: why blame the modality/technology or the practitioner when what we need is a complete mindset change in society, besides a revamp of existing laws. The coming months should see many more developments on this front. While we give an update in this issue, do write in with your views which we’ll be sure to feature in the forthcoming issue.

Viveka Roychowdhury viveka.r@expressindia.com

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6 IN IMAGING

JULY 2012

CONTENT IN IMAGING | JULY 2012

COVER

STORY

Teleradiology: A tale with many twists Teleradiology, with its ability to offer timely and improved diagnostic services, is here to stay but there is a long way to go before it achieves its full potential, finds Lakshmipriya Nair PAGE 16

Teleradiology in today’s world Dr Harsha Rajaram, General Manager, Telemedicine, Columbia Asia Hospitals, Bengaluru, outlines the relevance and need for teleradiology in healthcare and elaborates on the challenges that need to be tackled to facilitate its further growth PAGE 24

Onco-Imaging: Tapping its potential Dr Priya Chudgar, Consultant Radiologist, Kohinoor Hospital, outlines how imaging has evolved to play a pivotal role in oncology and elaborates on the major techniques used in onco-imaging PAGE 26

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Allengers: Foraying into digital radiography With DR systems becoming increasingly popular and finding acceptance in medical imaging domain, Allengers successfully forays into this domain with a range of digital radiography systems PAGE 30

NEWS

The Delhi High Court grants a stay on the Gazzete Notification to the PNDT Act Radiologists rejoice as the initial judgment goes in their favour RAELENE K AMBLI EH News Bureau

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he double judge bench of the Delhi High Court, on July, 23, 2012, passed a stay order on the Ministry of Health and Welfare's Gazzete Notification of June 04, 2012 and brought a new twist to the ensuing battle between the Central Government and Indian Radiological and Imaging Association (IRIA). After hearing the arguments from both sides, the court disapproved the Government's stand that radiologists/sonologists should visit no more than two clinics within a district to perform ultrasound and that they should compulsorily specify their consulting hours at each clinic. As per the Gazette Notification, the registration rates for ultrasound centres has also been arbitrarily hiked from Rs 3,000 to Rs 25,000 and from Rs 4,000 to Rs 35,000.

During the court proceedings, the government was represented by the Additional Solicitor General of India. He took an emotional angle and pleaded that the move was an attempt to curb female foeticide within the country. The government counsel also pointed out that the sex ratio is declining day by day in the country. The IRIA counsel was Vikas Singh, Sr Advocate and former Additional Solicitor General of India who convinced the learned judges that the new notification would adversely affect India’s healthcare delivery system, especially those who form the poorer JULY 2012

sections of the society. He further pointed out that this move will also result in an artificial shortage of radiologists in the country which in turn would be very detrimental to the entire healthcare system. Singh, in his argument, also said that IRIA is equally concerned with the rising numbers of sex-selective abortions but the measures taken by the government are misdirected. These measures will not affect the declining sex ratio in any way, on the contrary it would lead to the denial of ultrasound facility to the general public, even during emergency situations. IRIA's argument also highlighted that pregnancy ultrasounds form only about 2-5 per cent of the total number of ultrasounds done by radiologists, and that the other areas of usage would also be affected by this notification.

Commenting on the first achievement of the IRIA in this case, Dr Harsh Mahajan, Radiologist to the President of India and President, Indian Radiological & Imaging Association informed, “On July 9, 2012, we first filed a writ petition and pleaded to bring in a stay on the Gazzete Notification. Since it was an important issue the Delhi High Court had its first hearing on the July 10 itself. The Government counsel at that time was asked to file their petition which they couldn't do in a short period of time.

Therefore, the hearing was fixed for July 23, 2012. ” Speaking on the verdict passed, he further said,“We are happy that the judgment came in our favour.

We did not really raise the issue of increased charges in this hearing which was exclusively for grant of stay, though it does form part of our writ petition. We will take it up on the next hearing which is in September”. This case is an eyeopener for the nation and will further dig deep into this issue. Dr Mahajan commented, “IRIA would lend their full support towards eliminating this social stigma within our country. I am sure that with the unity of our members we will be able to engage with the government and other interested parties to rid our great nation of sex determination tests and sex selective abortions. IRIA and its members are law abiding and are equally interested to catch the culprits who perpetrate this heinous crime.”

The officials from the Ministry of Health and Family Welfare were not available for comment.

While investigating on this case, Express Healthcare also spoke to several obstetricians, gynecologists and radiologists across India who were of the opinion that this case, in its future proceedings will direct the Government to alter the PNDT Act, 1996 that permits any registered medical practitioner (RMP) to conduct ultrasound examinations with just six months' training in the field.

The first round of this battle goes to the radiologists. We will have to wait until September to see how this case pans out further and who has the final laugh. ■ raelene.kambli@expressindia.com IN IMAGING 9

NEWS

Fibroscan – a new device to track liver disorders It can assesses liver fibrosis non-invasively unlike invasive, painful liver biopsies

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ven today, hepatitis remains a largely unknown, undiagnosed and untreated group of diseases and hence the focus is on the importance of receiving appropriate treatment through timely diagnosis.

A tool which facilitates this is Fibroscan – a new device that assesses liver fibrosis non-invasively, unlike a liver biopsy that is invasive and painful.

Diagnosing fibrosis in patients with chronic Hepatitis, Fibroscan has been shown to be accurate and requires no liver biopsy.

“Fibrosis progression is highly unpredictable and an accurate result about the extent of damage to the patient’s liver is extremely important,” said Dr Ajay Kumar, Sr Consultant Gastroenterology, Indraprastha Apollo Hospitals. “Fibroscan is a newer investigation modality which gives us an idea of the extent of damage to the liver. In patients with metabolic disorder like fatty liver and alcoholic liver disease, it serves as next best to biopsy as it is completely safe and non invasive.”

An easy-to-use tool, Fibroscan provides multiple controls for reliable, accurate and reproducible assessments of liver tissue stiffness. Apart from measuring liver stiffness, Fibroscan allows assessment of controlled attenuation parameter, developed to detect liver steatosis. It is the only clinically validated device 10 IN IMAGING

for non-invasive fibrosis and steatosis quantification.

Dr SL Broor, Sr Consultant Gastroenterology, Indraprastha Apollo Hospitals, elaborated on the technique: “A scan that measures the ‘stiffness’ or ‘elasticity’ of the liver, Fibroscan uses an ultrasound scan to create waves and measure their speed. This tests the stiffness of the liver, indicating the extent of liver fibrosis. Although this scan is less sensitive in detecting mild or moderate liver fibrosis, it is very sensitive at ascertaining severe degree of damage. Patients having chronic liver disease in which liver biopsy cannot be done for fear of bleeding risk, Fibroscan is very useful to assess the liver damage and plan treatment.”

Adds, Dr Amitabh Dutta, Sr Consultant Gastroenterology, Indraprastha Apollo Hospitals, “Hepatitis can prevent the liver from performing numerous critical functions. Some common liver disorders such as Hepatitis A, Hepatitis B, Hepatitis C, and Hepatitis E are caused by viruses that attack and damage the liver.

It is imperative for people to fully comprehend the liver’s critical role in maintaining their overall health and well-being.

Until that happens, hepatitis will continue to debilitate patients’ lives and claim more victims year after year.” ■

GE Healthcare technology at London 2012 polyclinic

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E Healthcare, alongside the London Organising Committee of the Olympic and Paralympic Games (LOCOG), have showcased the broad range of medical imaging technologies that they will supply for the care of competing athletes at London 2012. The equipment, housed at the main polyclinic based in the Athletes’ Village in the Olympic Park in Stratford, will provide the athletes and team officials staying in the Village during the Olympic Games with access to excellent healthcare services. Technologies featured include MRI, ultrasound, X-ray, ECG, IT and monitoring systems.

GE Healthcare is working closely with medical leaders at the London 2012 Games to advance the use of advanced medical imaging technologies to optimise and improve athletic performance.

By making a wide range of medical technology available for use within the Olympic and Paralympic Village and all of the sporting events being held at the Olympic Park, clinicians will be able to diagnose potential injuries earlier or simply monitor treatment, to ensure that athletes are able to return to their sport as quickly as possible, helping them to stand the best chance of winning a medal. ■ EH News Bureau

EH News Bureau JULY 2012

NEWS

Study reveals Siemens imaging software syngo.via's efficiency Shows that it saves time without compromising accuracy

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iemens Healthcare conducted a study with six customers in Germany, Austria and Spain to quantitatively and qualitatively measure the efficiency of the software syngo.via compared to a conventional advanced visualisation workstation. The study results show that syngo.via can significantly help to save time when reading medical images, without compromising accuracy. For example, the observed average time savings from syngo.via for CT Cardiac amounted to 77 per cent compared to other reading solutions.

Additionally, the participating clinicians stated that syngo.via is performing better regarding usability than comparable software.

For a clinical institution to be successful, it is essential to obtain the highest possible diagnostic accuracy while maintaining a fast and efficient workflow. The 3D reading and advanced visualisation software syngo.via enables clinicians to meet the respective requirements by automatically loading for example CT or MR images into the appropriate application and sorting them into the disease-specific corresponding layout. Manual work steps are eliminated and the clinician can start diagnosing immediately. Siemens designed the syngo.via efficiency study with regard to following questions: What are the time benefits of using syngo.via compared to other reading software for a specific set of images? And which qualitative aspects in the use of syngo.via improve the diagnostic reading JULY 2012

process?

Six medical sites participated in the efficiency study which took account of a total number of seven different clinical workflows. To reflect their clinical routine, each participating site determined the case mix and measured 10 to 20 cases per workflow. The analysis of the study data showed that the use of syngo.via can achieve time savings and patient-centric productivity gains in all of the observed workflows. For example, the observed average time savings from syngo.via for CT cardiac amounted to 77 per cent and for an oncology diagnosis with PET/CT to 45 per cent. Using syngo.via when diagnosing oncology and neurology MR examinations resulted in 32 and 23 per cent average time savings, respectively. Analysis of images for CT vascular was 27 per cent and image evaluation for PET/CT and CT oncology follow-up 30 and 16 per cent faster compared to conventional advanced visualisation or PACS workstation. Siemens also conducted a usability survey among the study participants and they stated that syngo.via performs better regarding the aspects data preparation, usability of viewing and measurement tools, documentation and reporting than the former software.

For e.g. “syngo.via is an excellent tool to increase the productivity of radiologists working on cardiac images," said Professor Gudrun Feuchtner, Innsbruck University Hospital, Austria, for example. ■EH News Bureau

Growing cancer rates to boost radiation therapy

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report by GlobalData, pharma industry analysts claim that the radiation therapy devices market is growing with the increasing global number of cancer patients. The report states that the increasing number of cancer patients are due to a rising elderly population and the increased consumption of tobacco, especially in developing nations like China.

Therefore, there is a larger demand for cancer treatments which in turn would cause the worldwide radiation therapy market to grow from a value of under $2 billion in 2011, to $3.6 billion in 2018, at a CAGR of 9.1 per cent.

The penetration of linear accelerator machines and other radiation therapy devices is very less in countries such as China and India, but as awareness and purchasing power increase with the number of cancer patients, this is expected to change.

Equipment sales in traditional markets like the US and Europe, however, are expected to be propelled by replacement orders as people expect better and more efficient cancer treatments. In the global external beams therapy systems market, California-based Varian Medical Systems, Elekta AB, Accuray/ Tomotherapy and Siemens Healthcare are some of the major players. â– EH News Bureau IN IMAGING 11

NEWS

BARC scientists, Bombay Hospital introduce scanning procedures for cancer and brain disease

Super Religare opens regional centre in Bengaluru

These can be done everyday at little cost

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he department of Nuclear Medicine of Bombay Hospital has set up two new scanning procedures in collaboration with the Radiopharmaceuticals Division of Bhabha Atomic Research Centre (BARC) using indigenously produced radiopharmaceuticals for imaging brain diseases and cancer.

Till now the radiopharmaceuticals had to be imported and patients had to wait for long time. With the production of the new radiopharmaceuticals indigenously by BARC, these scanning procedures can be done everyday and the cost is low.

The two techniques are: DAT Scan and HYNIC-TOC Scan. The former is a brain scanning technique in which radiopharmaceutical is injected intravenously and image of brain is obtained after four hours. It is used for diagnosing Parkinson's disease when MRI is negative or inconclusive. It helps in detecting the areas of the brain which are affected in Parkinson's disease. It also helps in assessing the effect of treatment.

HYNIC-TOC scan is a whole body scanning technique in which radiopharmaceutical is injected intravenously and whole body images are obtained after four hours and are used for diagnosis of neuroendocrine cancers. The existing techniques 12 IN IMAGING

depend on importing the radiopharmaceuticals and are expensive. This new technique is indigenously produced by BARC and the product can be formulated every day at the nuclear medicine department using ready-to-use kits supplied by BARC and hence patients need not wait long. It is also not expensive and is useful in deciding which patient of neuroendocrine cancer will be benefit from isotope therapy.

Dr BA Krishna, Head of the department of Nuclear Medicine of Bombay Hospital said that the clinical studies have been set up by the department's technical staff in collaboration with BARC scientists. The technique has been standardised and nine patients of Parkinson's disease and eight patients of neuroendocrine cancers have been scanned so far with excellent quality images.

Dr MRA Pillai, Head of Radiopharmaceuticals Division, BARC said that he is satisfied that the clinical studies done with the products developed by BARC are giving excellent images. These products have been recently cleared by the adiopharmaceuticals Committee (RPC) and BARC will start manufacturing the products in larger scale to make it available for all Nuclear Medicine departments in the country. ■ EH News Bureau

It is one of the 28 SRL labs that has been accredited by NABL, Govt of India uper Religare Laboratories (SRL) has launched its eighth clinical reference laboratory, a state-of-art pathology and diagnostics centre, at Bannerghatta, Bengaluru. The 40,000 sq ft facility is Bengaluru’s largest standalone diagnostic centre, can handle more than 4,000 tests, ranging from the routine to highly advanced, and covering most diseases.

The facility has a high-end referral pathology set-up, and is also equipped with a range of radiology/consultation services like ultrasound, X - Ray, eye, ENT, dental, PFT, TMT, audiometry, 2 D Echo, physicians consultation, etc thus making it a comprehensive diagnostics set-up in the city.

Dr Sanjeev K Chaudhry, CEO, Super Religare Laboratories said “After opening a state-of-art imaging centre in New Delhi, we are happy to add world class diagnostic services for the people of Bengaluru.”

Kiran Vaidya COO, Super Religare Laboratories commented, "We are increasing our focus in southern state; Bangalore reference will be supporting our network labs for all south states. We will be expanding our network lab and collection centre presence through franchise model in Karnataka, Andhra Pradesh and Tamil Nadu.” ■ EH News Bureau JULY 2012

NEWS

Study: 3D body scans aid in treating eating disorders The study aimed to test the acceptability among ED patients to participate in 3D scanning

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study, carried out in collaboration between Robert Gordon University, the University of Aberdeen and the NHS Grampian Eating Disorder Service (NGEDS), championed the use of 3D laser scanning. The study looked into the body image perception of female patients with eating disorders (ED) patients and means to treat them through both 2D digital photography – which is widely used in the treatment of ED patients today – and 3D scanning.

Dr Arthur Stewart, of the Centre for Obesity Research and Epidemiology (CORE) from RGU’s Institute for Health and Welfare Research, was the principal researcher of this pilot study, which was funded by the Chief Scientist Office and has recently been published in the British Journal of Psychology. The study aimed to test the acceptability among ED patients to participate in 3D scanning, and to acquire novel data on the comparison between 2D imaging (measuring area from the frontal view only as is standard in current practice) and 3D scanning (measuring volume of all aspects of the body) and the corresponding 2D assessment of perception and dissatisfaction of patient body image.

The researchers concluded that treatment tools based on 2D representations might fail to completely depict the true size of JULY 2012

Philips announces 100 shipments of its mobile DR solution

specific body regions. Dr Stewart explained, “All existing methods for estimating perception accuracy or body dissatisfaction are based on 2D images, and the literature abounds with poorer estimations such as line drawings or silhouettes which are not specific to the patient in question.

Quantifying body shape via 3D scanning could offer a robust scientific platform from which to establish which body regions patients are dissatisfied with and so develop the basis for new treatment interventions of EDS.” The pilot research also sought to investigate the willingness of patients to be scanned. Of the 71 per cent of patients scanned, none failed to complete the procedure. As such, compliance among patients was considered high, despite patients’ anxiety due to their body image issues.

However, Dr Stewart cautioned, “Although 3D scanning holds the promise for being a better technique because it more fully represents the actual person in question, the process of patients confronting actual 3D representations of themselves is likely to make those with body image issues anxious. In addition, software approaches for assessing perception or dissatisfaction using a 3D shape are infinitely more complex. ■

hilips announced the 100th shipment of MobileDiagnost wDR, a mobile digital radiography (DR) solution with a wireless portable detector that facilitates diagnosis of immobile and critical care patients. MobileDiagnost wDR is a flexible solution that improves workflow and the efficiency of patient exams through an user interface and fast access to high quality digital images.

Built on Philips’ wireless portable detector, Eleva user interface, and UNIQUE imaging processing software, the MobileDiagnost wDR helps to accelerate clinician workflow by quickly delivering digital X-ray images. The mobility of MobileDiagnost wDR also improves patient care by avoiding stressful transports to a traditional DR room while delivering good image quality.

It has been commercially available globally since mid-2011, and the 100th shipment of MobileDiagnost wDR is an indication that hospitals are embracing of Philips’ mobile DR technology.

“Achieving 100 shipments of MobileDiagnost wDR has been rewarding because it is a new product that thoroughly addresses the needs of busy hospitals. It makes it easier for clinicians to provide timely care to critical patients, and helps enhance patient comfort without sacrificing image quality,” said Ronald Tabaksblat, Senior Vice President and General Manager, Philips Diagnostic X-ray, for Philips. ■

EH News Bureau

EH News Bureau

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C O V E R

S T O R Y

TELERADIOLOGY: A TALE WITH MANY TWISTS Teleradiology, with its ability to offer timely and improved diagnostic services, is here to stay but there is a long way to go before it achieves its full potential, finds LAKSHMIPRIYA NAIR “Anything one man can imagine, other men can make real.”

Jules Verne, Author

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elemedicine! One of the technological marvels in the world which testifies and proves the veracity of Verne’s words without any lingering doubts. Coined from Greek and Latin words, “tele” and “mederi” which mean 'distance' and 'to heal' respectively, The World Health Organization (WHO) defines it as, “the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation and for the continuing education of healthcare providers, all in the interests of advancing the health

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of individuals and their communities.” However, Time magazine puts it very simply and succinctly when it termed telemedicine as “healing by wire”.

TELEMEDICINE AND TELERADIOLOGY: TRACING THE ORIGINS Though telemedicine was born of a need to transcend boundaries of time and distance for ensuring first-class medical assistance to people residing even in the most far-flung and remote locations of the world, initially it was viewed with lot of misgivings. There were many sceptics and non-believers.

Even those who were more optimistic considered it as ambitious but 'futuristic' and 'experimental'.

However, proving all its cynics wrong, today it is very much a reality. There are several success stories of telemedicine projects across various parts of the world with diverse applications in IN IMAGING 17

COVER STORY patient care, education, research, administration and public health which makes it increasingly evident that telemedicine is here to stay.

In the past few years, telemedicine has diversified into more specialised forms, of which teleradiology has shown tremendous growth opportunities and application potential. Here, radiological images are transmitted from one location to another, through telecommunication systems, for analysis of all noninvasive imaging studies like digitised X-rays, CT, MRI, ultrasound, and nuclear medicine studies.

Teleradiology, as every other branch of telemedicine, owes its birth to imbalance of demand and supply. In this case, it is the inadequacy of diagnostic services and qualified radiologists in far-flung corners which gave rise to the need for teleradiology as a measure to bridge this gap. One of the first known instances of teleradiology is when dental X-rays were transmitted via the telegraph to a distant location way back in 1929. There was a time when digital cameras were used to take clinical photographs which were later downloaded, scanned and converted into the required format and then transmitted via the internet.

Undoubtedly a tedious task and that too without any guarantees of image clarity and hence accuracy of data.

Since then, the progress of technology for transmitting these images has been phenomenal.

Today, radiology equipment is extremely avant-garde and transmitting high-resolution images is a very swift process, thanks to high-speed internet and new-age softwares. The incorporation of picture archiving and communication systems (PACS), radiology information 18 IN IMAGING

EXPERT SPEAK DR ARJUN KALYANPUR, Chief Radiologist and CEO of Teleradiology Solutions, Bangalore

Dr Arjun Kalyanpur, Chief Radiologist and CEO of Teleradiology Solutions, Bangalore shares insight on the teleradiology market in India and its future prospects How has teleradiology evolved since its introduction in India?

Teleradiology in India has evolved and grown, although not as rapidly as in the West. The main changes in the teleradiology situation in India have been related to increased availability of broadband, improving infrastructure, increasing awareness of teleradiology and its potential and an increase in the number of providers.

How fast is it growing?

The segment, based on recent media reports, appears to be growing overall, although the precise rate of growth is difficult to determine, based on lack of clarity of scan numbers from other providers. Our own organisation, Teleradiology Solutions witnessed dramatic growth of 100 per cent between 2006-08 which decreased to around 20 per cent from 2009-

2010, and is currently in the 10 per cent range.

How has it changed healthcare delivery in India?

Teleradiology has changed healthcare delivery in India by allowing quality radiology services to be delivered to remote parts of the country – the current situation is that imaging equipment is being installed in various parts of the country by institutions such as the government, the armed forces and by private investors, however the number of radiologists is not increasing parallelly. Also most radiologists are concentrated in the metros. Teleradiology therefore enables the highest quality of radiology reporting to imaging centres in the smaller towns and rural areas. For example, Telerad

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COVER STORY

Foundation delivers high quality reports to remote locations in places such as Arunachal Pradesh and Jharkhand by extending the reach of radiologists in India and allowing them to report from anytime, anywhere. The use of teleradiology, with tools such as TeleradTech’s Radspa allow radiologists to increase their reach and scope of practice and also work more efficiently – additionally the practice of subspeciality reporting is also facilitated, and so the reporting standards in the entire country can be raised. It also shortens report turnaround times. Outsourcing radiology reporting is accompanied by service level agreements whereby the report turnaround times are carefully monitored and tracked, shortening the reporting cycle, decreasing patient waiting times, and benefitting the healthcare delivery system.

However, the main benefit, namely to provide immediate reporting in emergency settings, has yet to be realised as emergency medical services in India are yet not matured enough to derive the full benefit of such radiology support services.

Which prevents implementation of teleradiology in India?

The main challenges are infrastructural, as it is difficult to set up a critical medical service that has zero tolerance for downtime, in an environment where there are frequent power outages, unreliable net connectivity, traffic issues and bandhs prevent-

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ing staff from reaching work in time. These same challenges result in an increased cost of doing business as redundancy measures need to be planned at every stage of a teleradiology operation. Frequently issues of regional politics determine whether a project will be successful and enduring, as opposed to such issues as quality of service.

Lack of awareness about teleradiology is another constraint to its growth. Finally, a lack of respect for contracts and focus on price as opposed to quality of reporting is an issue that affects the atmosphere in which teleradiology is practiced.

What is the future of teleradiology in India?

The future of teleradiology in India is bright, given that there are such major manpower resource issues, and consequently such great potential for transformational impact. With the deployment of 3G telecom networks the last mile problems of the last decade that hindered the growth of teleradiology over the last decade have been eliminated. As low cost workflow technologies become available the access of radiologists to teleradiology is enhanced.

Teleradiology will increase the access of people in semiurban and rural India to high quality diagnostics. Thanks to teleradiology, the day when a patient has to get on a train or a bus simply to obtain an accurate radiologic diagnosis will soon be history.

systems (RIS), etc into teleradiology systems have further facilitated the production of instant yet accurate reports to be sent to the clinicians or surgeons.

GLOBAL TELERADIOLOGY MARKET: POISED FOR GROWTH Studies reveal that while the number of radiologists grew by two per cent annually, the growth rate in the number of examinations carried out registered more than 10 per cent. This has resulted in a widening gap between demand and supply.

The imbalance in the distribution of radiologists in different countries and regions has aggravated the problem further. Hence teleradiology; with the potential to make timely diagnostic services available to the patients anywhere, anytime; is being touted as ‘the ideal solution’ to ensure quality radiology service to one and all, irrespective of the time or location. As per data released by Frost & Sullivan, Europe's teleradiology market amounted to $184.1 million in 2010, of which more than 50 per cent of revenues were generated from the United Kingdom (UK) and Germany.

Now, various reports predict that the teleradiology market would show a northward curve in the next few years. A new market research, conducted by Global Information Inc, a Japanese information service company, forecasts that the global telemedicine market will register a CAGR of 18.7 per cent between 2011 to 2015. Similarly, a report published by Technavio, the research platform of Infiniti Research, predicts that the global teleradiology market will register a CAGR of 19.3 per cent during 2011 to 2015. UK, Spain and Scandinavia IN IMAGING 19

COVER STORY EXPERT SPEAK PARAG AGARWAL, Country Manager (India) Pellucid Networks

Parag Agarwal, Country Manager (India) Pellucid Networks gives his views on how teleradiology is shaping up in the Indian market and predicts its future progress

etc are expected to lead the teleradiology market globally as a result of their favourable regulatory environments, better clarity in cross border healthcare regulations, Europe's focus on e-health and pilot research programmes funded by the European Union (EU) like R-Bay to validate teleradiology's role in expending quality healthcare to all.

TELERADIOLOGY IN INDIA While the world looks at adopting teleradiology on a much larger scale than ever before, what is India’s stand on it? Introduced by Jhankaria Imaging, a private imaging centre, teleradiology was first successfully put to use in India in 1996. The motive was to transit images from the imaging centre to the homes of doctors, through a simple yet effective system, to report emergency CT scans. Subsequently, Siemens and then Wipro GE publicly demonstrat20 IN IMAGING

Tell us about teleradiology's growth in India.

It has become more relevant for entrepreneurial radiologists who are venturing out and starting their own teleradiology service businesses either as a group or as independents. With cloud technology, in the last few years, the cost of providing teleradiology services has not only come down drastically, but with flexible pay per use models, it has also led to the

ed the use of teleradiology but Teleradiology Solutions, a Bangalore-based company set up in 2002 by Dr Arjun Kalyanpur was instrumental in projecting teleradiology as an effective healthcare delivery tool in our country.

A SLOW START Given the fact that India is a country that faces an acute shortage of medical practitioners including radiologists, teleradiology should have picked up really well. However the reality is that though it has been over 15 years since the concept was introduced in the country; it hasn’t found many takers and its potential remains untapped. Speaking on the evolution of teleradiology in India, Dr Bhavin Jhankaria, Radiologist and Editor-in-Chief, Indian Journal of Radiology and Imaging says, “It has grown as expected with the growth in technology, but as a busi-

creation of several viable and fast growing businesses run by radiologists. As long as radiologists see the incentive of making themselves available remotely, with the same high levels of image quality,

ness and practice, not as much as expected.” However Dr Kalyanpur puts it more mildly and states, “Teleradiology in India has evolved and grown, although not as rapidly as in the West.” He further informs, “The main changes in the teleradiology situation in India have been related to increased availability of broadband, improving infrastructure, increasing awareness of its potential and an increase in the number of providers.”

BENEFITS GALORE……

Yet, the benefits that teleradiology can offer to this country are numerous. To name a few: Bridging the demand-supply gap: There is a shortage of qualified radiologists in our country, especially in the rural areas. Through teleradiology, even those living in the remote regions of the country will be able JULY 2012

COVER STORY

imaging centres will continue to demand and also contribute to the cost of teleradiology. For imaging centres, having a sophisticated workflow on the cloud also improves their turn around time, patient volume and ultimately revenue. So even the smallest of imaging centres in India is now open to teleradiology.

What kind of growth has this sector witnessed so far?

Growth of imaging centres is at 15-20 per cent per annum while radiologists are only growing at two per cent. As long as this gap remains, the growth rate of teleradiology will remain steady, at

to avail quality radiology services without having to travel long distances; thereby saving time, effort and often lives as well.

Round-the-clock service: It can also make certain that radiology services are available to those who need it at any place any time. Even in the cities teleradiology can be very useful since it would be a trusty ‘back up’ for on call residents.

Immediate reporting in emergency situations: Another important benefit of teleradiology makes it very easy to seek a second opinion and expert advice during all contingencies, even the ones that occur during “off hours”, and that too without wasting time which is of paramount importance in emergency situations.

Facilitates training and CME programmes: Young and inexperiJULY 2012

least on the demand side.

How has it changed healthcare delivery in India?

Specific to India, teleradiology is yet to make a tangible impact in the way healthcare is delivered. But as alluded earlier, it holds tremendous promise. The largest beneficiary ultimately, would be the patient, especially in critical emergency cases, and in the rural remote areas, where speed of diagnosis and intervention can save lives.

What are the roadblocks hinder the path of teleradiology services in India?

On the infrastructure side, definitely bandwidth and continuous power. On the delivery side, the government needs to play a more active role, at least at the State level, to sponsor the adoption of teleradiology where its needed most.

What is the future of teleradiology in India?

We are still some time away from teleradiology becoming the norm. However, for rural healthcare delivery, the government must step up its effort in partnership with private players as there is no other viable alternative to reach the masses.

enced radiologists can be trained on the nuances of radiology and experts knowledge can be imparted on the subject through teleradiology, thereby enhancing their skills and abilities, which in turn would translate in better quality services.

A lucrative business model: India, with its time difference, ability to offer cheap labour, and skilled support systems like IT, has the potential to attract outsourced projects for teleradiology from US, UK, Singapore and gradually build it up as a successful business model. It can take on lot of projects for ‘nighthawking’ another term for outsourced ‘on call’ night reporting.

This way, while hospitals in the US, UK, and Singapore will get proficient and timely professional help, India will be able to generate lot of jobs as well as revenue from the whole setup. The learning lessons will be an added benefit.

CHALLENGES TOO....

Now, the question that arises is that with so many benefits in the offing, what is holding back the growth of this sector? Why is it that we have only been able to scratch the surface, where teleradiology's true potential is concerned? Well, it is attributed to varied reasons.

According to Dr Jhankaria, the reason for this is 'costing'. He says, “Unless teleradiology is used as an in-house service, there is very little money to be made and the margins are wafer-thin.”

However, Dr Kalyanpur gives a detailed view on the topic. “The main challenges are infrastructural, as it is difficult to set up a critical medical service that has zero tolerance for downtime, in an environment where there are frequent power outages, unreliable net connectivity, traffic issues and bandhs preventing staff from reaching work in time. These same challenges IN IMAGING 21

COVER STORY result in an increased cost of doing business as redundancy measures need to be planned at every stage of a teleradiology operation.

Frequently, issues of regional politics determine whether a project will be successful and enduring, as opposed to such issues as quality of service. Lack of awareness about teleradiology is another constraint to its growth. Finally, a lack of respect for contracts and focus on price as opposed to quality of reporting is an issue that affects the atmosphere in which teleradiology is practiced.”

He also states, The main benefit that teleradiology offers, namely to provide immediate reporting in the emergency setting, is yet to be realised as emergency medical services in India are yet not matured enough to derive the full benefit of such radiology support services,” he explains.

Parag Agarwal, Country Manager (India), Pellucid Networks, has his own views as to why teleradiology is not picking up pace in India. He says, “On the infrastructure side, definitely bandwidth and continuous power is needed. On the delivery side, the government needs to play a more active role, at least at the State level, to sponsor the adoption of teleradiology where its needed most.”

Dr Harsha Rajaram, General Manager-Telemedicine, Columbia Asia Hospitals feels, “the lack of awareness on availability of such services, lack of standards and the inherent fear of losing their jobs on the part of local radiologists have hindered the progress. The demand for quality radiologists have skyrocketed the cost of hiring them, making their utilisation challenging.”

Drawing inferences from these varied sources, it can be concluded that India has to battle several 22 IN IMAGING

CASE STUDIES: SUCCESSFUL TELERADIOLOGY PROJECTS ◗ Teleradiology Solutions Ramakrishna Mission Memorial Hospital in Itanagar Arunachal Pradesh has an example of a highly successful teleradiology project within India. Supported by the Telerad Foundation, this project has been operational since 2007 and over 10,000 CT and MRI scans have been reported for the hospital by Teleradiology Solutions, free of charge. Similarly, their teleradiology project with the National Healthcare Group in Singapore has been a highly successful one since 2006 with over 200,000 examinations being reported till date. Dr Kalyanpur and his team have been able to reduce the report turnaround time from three days to one hour, an achievement that was acknowledged by the former Prime Minister of Singapore, Lee Kuan Yew in a speech he made.

◗ Columbia Asia A remote health care centre in Nagaland, was having difficulty in finding radiologists both in terms of location preference and affordability. The centre outsources its work to Columbia Asia.

Today for the last one year the center is able to provide the radiology services of highest quality to its patient by group of radiologist at Columbia Asia, 24 X 7, 365 days. An emergency CT is reported at any point of the day in less than 20 minutes and a routine CT reported in less than three hours. On an average the center does six to eight CT cases per day. Stringent quality control measures have ensured that the reports are accurate and reliable, the discrepancy rate is less 0.5 per cent.

challenges like lack of awareness, low-quality, pricing, lack of infrastructure, unfavourable regulatory environments and narrow mindsets before teleradiology can become really successful in India. As of now, it has played a very limited role in India's healthcare delivery.

Dr Jhankaria puts it very bluntly, “As yet, it (teleradiology) has not made much difference. While there are individual cases where radiology centres in under-serviced areas can be covered or multiple centres of a single practice can be covered,

etc. the overall impact is negligible.”

Agarwal from Pellucid also reiterates this view but is optimistic about its future. He says, “Specific to India, teleradiology is yet to make a tangible impact in the way healthcare is delivered. But as alluded earlier, it holds tremendous promise. The largest beneficiary ultimately, would be the patient, especially in critical emergency cases, and in the rural remote areas, where speed of diagnosis and intervention can save lives.”

JULY 2012

COVER STORY

FUTURE PREDICTIONS So, given this situation how will teleradiology fare in the future? Will it go on to achieve its full potential or will it lose ground due to the bottlenecks hindering its progress?

Again we receive mixed views on this front. Dr Jhankaria is of the opinion that it will be used more and more within practices and hospitals to consolidate multiple centres. “As a standalone business, I don't think there is much future”, he says.

However, Dr Rajaram gives a cautious view and says, “The increasing demand, shortage of radiologists and growing cost pressures would make it essential that resources are optimally utilised. The innovation and development in technology would provide options and make it inevitable for healthcare set ups to opt for teleradiology services. Inhouse radiologist would be the main JULY 2012

stay of all the hospitals, teleradiology would support and provide flexibility to the existing department.

Teleradiology will be utilised as a load optimiser, used for second opinion services and also to cover beyond working hours and for holidays. With the healthcare centers mushrooming in tier two and three cities all over the country creating a huge demand for skilled manpower. Teleradiology would help, atleast to a certain extent, by taking care of the radiology services in remote areas and helping provide quality healthcare.”

Dr Kalyanpur, on the other hand, is extremely optimistic about teleradiology's future in India. He claims, ”The future of teleradiology in India is bright, given that there are such major manpower resource issues, and consequently such great potential for transformational impact.

With the deployment of 3G telecom networks, the last mile problems of

the last decade that hindered the growth of teleradiology over the last decade have been eliminated. As low cost work-flow technologies become available, the access of radiologists to teleradiology is enhanced.

Teleradiology will increase the access of people in semi-urban and rural India to high quality diagnostics. Thanks to teleradiology, the day when a patient has to get on a train or a bus simply to obtain an accurate radiologic diagnosis will soon be history.”

Whose claims would be proved right is something that remains to be seen. However, as Agarwal puts it, “We are still some time away from teleradiology becoming the norm.”

While, it is evident enough that teleradiology's potential is tremendous, and it is now firmly ensconced in India, there is a long way to traverse before its true potential is explored and put to use. ■ IN IMAGING 23

IMAGING TECHNIQUES

TELERADIOLOGY IN TODAY’S WORLD Twenty-five year old Avinash is hit by a lorry as he rides home on his motorcycle on a poorly lit road one evening. He is rushed to a local nursing home where a CT scan is performed. In 15 minutes, a team of radiologists report the presence of internal bleeding confirming the medical officer’s diagnosis of head injury. Avinash is rushed into surgery, and a potential fatality is averted.

This sounds like any one of hundreds of road accidents that occur daily in India. So why does it merit any further discussion?

THE DIFFERENTIATOR ?

What differentiates this incident is that Avinash’s accident occurred in a small town in Nagaland which can only be reached by road. A qualified radiologist would have to travel 24 hours to reach here. The 15 minute turnaround time between taking a CT scan and obtaining a report was possible because a team of radiologists from Bangalore was available, able to obtain the scan and send back the report, all within a time span that makes the difference between life and death.

BOON FOR SMALL TOWN DWELLERS This is the new world of teleradiology. This technique of imaging has allowed healthcare providers to harness technology to provide quick, high-quality and widely accessible specialist care.

Let’s go back to Avinash’s story for a moment. Isn’t it unusual that a remote nursing home in Nagaland should have access to a CT scanner but not to a qualified radiologist?

24 IN IMAGING

Dr Harsha Rajaram General Manager, Telemedicine Columbia Asia Hospitals, Bengaluru

DR RAJARAM, OUTLINES THE RELEVANCE AND NEED FOR TELERADIOLOGY IN HEALTHCARE AND ELABORATES ON THE CHALLENGES THAT NEED TO BE TACKLED TO FACILITATE ITS FURTHER GROWTH

Unfortunately, the answer is no. Over the past few years, investments in Indian healthcare have grown rapidly, with the result that hospitals and diagnostic centers have mushroomed across the country. The bottleneck now has moved to manpower: recruiting and retaining a radiologist is increasingly challenging, even in the metros. By utilising the expertise of specialists, wherever they may be, teleradiology provides a means of overcoming this bottleneck.

Teleradiology allows patients to overcome the constraints of geography to access the benefit of this small pool of specialists

OVERCOMING GEOGRAPHICAL BOUNDARIES Today, over 70 per cent of clinical decisions are made on the basis of diagnostics like radiology and laboratory results. Further, medical science is evolving rapidly and developments like the 256-slice CT and 3T MRI produce images that can be interpreted only by highly qualified specialists. Teleradiology allows patients to overcome the constraints of geography to access the benefit of this small pool of specialists.

The other great benefit of teleradiology is in providing 24 X 7 coverage. This is one of the main reasons why 75 per cent of American hospitals contract with at least one teleradiology company, which JULY 2012

IMAGING TECHNIQUES helps them distribute the load and ensure radiologist availability throughout the clock. This in turn allows the rationalisation of escalating healthcare costs by optimising radiologist productivity, better utilising expensive CT and MRI systems and contributing to the development of imaging science by knowledge sharing.

Technology developments have facilitated teleradiology in several ways. The progress made in 3G networks, mobility devices and broadband connectivity has facilitated the quick transfer and seamless integration of radiology images across geographic locations.

Teleradiology has been built on the foundation of technology like PACS and video conferencing facilities which helped overcome the fundamental limitation of the radiologist not being able to view previous images and the inability to directly discuss cases with the reporting radiologist.

FACTORS LIMITING GROWTH OF TELERADIOLOGY Several factors have prevented teleradiology from growing as fast as requirements suggest. Primary among these is the ambiguity in the legal system which results in unclear liability sharing between different stakeholders and hence an unwillingness to take risk. The lack

of awareness and discomfort with technology among hospitals and physicians has also constrained growth. Further, it is currently often considered acceptable for non-specialists to read and report on complex radiology images.

Nevertheless, as the healthcare system evolves, both patient communities and insurers will increasingly

The lack of awareness and discomfort with technology among hospitals and physicians has also constrained growth. Further, it is currently often considered acceptable for non-specialists to read and report on complex radiology images JULY 2012

insist that reports be read by a qualified radiologist.

The other limitation in teleradiology adoption by hospitals has been the requirement for an onsite radiologist to perform ultrasound scans. The growing demand-supply gap will inevitably result in the development of sonologists, trained ultrasound specialists who represent a qualified alternative to an onsite radiologist. This is a trend that countries across the world have witnessed in response to radiologist scarcity and it is only a matter of time before it reaches India.

The growing demand, the acute shortage of radiologists, the complexity of the specialty and the enabling technology will continue to be growth drivers and ensure that teleradiology is here to stay. â– IN IMAGING 25

TECH SCAN

ONCO-IMAGING: TAPPING ITS POTENTIAL Medical imaging has become an essential component in many fields of clinical practice; and oncology is not an exception. Varied imaging modalities with newer techniques and software not only help in early diagnosis, but also in treatment planning and follow ups. Newer advances with MDCT applications and PET has brought a paradigm shift in oncology. Accurate detection and preoperative evaluation helps in surgical planning. Regular monitoring helps to follow up during treatment and post-treatment. Thus, imaging plays an important and integral role in oncology. Here we discuss newer imaging techniques and advances vis-a-vis their role in oncology.

ULTRASOUND Recent improvements in ultrasound such as tissue harmonic imaging, nonlinear signal processing and 2D matrix array transducers have introduced newer possibilities and paved the way for useful 3D imaging, while fast computing has allowed the production of real-time 3D scans (so-called 4D US imaging) Volumes can be displayed as series of multiplanar reformats or rendered 3D images, which improve appreciation of the relative position of structures, including flowing blood. Currently, the main clinical applications are in obstetrics but the approach shows promise in breast and prostate cancer and reveals the complexity of tumour vascularity in 26 IN IMAGING

Dr Priya Chudgar Consultant Radiologist, Kohinoor Hospital

DR CHUDGAR OUTLINES HOW IMAGING HAS EVOLVED TO PLAY A PIVOTAL ROLE IN ONCOLOGY AND ELABORATES ON THE MAJOR TECHNIQUES USED IN ONCO-IMAGING

3D sonogram of breast accurately depicts size and morpholgy of lesion a thorough manner. In interventional procedures, 4D ultrasounds are promising for needle biopsy guidance while 3D ultrasounds are used to guide radioactive seed implants in the prostate and for the breasts.

MDCT AND ITS ADVANCED APPLICATIONS The advent of multi-detector CT scanners has brought a new era in field of radiology. This produces faster and better scans with shorter breath hold and less amount of iodinated contrast. It proves a blessing for morbid patients with poor renal function who require repeated scans. Newer machines also produce lesser radiation hazards.

MDCT with excellent angiography views serve as a guideline for oncosurgeons, while hepatic volumetric helps to predict tumour volume. Lymph node detection undoubtedly helps in tumour staging, while CT with stereotactic guidance helps in radiotherapy planning.

Image-processing softwares help to localise the tumour regions; image JULY 2012

TECH SCAN

MR spectroscopy helps to predict tumour metabolites

Newer generation CT scan machine has revolutionised onco-imaging measurements help to quantify the tumour properties; image visualisations provide intuitive ways to present the tumour; image registrations help to fuse two images so that different tumour properties can be combined in one view; finally, CAD could be used in the clinical diagnosis/detection of tumours.

Medical image processing has evolved into an established discipline. It is a very active and fastgrowing field. Image processing techniques have already shown great potential in detecting and analysing tumours in clinical images and this trend will undoubtedly continue into the future.

MRI WITH SPECTROSCOPY AND OTHER APPLICATIONS High performance MRI systems with newer sequences using diffusion, perfusion and dynamic contrast has furthered onco imaging.

JULY 2012

MRIs, with increasingly sophisticated imaging capabilities serve as problem-solving tools in most of the cases.

Neuroradiology and imaging of brain tumours is not complete without MRI and spectroscopy.

Brain tissue is complex and is composed of many metabolites, some of which have unique magnetic resonance frequencies. However, most conventional MRI scans depend only on water and fat peaks to generate sufficient signal to generate an image. By selectively measuring the peaks of other metabolites relative to water, a spectrum that contains important clinical information can be generated. Two metabolites of particular importance in the brain are N-acetyl acetate (NAA) and choline (Ch) (31). NAA is a structural component of intact neural tissue.

Choline is a membrane component of cells. In tumours, NAA would be

expected to decrease in concentration whereas choline would increase in concentration. Thus, the ratio of NAA/Ch decreases in tumours compared to normal brain tissue, and this ratio appears to have prognostic information.

Tumours with low NAA/Ch ratio have poorer prognosis.

PET TECHNOLOGY WITH COMBINED PET/ CT SYSTEMS. These systems are especially helpful for detailed morphological and functional evaluation of disease. PET-CT has revolutionised onco imaging by adding precision of anatomic localisation to functional imaging. Surgical planning, radiation therapy and cancer staging have been changing rapidly under the influence of PET-CT. A PET/CT system significantly decreases the number of equivocal findings.

MAMMOGRAPHY AND RELATED NEWER TECHNIQUES: Discussion about onco-imaging cannot be complete without mammography. Mammography screening programmes helps for early detection of breast cancer, thus IN IMAGING 27

TECH SCAN reducing death from breast cancer.

Computer aided detection helps to pick up cancer, missed on mammography.

Elastography uses principle of the tissue’s distortion (strain) under an applied stress (e.g., compression via the transducer), known as elasticity imaging or elastography. The images produced have very high contrast and may significantly improve lesion detection within the breast, prostate and liver.

HIFU HIFU or high-intensity focused ultrasound surgery, as a therapeutic technique is not a new concept but recent advances in probe design and alternate ultrasonic imaging methods make it likely to become a realistic clinical tool in the near future. HIFU uses a highly focused ultrasound beam to coagulate a well-defined volume of tissue by heating it to above 50 degree celcius. Maintenance of this temperature for one to seconds results in cell death, and a single ultrasound exposure destroys a cigarshaped volume of tissue of 0.5 ml.

The surrounding tissue is not damaged and there is a very sharp line of demarcation between coagulated and viable tissue. This completely non-invasive technique has been used to treat malignant tumours of the liver, prostate and kidney and benign breast via a percutaneous or transrectal approach without the need for general anaesthesia.

Currently, HIFU tissue ablation damage is best observed using MRI, however it often renders the treatment cumbersome and expensive. Since B-mode ultrasound cannot distinguish between coagulated and normal tissue, alternate ultrasonic imaging methods such as elastography, reflex transmission 28 IN IMAGING

Newer advances with MDCT applications and PET has brought a paradigm shift in oncology. Accurate detection and preoperative evaluation helps in surgical planning

PET/CT picks up disease activity and reduces false positive findings imaging and thermal imaging are likely candidates to depict the tissue damage. HIFU could also be deployed intraoperatively, e.g., in the treatment of liver metastases.

ULTRASOUND DRUG AND GENE DELIVERY Exposure to ultrasound causes a transient increase in cell membrane permeability, an effect known as sonoporation. Using this technique, tissues can be targetted to stimulate cellular uptake of a drug (e.g., a chemotherapeutic agent) or a gene. Sonoporation requires high acoustic powers (higher than that used in diagnosis and equivalent to those used in physiotherapy) but

the power needed is markedly reduced when micro bubbles are also present. A drug or gene can be incorporated in or on the surface of the micro bubbles and tracked in the circulation with an imaging beam; when they are exposed to high power US, the micro bubbles rupture, releasing the agent near the target tissue. In the case of oncological drugs, this has the advantage of decreasing the dose of the drug needed, so reducing systemic side effects. Encouraging initial in vitro studies have demonstrated sonoporation without inducing cell death.

CONCLUSION This topic of newer advances in onco imaging is unending. Though the list may look elaborate, it is only like tip of iceberg. Still newer and better applications are emerging. Be it contrast enhanced ultrasound or MR lymphangiography, ongoing research will throw light into clinical and advanced applications of many such techniques. No cancer patient can do without digital radiograph, mammogram, periodic ultrasound or cross-sectional imaging. Evolving role of PET CT will help for accurate staging and hence further management. Future developments with advent of molecular imaging and many more advances will eventually help to increase overall life expectancy. â– JULY 2012

PRODUCT UPDATE

Allengers: Foraying into digital radiography With DR systems becoming increasingly popular and finding acceptance in medical imaging domain, Allengers successfully forays into this domain with a range of digital radiography systems

T

hough X-rays having been in existence for a long time, digital radiography has just been around since last two-three decades.

In the past few years, something radically different has emerged in the medical imaging domain, offering a new standard for digital X-ray image capture. And that is the emergence of digital radiography.

Digital radiography (DR) systems have currently caught the notice of many healthcare/medical centres as the most in demand equipment to use it as an urgent care system. The DR unit, coupled with its software, has converted many medical facilities into state-of-the-art digital radiography centres.

Earlier, the process of digital radiography involved radiographs being scanned and sent from one computer to another where the images were then stored in PACS. After that, computed radiography (CR) and DR followed. In CR, the phosphor plates were used to store along with a reader for reading those images and a laser printer to print them. As this method was slow, DR made its entry with full throttle.

The DR, being totally cassette-less, is much more efficient because the image is available immediately. The current practice of radiology, across the world, involves extensive handling of digital images. In recent times, there has been a growing trend towards adopting digital radiography mobile systems due to its convenience and speed despite its cost. DR is the

30 IN IMAGING

JULY 2012

PRODUCT UPDATE fastest digital imaging available at this time and speed is a very important aspect to improve the efficiency, a distinct advantage, especially while performing bed-side X-rays and in trauma cases.

ALLENGERS’ DR SYSTEMS Allengers, a Chandigarh-based medical equipment manufacturing company, has also successfully forayed into this segment of manufacturing a range of digital radiography systems like: ● DR system with auto-tracking ● DR system with U-arm stand ● Mobile DR system, which has been the most sought after system. Seven of such systems have been successfully installed at PGIMER-Chandigarh in their trauma and advanced paediatric departments ● Full field digital mammography (FFDM). Although this technology is at a very nascent stage, it would also be the technology of the future as it would address the needs of the radiologist in the screening of breast cancer in a more efficient manner. A fully isocenteric motorised gantry and state-of-the-art selenium detector with high resolution would makes this equipment the most sought after. The largest motivator for healthcare facilities to adopt Allengers FFDM is its potential to reduce costs associated with processing, managing and storing films.

Not to mention the other advantages like higher patient throughput, increased dose efficiency and greater dynamic range of digital detectors makes DR the most sought after technology. The advantages of DR outweigh that of all other imaging modalities.

So, the future of radiography will be digital and Allengers, an Indian MNC, which has been revolutionising the medical world since last 25 years with it’s wide diagnostic range of medical equipments is further striding fast to make its mark in the digitalised technology based medical equipments, says Ajay Mohan, HeadStrategic Marketing at Allengers-Chandigarh.

For more info contact: www.allengers.com JULY 2012

IN IMAGING 31

PRODUCT UPDATE

Perfint Healthcare launched MAXIO – a robotic ablation tool It is an intelligent robotic ablation tool set to change the face of interventional oncology

P

erfint Healthcare Corporation launched MAXIO, an integrated planning, navigation and robotic targeting system for CT-guided tumour ablation. The new robot is a first-of-its-kind, advanced tool which is expected to change the way healthcare experts approach interventional oncology and cancer care.

MAXIO combines tumour visualisation in 3D and procedure planning with robotic targeting that helps clinicians achieve consistent procedure quality. During the planning phase, e clinicians can ‘see’ the tumour and ry surrounding structures, determine

was to create a solution that would make life-saving ablation procedures available to a greater number of cancer sufferers. To do that, we realised that the complex techniques used by interventional radiologists would have to be made simpler and more predictable. That’s what we’ve done with MAXIO”.

Tumour ablation is an effective alternate to surgery for inoperable tumours. Tumour ablation is an image guided minimally invasive procedure in which devices such as needles are used to deliver thermal or other energy to destroy the tumour. Visualisation, planning and needle placement are key to successful tumour ablation.

MAXIO helps clinicians visualize, plan and perform tumour ablation safehelp clinicians to verify and ly with consistent quality MAXIO was developed through extend the procedure if needed. The use in ablation,complex biopsy, tool• Indicated helpsforsimplify proce- support under the BIPP scheme of drug delivery, drainage and FNA dures while ensuring a high degree the Department of Biotechnology • Robotic assistance for probe placement and meets the best-in-class stanof accuracy.

• Easy-to-use touch screen Commenting his company’s dards globally. The product com• Works from either sideon of CT table • Compacts for storage latest innovation, Nandakumar plies with CE marking requirements.

• Breath hold indicator MAXIO’s workflow and robotic Subburaman, CEO and Founder of registration Optical device Perfint Healthcare stated, targeting will make it easy for large “Interventional Oncology and in scale adoption of tumour ablation in specific tumour ablation is rapidly highly populous societies such as in becoming an effective alternate to India, China, Indonesia and Latin Post-procedure check scansfor viewed surgical treatment cancer, glob- America - where there is an urgent on MAXIO software provide tools to need to create high quality cancer ally.help MAXIO brings the confirm whether ablation has practice of successfully destroyed the tumor, interventional oncology to a whole care infrastructure, quickly and at a or whether additional treatments new level.” He added, “Our goal low cost. ■ the best approach to reach the tumour, select the appropriate number and type of energy probes, visualize estimated ablation volumes and determine the sequence of probe placement. MAXIO’s robotic targeting system then helps the clinician advance the probes as planned, to reach the tumour safely. Once the ablation procedure has been performed, MAXIO’s visualisation tools

Execution

Validation

32 IN IMAGING

JULY 2012

PRODUCT UPDATE

Carestream Health ships DRXRevolution Mobile X-Ray system New system delivers major improvements in conducting bedside X-ray exams

C

arestream has commenced shipping its DRX-Revolution Mobile X-Ray System and several healthcare facilities around the world who have already placed orders for this new system.

The new mobile X-ray system delivers good image quality, exceptional maneuverability and rapid access to patient medical images.

The DRX-Revolution offers a solution for specific needs voiced by several radiology professionals who were involved in the product’s design. For example, a unique software tool creates companion images from the original exposure: one image is optimised to show tubes and lines so physicians can verify placement, and another optimised image accentuates the appearance of free air in the chest cavity for easier visualisation of the pneumothorax.

The DRX-Revolution’s long, extendable tube head helps radiographers easily capture X-rays despite the presence of bedside medical equipment. The system’s two monitors (the main 19-inch monitor and an 8-inch tube head monitor) allow technologists to capture and review images without moving away from the patient’s bed.

The DRX-Revolution also uses the same software and graphic user interface as other DRX products, which makes it very easy to use, improves productivity and allow technologists to use the mobile X-ray system with minimal training.

All digital X-ray systems in

JULY 2012

Carestream’s DRX family, including the DRX-Revolution, share the same DRX-1/DRX-1C wireless detector, which offers flexible positioning and image availability in less than five seconds. Carestream’s product family includes: CARESTREAM DRX-1 System, CARESTREAM DRX-Mobile Retrofit Kit, CARESTREAM DRX-Evolution modular DR suite, CARESTREAM DRX-Transportable System and CARESTREAM DRX-Ascend System. ■

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PRODUCT UPDATE

Carestream Dental launches CS 1200 It is an affordable, easy-to-share camera that provides enhanced imaging, supporting diagnosis and enhanced patient care

A

s the most recent addition to the company’s full range of intraoral cameras, Carestream Dental has launched the CS 1200 intraoral camera, which provides high image quality at an affordable price.

The affordable CS 1200 captures crisp, clear images that reveal even the smallest cracks, caries and other anomalies with the best-in-class image resolution of 1024 x 768.

The CS 1200’s 6-LED illumination system automatically adjusts to ensure perfectly and uniformly lit images in any lighting condition, and the camera’s wide focus range captures a variety of images including macro, single teeth, arches and smiles.

“Dental professionals want to obtain the highest quality images for optimal diagnosis, treatment planning, patient communication and case documentation,” said Edward Shellard, DMD, Chief Marketing Officer and Director of Business Development for Carestream Health, Inc. “Providing practitioners with an affordable entry point into digital imaging, the CS 1200 puts high quality intraoral images within reach of almost any practice.”

34 IN IMAGING

The CS 1200 also features a USB 2.0 high speed connection, enabling easy sharing between operators.

Additionally, the CS 1200 can store up to 300 images within the camera itself. With a touch of a button, the images can be viewed on a PC, eliminating the need for docking stations or memory cards and improving practice efficiency. Fully TWAINcompliant, images can be stored and archived in Carestream Dental’s Imaging Software, as well as other leading imaging software.

“The CS 1200’s unique ability to store up to 300 images within the camera streamlines practice workflow with no memory cards or extra storage devices required,” said Pinkesh Garg, General Manager, Carestream Dental – India. The compact CS 1200 is comfortable during use for both the operator and the patient. The camera’s ergonomic, lightweight design fits in hands of any size, ensuring easy handling and reducing operator fatigue. Built with a round head and tapered shape, the camera offers improved patient comfort during exams.

The CS 1200 is also easy to install and use, minimising training time and improving practice productivity. The camera is fully backed by expert support and extended warranty programmes. ■ JULY 2012

RADIOLOGY WORKSTATIONS

advanced clinical fMRI solutions  BOLD, DTI and Perfusion analysis software  tumor volume, segmentation and evaluation software

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EVENTS LISTING Neuroradiology Teaching Program Date: August 10-12, 2012 Venue: Child development center, near Medical College, Thiruvananthapuram Organisers: IRIA KSC, MCH Tvm, SCTIMST, RCC Topic: Neuroradiology: X-ray, USG, Dopler CT, MRI, Interventional Radiology, SPECT & PET. Case- based reviews will be the main attraction. Each lecture to be presented like a classroom lecture with interactions Speakers: Dr Kesavadas, Dr Bejoy Thomas, Dr Kapilamoorthy, Dr, Santhosh Kannath,

Dr Jayadevan, Dr Narendra Bodhey, Dr Prakash Muthuswami, (SCTIMST), Dr K Ramachandran, Dr Manjusha, Dr Sumod (RCC), Dr Hari, Dr Rajendran, Dr Anilraj, Dr Jayasree, Dr Gomathi, Dr Ratnakumary, Dr Sudheer(Medical Colleges)

Venue: Chennai Organiser: Radiologycourse.org & Saveetha University Topics: This longest running FRCR 2B teaching course covers all aspects on the exam over two days: MacMini workstations for every candidate - long cases / rapid reporting packets; viva stations; focussed topics; discussion; feedback excellent feed backs from previous candidates.

JULY 2012

Date: September 6-8, 2012

Contact: Dr Anil Raj, 9447071771 Dept. of Radiodiagnosis, Medical College, Thiruvananthapuram

Venue: Bruges, Belgium

Tel: 9446594311, 9495533352

Topic: Abdominal Viscera, Genitourinary, Interventional Radiology

Email: akshayanilraj@gmail.com, drjayasreel@yahoo.com Website: www.iriakerala.org

14th Chennai FRCR 2B teaching Course Date: August 15-16, 2012

3rd Update in Medical Imaging Meeting on Abdominal and Urogenital Imaging

Speakers: Examiners from the UK and India. Many are trained in the UK and India and are teachers at UK FRCR teaching courses and University Hospitals.

Contact: In association with Saveetha University, Chennai, radiologycourse@yahoo.com

Organiser: Update in Medical Imaging

Contact: King Conventions, Korte Meer 18, B-9000 Ghent Tel: +32 (0)9 235 22 95 Email: imaging@kingconventions.be Website: http://www.update-medicalimaging.be

To tie up with

Tel: 0422 2544001 for further information Email: Radiologycourse@yahoo.com

for Media Partnerships Contact tushar.kanchan@expressindia.com

Website: www.RadiologyCourse.org IN IMAGING 37

EVENTS LISTING 3rd Bangalore FRCR 2B Radiology Revision Course on OSIRIX Date: August 18-19, 2012 Venue: St John's National Academy of Health Sciences Auditorium, Bangalore Organiser: UK Radiology Courses Topics: The course will replicate the UK courses in content and delivery. The candidates will get exposure to wide variety of cases and practice sessions with vivas conducted by UK trained and practicing consultant radiologists. The two-day course aims to provide wide range of cases to cover all formats of FRCR 2B exam.

Rapid Reporting: Six to eight sets of rapid reporting cases as part of the two-day course with feedback and discussion.

Long cases: Upto eight sets of long cases (six cases in each set) with feedback and discussion.

Speakers: UK Practising Radiology Consultants Contact: Dr Arun George, MD, Consultant Radiologist, Radiology Department, St John's National Academy of Health Sciences, Sarjapur Road, John Nagar, Koramangala, Bangalore, Karnataka, 560034

15th Annual Conference of Indian Society of Neuroradiology Date: September 20-23, 2012 Venue: NEHU Campus, Shillong Organiser: Indian Society of Neuroradiology Topic: Neuroradiology, Diagnostic and Interventional

Tel: 9342569077 Email: info@ukradiologycourses.co.uk Website: www.ukradiologycourses.co.uk

Speakers: Eminent national faculties in neuroradiology both diagnostic and interventional and also renowned international faculties in neuroradiology

14th Asian Oceanian Congress of Radiology 2012

Contact: Dr C Daniala Radiology Dept, NEIGRIHMS, Shillong – 793018

Date: August 30- September 2, 2012

Krishnamurthy (US), Dr Michael Michell (UK), Prof Hiromu Mori (Japan), Prof Greg Sorensen (US), Prof Jacob Sosna (Israel)

Tel: 09436312898

Contact: Congress Managers,

Website: www.isnr2012.in

Venue: Sydney, Australia Organiser: AOCR and The Royal Australian and New Zealand College of Radiologists Topic: Neuroradiology, Diagnostic and Interventional Speakers: Prof Juerg Hodler (Switzerland), Dr John Hoe (Singapore), Dr Barry Katzen (US), Dr Rajesh 38 IN IMAGING

Email: isnr2012@gmail.com

Tel: +612 9265 0700 Email: aocr2012@arinex.com.au Website: www.aocr2012.com JULY 2012

New from Varian Interay:

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For more information contact us or your preferred dealer.

USA Contact Information Varian Interay • 1-800-INTERAY • TEL 1-843-767-3005 • FAX 1-843-760-0079 E-mail interay.sales@varian.com

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TEL +91 22 67852200/2210 • FAX +91 22 28385614 • CELL +91 9987540900

Europe Contact Information Varian X-ray Products Germany • TEL 49-2154-924-980 • FAX 49-2154-924-994 E-mail sales-xray@varian.com

www.varian.com/interay Lightspeed®, Brightspeed®, and Performix® are registered trademarks of GE Corporation