Finding Value in Digital Breast 29 Tomosynthesis/media/DOWNLOADS/us/product/...injectors, this is spurring increased adoption of technologies like syringeless injectors, which can

The Technology Solutions Resource for Medical Imaging & Radiation Oncology Professionals | www.itnonline.com | March 2017

Finding Value in Digital Breast Tomosynthesis

High-intensity Focused Ultrasound | 18Technology Report: Enterprise Imaging | 22COMPARISON CHARTS

Contrast Media Injectors | 3Breast Tomosynthesis | 30

29

SBI/ACR Breast Imaging Symposium 2017 | April 6-9 | Los Angeles, Calif.Scranton Gillette Communications

radiologysolutions.bayer.com

DISCOVER YOUR DEPARTMENT’S UNTAPPED POTENTIAL.

Automated. Accurate. Accessible.

Are you making the most of your CT and MR investments?

Unless you’ve connected your Medrad® Smart injectors to a

technologically advanced contrast dose management (CDM)

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and documentation accuracy.

With tools from Bayer in Radiology, you can:

• Track cumulative contrast dose

• Reduce documentation errors and information gaps

• Investigate and tie information to outcomes

Bayer, the Bayer Cross, Medrad®, MRXperion™, and Stellant® are trademarks of the Bayer group of companies. ©2017 Bayer. All rights reserved.

Bayer HealthCare LLC, 100 Bayer Boulevard, PO Box 915, Whippany NJ 07981

PP-MRX-US-0111 February 2017

NOW AVAILABLE!

The latest Medrad® SMART Injector. The Medrad® MRXperion™ MR Injection System.

3 March 2017 | itnonline.com | Imaging Technology News

COMPARISON CHART Contrast Media Injectors

W ith medical imaging use on the rise, contrast media use is expected to grow as well, according to a May 2016 report from market research firm

GlobalData. According to the report, the global market value for contrast injectors was $830 million in 2015, and that number is expected to reach nearly $1.8 billion by 2022 — an increase of nearly $970 million in just seven years. The growth will largely be driven by increasing use of computed tomography (CT), magnetic resonance imaging (MRI) and angiography procedures, as well as increasing disease burdens, according to GlobalData.

In the United States, healthcare reform has been another major driver of innovation. Reform efforts such as the Medicare Access and CHIP Reauthorization Act (MACRA) are poised to alter the way clinicians are reimbursed, providing incentives for them to practice more efficient, value-based care and evaluating their performance based on the quality of care delivered. In the world of contrast injectors, this is spurring increased adoption of technologies like syringeless injectors, which can improve imaging exam efficiency, and contrast dose recording systems, which can serve as a mechanism for measuring quality of care.

Syringeless Injectors Syringeless power injectors have emerged in recent years as a solution to reduce contrast media waste. The Joint Commission does not allow the reuse of unused doses from single-use syringe injectors, so this option gives facilities the opportunity to use contrast media as efficiently as possible. Syringeless injectors have also been demonstrated to reduce exam times, leading to increased patient throughput. A study published in the Journal of the American College of Radiology in 2012 compared the efficiency of a dual-syringe injector with a syringeless injector in 275 consecutive CT exams. The syringeless injector saved over 2 minutes per exam, resulting in an increased throughput of 2.6 patients per day.1

The first syringeless injector on the U.S. market, Bracco’s CT Exprès 3-D, launched at the 2016 Radiological Society of North America (RSNA) annual

meeting in November. The multi-dose delivery system is designed for multi-patient use to increase the number of scans clinicians can perform in a day. The system is used in combination with the Isovue Imaging Bulk Package (IBP) and saline (0.9 percent sodium chloride injection USP). IBP was recently defined by the United States Pharmacopeia as the only contrast medium container for multi-dose, multi-patient use directly in the radiology room.

Bracco’s other newest release, launched in February, is SmartInjectCT, which packages the EmpowerCTA+ contrast injection system with the Nexo Contrast Dose monitoring solution. Empower syringeless injectors are able to use every drop of contrast loaded into the system for maximum economy. These syringeless systems use a bulk 500 mL bolus, and the injectors meter out each dose as needed. EmpowerCTA+ launched in March 2015 and is indicated for the vascular administration of contrast and flushing media in conjunction with CT scanning. It allows users to fully customize the injection experience for each patient with real-time variable flow rates, saline advance and saline jump.

Guerbet launched its syringe-free injection system, FlowSens, in March 2014. Composed of a softbag injector and associated disposables, the system uses a hydraulic, syringe-free injector to deliver contrast media. It is compatible with the company’s ScanBag solution and any type of contrast agent available on the market.

Dose Recording Systems While medical imaging and contrast use are on the rise, several recent studies have raised concerns

about potential lingering effects of contrast agents, particularly gado-linium. As a result, several vendors offer their own methods of recording contrast dose and sending the infor-mation directly to a picture archiving and communication system (PACS), electronic medical record (EMR) or other data storage system.

Bracco’s EmpowerCTA systems are supported by the Nexo Contrast Dose monitoring solution, which automatically delivers all injection information to a centralized server. This allows for enterprise-wide injector management. According to Bracco, Nexo has the ability to capture four Improvement activity measures under the Merit-based Incentives Payment System (MIPS),

one of the two new alternative reimbursement tracks offered under MACRA.

Medrad most recently released version 2.5 of the Radimetrics Enterprise Platform at RSNA 2014. The latest release of Radimetrics features more advanced contrast dose analytics, with new charts and data options to help identify repeat injections and issues associated with intravenous administration. The platform is integrated onto several of Medrad’s systems, including the MR Xperion.

Mallinckrodt launched its own contrast dose monitoring solution, the OptiSync data management system, in the fall of 2014 to complement its OptiVantage dual-head CT contrast delivery system. Operators can access all patient and pharmaceutical information with the scan of a barcode, and injection data — including the patient, drug, dose and administration — is transmitted to HL7-based healthcare systems while patient records are automatically updated. This creates a shared facility database that can help users assess areas where they can reduce errors, increase productivity or improve efficiency.

Other Recent System ReleasesIn February 2016, Guerbet announced U.S. Food and Drug Administration (FDA) clearance for the OptiOne single-head contrast delivery system. OptiOne is manufactured by Liebel-Flarsheim, one of the companies Guerbet acquired in November 2015 when it purchased Mallinckrodt’s Contrast Media and Delivery Systems (CMDS) business. The entry-level single-head injector is designed for injection of radiopaque CT contrast agents into the vascular system. It uses a motor-driven syringe mechanism with microprocessor control of the flow rate, volume, pressure and timing. All operations are performed on the touch-screen console, and the system has the ability to accommodate prefilled or empty syringes. itn

Reference1. Ma, X., Singh, A., Fay, J., Boland, G., et al. “Comparison of Dual-Syringe

and Syringeless Power Injectors in Outpatient MDCT Practice:

Impact on the Operator’s Performance, CT Workflow, and Operation

Cost.” Journal of the American College of Radiology. Published

Aug. 2012.

Advances in Contrast Media Injector TechnologyBy Jeff Zagoudis

Comparison chart compiled by Imaging Technology NewsScranton Gillette Communications assumes no responsibility or liability for any errors or omissions in this chart.

Participants

Bayer HealthCarewww.healthcare.bayer.com

Braccowww.bracco.com

Guerbetwww.guerbet-us.com

Nemotowww.nemotous.com

Scranton Gillette Communications obtained the product specifications from the manufacturers.



Company name Bayer HealthCare Bracco SpA

Product Medrad Stellant Dual CT Injection System w/ Certegra Workstation

Medrad Stellant Dual CT Injection System

Medrad MRXperion MR Injec-tion System

Medrad Spectris Solaris EP MR Injection System

Medrad Mark 7 Arterion Injection System

EmpowerCTA+ Injector System

CT Exprès 3D System

FDA cleared, year Yes 2003 (Launched Certegra Workstation 2012)

Yes, 2003 Yes 2015 Yes 2004 Yes 2011 Yes Yes

CE mark, year Yes Yes Yes Yes 39233 Yes Yes

Type (for which imag-ing modality)

CT CT MR MR Angiography CT CT

For cardiac imaging Yes Yes Yes Yes Angiography N/S N/S

Other types of exams N/A N/A N/A N/A N/A N/S N/S

For use in veins or arteries

N/A N/A N/A N/A Both N/S N/S

Does system record contrast dose used

Yes No Yes No Yes Nexo provides patient past records for better insights, utilizing documentation and referencing to ensure accuracy

N/S

How does this data interface with PACS, CVIS or other report-ing software

Yes No Yes No N/A Multi-injector control with seamless RIS/PACS connectiv-ity for a smoother workflow

N/S

Other software features

Certegra P3T 2.0 software Certegra P3T 2.0 software Onboard eGFR and weight based dosing calculators. KVO provides greater automation of injection process

Independent KVO (keep vein open) provides greater auto-mation of injection process

Variable Flow software with the Medrad VFlow Sterile Hand Controller

Nexo provides protocol management for centralized, standardized quality and compliance

N/S

What differentiates your system from other vendors

Scalable platform that is able to be upgraded with informatics technology can automate data capture and export to PACS, RIS, SR systems; onsite field service and remote support through VirtualCare

Onsite field service as well as remote support through VirtualCare

Connection to the modal-ity worklist; optional MR Informatics connectivity can automate data capture and export to PACS, RIS, SR systems; field service and VirtualCare Remote Support

Onsite field service as well as remote support through VirtualCare Remote Support

Unique, front load syringe; color, interactive user interface; ergonomic design; flexibility of multiple con-figurations

Nexo is a centralized, server-based system for standard-ized contrast delivery management

N/S

Number of syringes 2 2 2 2 1 2 N/A

Drive mechanism Electromechanical Electromechanical Electromechanical Electromechanical Electromechanical Electromechanical Electromechanical

Syringe style Two Two Two Two One Yes No

Syringe capacity, mL 200 contrast, 200 saline 200 contrast, 200 saline 65 contrast, 115 saline 65 contrast, 115 saline 150 2 - 200 N/A

Disposable Yes Yes Yes Yes HPCT Yes Yes

Prefilled No No No No No No No

Reusable No No No No No No No

Flow range, mL/sec 0.1-10 mL/sec in 0.1 mL/sec increments

0.1-10 mL/sec in 0.1 mL/sec increments

0.01-3.1 in 0.01 mL/sec incre-ments, 3.1-10 in 0.1 mL/sec increments

0.01-3.1 in 0.01 mL/sec incre-ments, 3.1-10 in 0.1 mL/sec increments

Fixed 0.1-45 mL/s 0.1-10, real time variable flow rate control increases/decreases flow rate based on clinical need

0.5-9 mL/s (in steps of 0.1 mL/s), max. flow rate depends on in-jected solution, prewarmed state and needle size

User throughput features

Auto fill/prime Auto fill/prime Auto fill/prime, eGFR calc. N/A Simple, color user interface Protocol fill; auto purge; arming at the injector; dual initializing, simple and intuitive user interface, saline advance, saline jump, fill rate, protocol storage, update protocol library

No syringes for reduced filling and cleanup; user-friendly interface with dual touch screens; easily switch between contrast bottles at any point during the procedure

Volume range, mL 1 - 200,1 increments 1 - 200,1 increments 0.1 contrast, 1 saline 1 increments 1-150 in 1 increments 1 - 200 in user-specified increments of 1

N/A

Delivery pressure range, bar (psi)

50 - 325 psi max 50 - 325 psi max 100 - 325 psi 100 - 325 psi 100-1,200 psi in 1 psi incre-ments

40-325 Syringeless 132

Pressure monitoring Pressure monitored and displayed on real-time pres-sure monitor graph during injection

Pressure monitored and displayed on real-time pres-sure monitor graph during injection

Pressure monitored and displayed on real-time pres-sure monitor graph during injection

Pressure monitored and displayed on workstation during injection

Yes Yes, with accessory tubing that have one way valves and large diameter tubing to reduce pressure

Yes

Selectable pressure, increments

50, 100, 150, 200, 250, 300, 325

50, 100, 150, 200, 250, 300, 325

100, 150, 200, 250, 300, 325 100, 150, 200 1mL increments 1 N/A

Imaging Technology News | itnonline.com | March 2017 5

Comparison Chart Compiled by Imaging Technology News Scranton Gillette Communications assumes no responsibility or liability for any errors or omissions in this chart.

Editor’s Note: Additional submitted information also appears on our website at www.ITNonline.com. N/A = Not applicable N/S = Not specified

Guerbet Nemoto Kyorindo Co., Ltd.

EmpowerMR Injector System OptiVantage Dual-Head CT Contrast Delivery System with RFID

OptiStar Elite MR Contrast Delivery System

Angiomat Illumena Contrast Delivery System

OptiOne Single-Head Contrast Delivery System

OptiStat Hand-Held Contrast Delivery System

Dual Shot Alpha 7 Rempress

Yes Yes, 2007 Yes, 2008 Yes, 1997 Yes, 2016 Yes, 2002 K133189, 2014 K092896, October 2010

Yes Yes, 2005 Yes, 2008 Yes, 1998 Yes, 2015 No Yes, March 2013 Yes, April 2008

MRI CT MRI Angiographic, CT CT CT CT Angio

N/S N/S N/S N/S N/S N/S Yes Yes

N/S N/S N/S N/S N/S N/S Indicated for all CT examina-tions

Indicated for all angio examinations

N/S N/S N/S N/S N/S N/S Veins Arteries

N/S No No No No No The injector will maintain a record of the last 100 injections

No

N/S N/S N/S N/S N/S N/S Not available in USA N/A

N/S N/S N/S N/S N/S N/S MultiUser config, timing bolus, NPT, SD card upgrades

Infusion mode, trace shot mode, X-ray or inject delay

N/S Prefilled contrast media syringes, optional RFID and OptiBolus bolus-shaping software, fully programable powerhead for scanner-side operation, Patency Check,Timing Bolus and CAN interface

Built-in Patency Check feature, auto home ram, Timing Bolus feature, scanner side operation

Cardio, angio and CT operat-ing modes

Prefilled contrast media syringes, OptiBolus bolus-shaping software, fully programable powerhead for scanner-side operation, tim-ing Bolus and CAN interface

Hand-held, portable injector, includes remote control con-sole, prefilled contrast media syinges or empty syringes and offers multiple mounting options

Body weight protocol includ-ing heart mode, simplified sy-ringes, ease of use, reliability and only 2 component system

Compact size with small pow-erhead for easy maneurver-ing; designed specifically for quick and easy operation as required by the surgical environment

2 2 2 1 1 1 2 1

Hydraulic Electromechanical Electromechanical Electromechanical Electromechanical Electromechanical Electromechanical Electromechanical

Yes Prefilled, prefilled w/RFID and empty

Prefilled and empty Prefilled and empty Prefilled and empty Prefilled and empty Handheld style PET syringes with patented safety notch

High pressure syringe

2 - 100 mL A and B: 200 A and B: 60 150, 200 200 130 200 and 100 150

Yes 200 mL 60 mL 150 and 200 mL 200 mL 130 mL Yes Yes

No 50, 75, 100, 125; Saline: 125 10, 15, 20, 30; Saline: 50, 125 50, 75, 100, 125 50, 75, 100, 125 50, 75, 100, 125 Yes No

No N/A N/A N/A N/A N/A No No

0.1-10, real time variable flow rate control increases/decreases flow rate based on clinical need

0.1 to 10 Side A: 60 mL syringe: 0.1 - 10 mL/s; 10, 15, 20 and 30 mL syringe: 0.1 - 8; Side B: 0.1 - 8mLs in increments of 0.1 mL

Angio: 0.1 - 40, CT :0.1 - 10 0.1 to 10 0.1 - 6 mL/sec 0.1 - 10 0.1 - 25

Auto-initialize and auto-fill Compatible w/ Ultraject pre-filled syringes; RFID captures, stores and transmits data; optional optibolus software provides decelerating flow rate for uniform enhance-ment; timing bolus, dual auto fill; auto home after injection; auto purge; patient volume delivered indication

Compatible w/ Ultraject prefilled syringes; auto retract seq. for tech to remove both syringes from powerhead w/out waiting for both rams to fully retract; when using glass vials, tech fills syringes outside of the magnet room; Timing Bolus feature to inject spec. amount of contrast to determine the optimum transit time of imaging agent to ROI

Compatible w/ Ultraject prefilled syringes; multimo-dality design allows the user to switch between cardiac, angio and CT modes with the touch of 1 button

Compatible w/ Ultraject prefilled syringes; Optional Optibolus software provides decelerating flow rate for uni-form enhancement; Timing Bolus, auto-fill, auto home after injection; auto purge; patient volume delivered indication

Set and adjust flow rate and volume, start/stop or pause injection, scan delay and elapsed timer

N/S N/S

1 - 100 in 1 increment 1 mL to volume in syringe 1 mL to volume in syringe 1 mL to volume in syringe 1 mL to volume in syringe 1 mL to volume in syringe 1 ml up to syringe size 1 ml up to syringe size

40-300 25 nominal - 325 peak psi 10, 15, 20, 30, 50 mL prefilled syringes at 200 psi; 60 mL empty syringes at 150 psi; 125 mL prefilled at 100 psi

Angio 150 and prefilled syringes: 75-1,200 psi; angio 200 mL syr: 75-900 psi; CT: 75-300 psi

25 nominal - 325 peak psi 50 - 270 peak psi 10 - 300 50 - 1,200

Yes, remote control Yes, built in, user program-mable pressure limit

Yes, built in, user program-mable pressure limit




Direct pressure sensor monitor

Pressure is monitored via the motor current

1 5 psi 10 psi 1 psi 5 psi Automatic 10 psi increments 50 psi increments

Delivery systems designedthe way you work.

For sales, service and support, contact your local sales representative or distributor.

Call 1.855.678.4250 or visit www.guerbet.com.

Control where you need it Get control where you need it with auto-fill,

tilt enable, CAN class 4 and relay interface capabilities, and manual flow knobs calibrated and color-coded for easy use.

Help safeguard patients with Patency Check® and Auto Purge features.

Work efficiently with Timing Bolus® feature, multi-phase protocol storage and Auto Home feature.

Workfl ow effi ciency Perform both single and dual syringe injections,

and save up to 40 four-phase protocols.

Minimize delays with console-enabled injector controls and Auto Retract.

Color touchscreen features intuitive graphic design.

Battery-free operation and prefilled compatible.

d to work

GU01171011

Simple. Flexible. Reliable. Easy operation with auto-fill, Auto Purge

and Auto Home features.

Adapt to your workflow with multi-purpose functionality, multi-phase programming and multi-phase storage for up to 40 protocols.

Created for convenience and control, with compact design, disposable or prefilled syringe compatibility and Timing Bolus® feature.

The multi-modality injector Gain flexibility to perform single- or multi-injection

procedures, switch operating modes with a single button, and store and recall up to 45 user-defined protocols.

Support efficiency with LED display that automatically flips as powerhead rotates, and fill control bar featuring one-finger operation.

Console features easy tilt and rotation, and hand and foot switches for comfortable system operation.

Optional Air Detection Aid & Warning System (ADAWS) helps reduce the chance of injecting air into patient.


Company name Bayer HealthCare Bracco SpA

Adjustable rise time N/A N/A No No 0.0-9.9 seconds in 0.1 mL increments

Yes, the flow rate can ramp up or down during the injection

No

Adjustable volume stop type

Electrical Electrical Electrical Electrical System adjustable by operator

Automatic electronic Automatic electronic

Increments 1 mL 1 mL Contrast: 0.1 mL increments; saline: 1 mL increments

Contrast: 0.1 mL increments; saline: 1 mL increments

0.1 mL 1 0.1

Synchronization with X-ray generator

Triggering interface with CT scanner

Triggering interface with CT scanner

N/A N/A Yes, ISI capability Yes Available April 2017

Console controls Interactive, color touch screen Interactive, color touch screen Interactive, color touch screen Interactive, color touch screen Interactive, touch screen Touchscreen at both injector head in scan room and re-mote display in control room

Touchscreen at both injector head in scan room and remote display in control room

Synchronization with ECG

N/A N/A No No N/A No No

Ceiling suspension Yes Yes No No Yes Yes Yes

Suspension manu-facturer

Mavig Mavig N/A N/A Mavig N/S N/S

Number of injector head mounting options

Three - ceiling, wall, pedestal Three - ceiling, wall, pedestal Pedestal with integrated IV pole

Pedestal with integrated IV pole

Three Floor stand or ceiling Floor stand or ceiling

Fully integrated, self-contained unit

Yes Yes Yes Yes Yes Yes Yes

Saline injection capabilities

Yes, before and after contrast Yes, before and after contrast Yes, before and after contrast Yes, before and after contrast No Yes Yes

Air embolism detector FluiDots and air expelled indicators

FluiDots and air expelled indicators

Display on injector head FluiDots and air expelled indicators

No No Yes

Extravasation detection

Yes,XDS extravasation detector using RF wave technology.; minimizing extravasation techniques coincide w/ACR guidelines including saline test injection and injection site monitoring; on-site training provided by registered radiologic tech-nologist

Yes, XDS extravasation detector using RF wave technology.; minimizing extravasation techniques coincide w/ACR guidelines including saline test injection and injection site monitoring; on-site training provided by registered radiologic tech-nologist

No No No Optional No

Operator alerts Yes, armed indicator lights, scan delay, inject delay and injection complete tones

Yes, armed indicator lights, scan delay, inject delay and injection complete tones

Yes, armed, test injecton, scan and inject delay, overpres-sure, injection complete tones

Yes - armed, test injecton, scan and Inject delay, over-pressure, injection complete tones

N/S Voice prompts on remote, confirm injection status

Remote and injector visual and au-dible alerts to facilitate immediate response; also enhance workflow and patient throughput

Overpressure protection

Yes, pressure limit: user selectable pressure limit; overpressure alert message

Yes, pessure limit: user selectable pressure limit; overpressure alert message

Pressure limit setting control with 6 factory presets from 100 - 325 PSI, overpressure alert message

Pressure limit setting control with 6 factory presets from 100 - 325 PSI, overpressure alert message

Yes Yes Yes

Console size, H x W x D, in.

13.5 x 15.8 x 10.2 13.5 x 15.8 x 10.2 13.46 x 15.75 x 10.23 10.9 x 11.9 x 10.5 12.62 x 11.042 x 3.040 17.8 x 33 x 71.1 (7 x 13 x 28) 11.8 x 7.9 x 8.7

Weight, lb. 17.6 workstation, 31.5 system 17.6 workstation, 31.5 system 19.2 workstation, 100.7 system and power supply

15 display, 60 system 146 8.2 10

Voltage, VAC 0.9 head only, 49.1 sys-tem,100-240

0.9 head only, 49.1 sys-tem,100-240

100-240, 50/60 Hz 100-240, 50/60 Hz 100-240, 50/60 Hz, 100-240 100-240

Warranty 1 year MFG Warranty, which includes VirtualCare con-nection

1 year MFG Warranty, which includes VirtualCare con-nection



1 year manufacturer warranty 1 year, optional 2, 3, 4 and 5 years

1 year, optional 2, 3, 4 and 5 years

Special features, options, additional product information

Informatics ready platform, storage/recall of up to 250 protocols, Certegra P3T 2.0 Software, VirtualCare

Informatics ready platform, storage/recall of up to 250 protocols, Certegra P3T 2.0 Software, VirtualCare

Informatics ready platform, storage/recall of up to 60 protocols, VirtualCare remote support

N/S Arterion enables operator to manage protocols, arm, review injection history, set options and view help topics

Saline advance pre-tests injection site for vein patency using saline prior to contrast injection; tilt lock prevents injection until head has been tilted into run position; fully compatible with Nexo; server based decision support system for patient care and contrast management; allows centralized contrast protocol creation and implementation from single location across all networked injectors; document contrast delivery by patient, by room or by department with key per-formance indicators; meets requirements of BSI, CSA, IEC 60601-1, ISO 9000, and UL 2601-1

Reduces contrast media waste; able to program, store protocols with up to 8 phases; indicated for use in CT procedures for the deliv-ery of Isovue (Iopamidol Injection) contrast media as supplied in an Imaging Bulk Package (IBP), for a maximum of 20 bottles of contrast media or a maximum of ten (10) hours, whichever comes first, per Day Set III HP disposable; the bottle spike disposable is for single-bottle use only and must be discarded with the contrast media bottle; the patient set disposable must be discarded after each patient procedure



Comparison Chart Compiled by Imaging Technology News Scranton Gillette Communications assumes no responsibility or liability for any errors or omissions in this chart.

Editor’s Note: Additional submitted information also appears on our website at www.ITNonline.com. N/A = Not applicable N/S = Not specified

Guerbet Nemoto Kyorindo Co., Ltd.

No N/A N/A 1-10 seconds N/S N/A Selectable 0 sec or 2 sec Setting from 0 to 9.9 sec

Automatic, servo-hydraulic Automatic, electronic Automatic, electronic Automatic, electronic Automatic, electronic Automatic, electronic Automatic electronic stop Electronic and mechanical stop

1 N/S N/S N/S N/S N/S Automically controlled by device

Automically controlled by device

No N/A N/A Yes Yes N/A CAN Class 4 Logic interface

Injector and remote N/S N/S N/S Yes Yes Color LCD with touchscreen GUI

Color LCD with touchscreen GUI

No N/A N/A Yes N/A N/A No No

No Yes No Yes Yes N/A Yes Yes

N/S Mavig N/A Mavig Mavig N/A Mavig Mavig

Floor Rolling stand and ceiling Rolling stand and mobile coach floor / wall mount

Pedestal, ceiling, wall, table and remote stand

Rolling stand and ceiling Portable, wall, IV pole or CT gantry

Pedestal and ceiling mount Pedestal, ceiling and table mount

Yes No No Yes No Yes No Yes

Yes Yes Yes Yes No No Yes No

No No No Yes No No Pressure limiting and graph aide detection

Pressure limiting/graph aide detection

No Yes Yes No No No Not available in USA No

Voice prompts on remote, confirm injection status

Yes Yes Yes Yes Yes Various operator alerts are provided to ensure proper user interaction and settings with the device

Various operator alerts are provided to ensure proper user interaction and settings with the device

Yes Yes Yes Yes. Yes Yes Monitoring with pre-alert messages and automatic stop if pressure exceeded

Monitoring with pre-alert messages and automatic stop if pressure exceeded

27.9 x 33 x 10.2 (11 x 13 x 4) 12.3 x 8.5 x 2.5 12.3 x 8.5 x 2.5 12.3 x 8.5 x 2.5 12.3 x 8.5 x 2.5 6 W x 2 D x 1.8 H 4.2 x 10.6 x 9.8 8.3 x 9.6 x 3.5

4.5 5.8 (2.6) 5.8 (2.6) 5.8 (2.6) 5.8 (2.6) 0.3 59 147

100-240 100-120 or 220-240, 50-60 Hz

100-120 or 220-240, 50-60 Hz

110-120 or 220-240, 50-60 Hz

100-120 or 220-240, 50-60 Hz

Unit automatically adapts for input voltages from 100 to 230

100 - 240/50/60 Hz 100 - 240/50/60 Hz

1 year, optional 2, 3, 4 and 5 years

1 year parts and labor, ex-tended service plans available




1 year parts and labor Standard 2 years Standard 2 years

Tilt lock prevents injection until head has been tilted into run position; hydraulic system does not require batteries; fully MR compatible up to 7T; connectivity to injector reporting information system (IRiS) contrast management tool

Programmable powerhead touchscreen; Patency Check feature for extravasation pre-vention; setup for dual-head, simultaneous or single-head protocols; interface for CT; optional optibolus bolus shaping software; manufac-turing ISO 13485, 2003 and TUV certified; FDA cleared; CE marked; UL, cUL and CSA approved

Battery-free power source, Patency Check feature for extravasation prevention; status indicator line on console, dual syringe w/ multiple user defined phases; color coordinated push rods and touchscreen; mftrg ISO 13485, 2003 and TUV certi-fied; FDA cleared; CE marked; UL, cUL and CSA approved

Versatile exam modes; switch between cardiac, angio and CT modes; ceiling, wall, ped-estal or table mounts; accom-modates Ultraject prefilled syringes; ADAWS optional; manufacturing ISO 13485, 2003 and TUV certified; FDA cleared; CE marked. UL, cUL and CSA approved; Japanese Shonin approved

Capable of utilizing prefilled or empty syringes, fully programmable powerhead touchscreen for scanner side operation, optional OptiBolus bolus-shaping software; FDA cleared. CE marked; UL, cUL and CSA approved

Capable of utilizing prefilled or empty syringes; portable, lightweight, durable design

Body weight protocol pro-vided as a standard protocol

Footswitch option, table rail mounting option

Work with quality, in any application.Our delivery systems are designed to work the way you do.

Schedule your in-person demo today.Contact your representative to schedule your

free demonstration by calling 866-223-4434, or

visit www.Guerbet.com for more information.

Guerbet contrast delivery systems are all part of our Imaging Solutions & Services platform – a family

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IMAGING 3 | Contrast Media Injectors Comparison Chart

14 | Global Imaging Trends A look into what will drive the medical imaging market’s future growth.

16 | Imaging Technology Products

RADIATION ONCOLOGY18 | High-intensity Focused Ultrasound Off ers New Opportunities The emerging technology of focused ultrasound expands into many treatment areas as a noninvasive alternative to surgery, radiation therapy or chemotherapy.

21 | Radiation Oncology Products

INFORMATION TECHNOLOGY22 | RSNA Technology Report 2016: Enterprise Imaging In an itnTV video, Contributing Editor Greg Freiherr describes enterprise imaging advances shown at RSNA 2016.

25 | Information Technology Products

BUSINESS26 | Prioritizing Patient Satisfaction As the healthcare system begins placing greater emphasis on value, providers should make patient satisfaction a high priority throughout the whole patient experience.

WOMEN’S HEALTH 29 | Breast Tomosynthesis Comparison Chart

32 | Women’s Health Products

DEPARTMENTS12 | From Your Editor by Melinda Taschetta-Millane

13 | News Briefs

34 | The Last Read by Greg Freiherr

contents

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About the coverGE’s Senographe Pristina

3-D mammography platform allows for excellent visualization of

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PHOTO COURTESY OF GE HEALTHCARE

The Technology Solutions Resource for Medical Imaging & Radiation Oncology Professionals | www.itnonline.com | March 2017

Finding Value in Digital Breast Tomosynthesis

High Intensity Focused Ultrasound | 18Technology Report: Enterprise Imaging | 22COMPARISON CHARTS

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from your editor

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Melinda Taschetta-Millane

Artifi cial intelligence (AI), or deep learning, continues to be an ongoing topic of conversation. According to a new report by Signify Research, an independent supplier of market intelligence and consultancy to the global healthcare information technology industry, this will lead to a $300 million market by 2021.

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The report stresses that in most countries, there are not enough radiologists to meet the ever-increasing demand for medical imaging, and many radiologists are already working at full capacity. It’s likely the situation will worsen as imaging volumes increase faster than new radiologists can enter the fi eld.

A new breed of image analysis software has emerged that uses deep learning to help alleviate some of the more repetitive and time-consuming tasks routinely performed by radiologists. This growing array of products automates the various stages of the imaging diagnosis workfl ow.

“Radiology is evolving from a largely descriptive fi eld to a more quantitative discipline. Intelligent software tools that combine quantitative imaging and clinical workfl ow features will not only enhance radiologist productivity, but also improve diagnostic accuracy,” said Simon Harris, principal analyst at Signify Research and author of the report.

But it is still early in the game for deep learning in medical imaging. Few products are available, and it remains unclear how deep learning will deal with multiple variations in protocols and procedures. And, many radiologists remain skeptical.

“Deep learning is a truly transformative technology and the longer-term impact on the radiology market should not be underestimated. It’s more a question of when, not if, machine learning will be routinely used in imaging diagnosis,” Harris concluded.

If you want to learn more about the Signify Research study, visit http://bit.ly/2lnCEau.

ITN a Neal Awards Finalist

Also, I’m proud to announce that ITN is again a fi nalist in the prestigious Neal Awards editorial excellence competition in the category “Best Commentary/Blog” for Greg Freiherr’s ongoing Last Read column. (You can read Greg’s latest column on page 34 of this issue.) Now in its 63rd year, the Neal Awards recognize the best in business-to-business editorial across standalone and integrated media channels. Dubbed “the Pulitzer Prize of business media,” the Neal Awards are b-to-b’s most prestigious and sought-after editorial honors.

ITN’s sister publication, Diagnostic and Interventional Cardiology (DAIC), is also a fi nalist in the category of “Best Use of Social Media.” Winners of all categories will be announced in early April.

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News Briefs

Study Finds Medicare Imaging Utilization Highest in First Half of Each Year

Astronauts’ Brains Change Shape During Space ight

According to new research, Medicare imaging utilization varies reasonably consistently on a quarterly basis and is highest in the fi rst half of the year. The study, supported by research grants from

the Harvey L. Neiman Health Policy Institute, is published online in the Journal of the American College of Radiology (JACR).

The researchers evaluated associations of an array of patient factors as well as within-year temporal variation on the

utilization of imaging in the Medicare population. Using Centers for Medicare and Medicaid Services (CMS) data, they identifi ed imaging events nationally per 1,000 Medicare benefi ciaries from 2008 through 2014 on a quarterly basis.

“We observed that nationally, Medicare imaging utilization increased 1.3 percent from 2008 to 2009 (3,496 to 3,542 imaging events per 1,000 benefi ciaries), and then decreased on average 1.2 percent annually to 3,331 events per 1,000 benefi ciaries in 2014,” said Andrew Rosenkrantz, M.D., MPA,

an associate professor of radiology at NYU Langone Medical Center and a Neiman Institute affi liate research fellow.

Rosenkrantz and his colleagues found that imaging utilization events in the Medicare population varied considerably based on patient comorbid conditions. They also discovered that utilization was highest in those with dual Medicaid eligibility and in those on Medicare due to end-stage renal disease.

“Our fi ndings indicate that a wide range of patient factors — most outside of radiologists’ control — heavily infl uence such variation. Thus, these factors will need to be properly considered in order to reliably defi ne the risk level of any individual physician’s patient panel,” added Rosenkrantz.

“We believe that our observations have implications regarding eff orts under the Medicare Access and CHIP Reauthorization Act to more precisely track utilization and associated variation in utilization for individual physicians. Such eff orts will be important in creating metrics that appropriately consider patient population complexity and the impact of deductibles and co-pays on imaging utilization,” noted Richard Duszak, M.D., FACR, professor and vice chair for health policy and practice in the department of radiology and imaging sciences at Emory University and affi liate senior research fellow at the Neiman Institute. “As radiologists embark on new payment models, within-year temporal variation in imaging and specifi c features of patient population attributed to their practices could have important fi nancial consequences.”

Magnetic resonance imaging (MRI) exams before and after

space missions reveal that astronauts’ brains compress and expand during spacefl ight, according to a University of Michigan study.

The fi ndings could have applications for treating other health conditions that aff ect brain function, said principal investigator Rachael Seidler, U-M professor of kinesiology and psychology.

The study, believed to be the fi rst to examine structural changes that take place in astronauts’ brains during spacefl ight, found that the volume of gray matter increased or decreased, and the extent of the alteration depended on the length of time spent in space.

Seidler and colleagues examined structural MRIs in 12 astronauts who spent two weeks as shuttle crew members, and 14 who spent six months on the International Space Station. All experienced increases and decreases in gray matter in diff erent parts of the brain, with more pronounced changes the longer the astronauts spent in space.

“We found large regions of gray

matter volume decreases, which could be related to redistribution of cerebrospinal fl uid in space,” Seidler said. “Gravity is not available to pull fl uids down in the body, resulting in so-called puff y face in space. This may result in a shift of brain position or compression.”

The researchers also found increases in gray matter volume in regions that control leg movement and process sensory information from legs, which may refl ect changes related to the brain learning how to move in microgravity. These changes were greater in space station astronauts because their brains were learning and adapting 24/7.

“It’s interesting because even if you love something you won’t practice more than an hour a day,” Seidler said. But the brain changes researchers observed were equivalent to someone practicing a new skill round-the-clock.

“In space, it’s an extreme example of neuroplasticity in the brain because you’re in a microgravity environment 24 hours a day,” Seidler said.

Though they have not pinpointed the exact nature of the changes yet, the fi ndings may lead to new ways of thinking about certain health

conditions — for example, people on long-duration bed rest or people who have normal pressure hydrocephalus, a condition in which cerebrospinal spinal fl uid accumulates in ventricles in the brain and causes pressure.

Seidler said the brain changes could refl ect new connections between neurons, and she’s leading another long-term study that will help determine the repercussions on cognition and physical performance, as well as how long the brain changes last. For example, even after balance returns, the brain might still recruit diff erent pathways to compensate for the structural brain changes caused by spacefl ight.

“The behavior may return to normal, but the way the brain controls the behavior may change,” she said.

These results largely parallel fi ndings from a long-term bed rest study that Seidler is leading, in which volunteers spent up to three months in a downward tilted position, and brains shifted up.

The research is supported by a grant from NASA. The study, “Brain structural plasticity with spacefl ight,” appeared in the journal Nature Microgravity.

• vRad Chief Medical Offi cer Joins ACR CommitteevRad (Virtual Radiologic) announced that its Chief Medical Offi cer Benjamin W. Strong, M.D., (ABR, ABIM) recently received two American College of Radiology (ACR) appointments due to his emergency radiology expertise and long-term commitment to the clinical practice of teleradiology. • iCAD Appoints Executive Vice President and CFOiCAD announced that Richard C. Christopher has been appointed executive vice president and chief fi nancial offi cer. He has more than 25 years of fi nancial management experience, having served as CFO of two public companies with dermatology-related businesses. Upon Christopher’s joining of the company, interim chief fi nancial offi cer R. Scott Areglado will resume his role as vice president/corporate controller. • RSNA Names New EditorThe Board of Directors of the Radiological Society of North America (RSNA) announced that David A. Bluemke, M.D., Ph.D., Ms.B., FAHA, FACR, will become editor of the journal Radiology in January 2018. Bluemke is the radiologist-in-chief of Radiology and Imaging Sciences at the National Institutes of Health (NIH) Clinical Center and senior investigator at the National Institute of Biomedical Imaging and Bioengineering (NIBIB) in Bethesda, Md. He also is adjunct investigator for the National Heart, Lung and Blood Institute (NHLBI). Eff ective July 1, 2017, he will become professor of radiology in the Department of Radiology at the University of Wisconsin – Madison School of Medicine and Public Health (UW – Madison). • ASTRO Supports NominationsThe American Society for Radiation Oncology (ASTRO) expressed its support for the nominations of Tom Price, M.D., as Health and Human Services (HHS) Department secretary and Seema Verma as Centers for Medicare and Medicaid Services (CMS) administrator. • Hologic Board of DirectorsAmy Wendell has been elected to Hologic’s Board of Directors. Wendell also was appointed to the company’s Audit and Finance Committee.• ACR Confers HonorsThe American College of Radiology (ACR) Board of Chancellors (BOC) selected three innovators as 2017 Gold Medalists for their extraordinary service to the college or radiology. Honors will be bestowed during ACR 2017 in Washington, D.C.. The following individuals will receive the ACR Gold Medal: Bruce J. Hillman, M.D., FACR, of Wake Forest, N.C., professor of radiology and medical imaging and health evaluation sciences and former chair of radiology, University of Virginia, and founding and current editor-in-chief of the Journal of the American College of Radiology (JACR); John A. Patti, M.D., FACR, of Lynnfi eld, Mass., senior lecturer in radiology at Harvard Medical School and thoracic radiologist at Massachusetts General Hospital and Harvard Medical School, both in Boston, and past chair of the board and president of ACR; Jeff rey C. Weinreb, M.D., FACR, of New Haven, Conn., professor of radiology and biomedical imaging and vice chair for strategic planning and innovation at Yale-New Haven Hospital/Yale School of Medicine, and past BOC member and vice-president of ACR.


IMAGING Global Trends

The emerging markets of Asia-Pacifi c and Latin America will drive the medical imaging market by more than 5 percent by 2021. Globally, medical imaging has transformed the methods of diagnostics and has made the diagnosis and treatment of several medical conditions more eff ective and effi cient in the modern era. Growing awareness about the usage of imaging devices for treatment in the healthcare segment and advancements in technologies is driving the global market for medical imaging worldwide.

The global market for medical imaging was worth $30.05 billion in 2015 and it is expected to reach $40.56 billion in 2021, expanding at a compound annual growth rate (CAGR) of 5.1 percent between 2016 and 2021. Medical imaging equipment can be defi ned in many ways, but here is mainly categorized as X-ray devices, computed tomography (CT) scanners, magnetic resonance imaging (MRI) scanners, ultrasound devices and nuclear imaging scanners.

X-ray DevicesX-ray devices currently dominate the medical imaging market worldwide, while the nuclear imaging market is anticipated to grow at the highest CAGR by 2021.

A research report published by Infi nium Global Research1 found that X-ray devices dominated the global medical imaging market, and are expected to continue to do so with a market share of 29.36 percent by 2021. The market size of X-ray devices is projected to grow at a CAGR of 5 percent over the period of 2016 to 2021. X-ray imaging is the oldest form of medical imaging, while it has evolved multifold in order to make diagnosis and treatment more reliable. With advancements in this segment, digital X-ray and 3-D

X-ray have become a trend in the recent past. Moreover, advanced X-ray systems help reduce the radiation dose.

Nuclear ImagingWith growing demand for radiation devices for the treatment of various types of cancers and neurological medical conditions, the market size of nuclear imaging is expected to grow at the highest CAGR over the forecast period. It is projected to grow at a CAGR of 10 percent between 2016 and 2021. Currently, with an increased number of cancer patients, the demand for nuclear imaging devices is anticipated to experience signifi cant growth. Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) are nuclear imaging instruments used in nuclear imaging. Among the two, SPECT accounted for the largest segment in 2014 and 2015.

UltrasoundAccording to research conducted for the report,

ultrasound imaging accounted for the second largest share — 21 percent — in 2015, while MRI accounted for 19 percent share in the same year.

A growing geriatric population and rising number of cancer patients are likely to drive the global market of medical imaging, while high risk of radiation

IMAGING A look into what will drive the medical imaging market’s future growthBy Infi nium Global Research

Global

Figure 1: Digital/synthetic reference object (DRO) analysis of the medical imaging market


exposure is a primary restraining factor. The geriatric population is exposed to a higher threat of cancer and neurological disorders. Moreover, signifi cant environmental changes are likely to create more health concerns for this segment of the population worldwide. Further, technological advancements in diagnostic imaging instruments are expected to escalate the growth in this market by 2021.

One of the main risks associated with medical imaging modalities is high risk of radiation exposure associated with these devices, however it is also an important factor aff ecting the growth in the medical imaging market over the forecast period. (See Figure 1.) Additionally, stringent regulations pertaining to use of radiation devices in developed markets such

as the U.S. and U.K. are anticipated to restrain the growth in this market over the forecast period.

Asia-Pacifi c MarketThe Asia-Pacifi c market is projected to grow at the highest CAGR after dominating the global market in 2015. The study estimated Asia-Pacifi c to be the largest market for medical imaging instruments,

with the growth in this market driven by emerging markets such India and China, while Japan accounted for the largest market share in the region in 2015. (See Figure 2.) A large consumer base in this region is the primary driving factor that is expected to boost the growth over the forecast period. Emerging markets such as India and China are projected to

experience signifi cant growth over the forecast period due to rapid infrastructure development in the healthcare sector in these markets of Asia-Pacifi c.

North America, which was the second largest market for medical imaging devices in 2015, is currently dominated by the U.S. It is the largest market for medical imaging devices among the countries in the world market. Although the U.S. market presents the most stringent laws pertaining to usage of radiation devices, it also presents the most technologically advanced medical imaging modalities in the world. itn

Reference:1. “Global Medical Imaging Market: Analysis, Trends and Forecast 2016

to 2021,” Infi nium Global Research, http://www.researchandmar

kets.com/ Accessed Jan. 9, 2017.

Infi nium Global Research is a business consulting and market research fi rm; a group of experts who cater to fulfi lling business and market research needs of leading companies in various industry verticals and business segments. The company also serves government bodies, institutes and non-profi t/non-government organizations to meet their knowledge and information needs.

“ The global market for medical imaging was

worth $30.05 billion in 2015 and it is expected

to reach $40.56 billion in 2021, expanding at a

CAGR of 5.1 percent between 2016 and 2021.”

TRENDSFigure 2: Global Medical Imaging market by region, percentage share (2015)

North America

Latin America

Europe

Asia

30.0%

7.5%

26%32.5%

ROW accounted for 4% in 2015


Imaging | PRODUCTS |

App-Based, Pocket-Sized Dual-Probe Ultrasound

Vscan Extend from GE Healthcare is a new generation of pocket-sized, dual-probe ultrasound. From the hospital and ambulance to

more rural environments, Vscan Extend uses high image quality and wireless connectivity to help users increase clinical confi dence and improve patient care. Vscan Extend off ers an intuitive touch screen and weighs just 406 grams. The system off ers smooth integration with hospitals’ DICOM systems to complement existing documentation and reporting solutions along with cloud-based image storage and communication. Vscan Extend is GE Healthcare’s fi rst ultrasound system to leverage the GE Marketplace that off ers applications with a range of capabilities, such as assessing heart failure patients, measuring bladder volume and off ering cloud-based image communication. The system comes with high-level data security standards, ensuring encrypted data both at rest and on the move. GE Healthcare | www.gehealthcare.com

Musculoskeletal Ultrasound EducationKonica Minolta Healthcare Americas Inc. has partnered with 7Dimaging to strengthen its educational resources for musculoskeletal ultrasound (MSK) by off ering the mskNAV Education Tool. mskNAV is a portable and user-friendly, tablet-based educational resource that assists users from beginner to advanced in enhancing their ultrasound scanning skills in MSK procedures. The partnership allows Konica Minolta to distribute 7Dimaging’s mskNAV interactive ultrasound training software with its portfolio of ultrasound products. The company will provide on-site training and education in the area of MSK ultrasound, and the tool will complement the educational continuum already off ered by Konica Minolta for physicians to perform confi dent examinations and ultrasound-guided injections.Konica Minolta Healthcare | www.konicaminolta.com/medicalusa

MRI Tools for Multiple SclerosisSiemens Healthineers and Biogen will jointly develop magnetic resonance imaging (MRI) applications with the intent of quantifying key markers of multiple sclerosis (MS) disease activity and progression. Biogen is a biotechnology company with a deep focus on neurological and autoimmune conditions. To execute this strategy in the fi eld of neurology, Siemens Healthineers will cooperate with Biogen and contribute its strength in medical imaging. MRI is routinely used to support physicians in diagnosing MS, measuring disease activity and monitoring response to therapy. Clinicians qualitatively evaluate MRIs by comparing the current MRI to the previous MRI. Numerous studies have demonstrated that quantitative MRI measures

may provide additional information about disease prognosis and therapeutic eff ect, but today quantitative measurement techniques with the precision and sensitivity required for MS are typically only available in the research setting. With the development and validation of automated MRI applications to quantify key markers of MS, including new T2 lesions and brain atrophy, patients could benefi t from the availability of enhanced data at the point of care.Siemens Healthineers | www.usa.siemens.com/healthcare

MRI-compatible IV Infusion PumpIradimed Corp. received U.S. Food and Drug Administration (FDA) 510(k) clearance for its MRidium 3860+ magnetic resonance imaging (MRI)-compatible IV infusion pump system, including its Dose Error Reduction System (DERS) software feature. The MRidium 3860+ MRI-compatible IV infusion pump system provides a seamless approach that enables accurate, safe and dependable fl uid delivery before, during and after an MRI scan. This is important to critically ill patients who cannot be removed from their vital medications, and children and infants who must generally be sedated in order to remain immobile during an MRI scan. The MRidium 3860+ system has been designed with a non-magnetic motor, uniquely designed non-ferrous parts and other special features in order to safely and predictably deliver anesthesia and other IV fl uids during various MRI procedures. The system can operate dependably in the presence of 0.2T to 3T magnets and is fully operational up to the 10,000 gauss-line. This means it is highly versatile and can operate virtually anywhere in the MRI scanner room, including close to the MRI scanner.Iradimed Corp. | www.iradimed.com

Medical Imaging ConsolidationHitachi Ltd. formed a new Americas business group focused on consolidating its various medical imaging off erings while expanding its focus on healthcare innovation and informatics. The company will combine Hitachi Aloka Medical America Inc. into Hitachi Medical Systems America Inc. on April 1, 2017, which will then change its name to Hitachi Healthcare America Corp. The newly formed company will function as the regional headquarters, providing sales and maintenances services while driving an enhanced customer-focused strategy for growing the company’s current medical modality segments. The company will also drive the expansion of its healthcare innovation and strengthen its informatics-related medical businesses in the Americas. Hitachi also announced its intention to integrate its Innovation and Informatics Division, which currently belongs to Hitachi America Ltd. into the new Hitachi Healthcare America Corp. The company will focus on collaborative creation with its Americas-based key partners and customers to realize advanced medical technology and informatics solutions, such as using radiation therapy treatment data and artifi cial intelligence to support creating better treatment plans.Hitachi Healthcare America Corp. | www.hitachimed.com

Samsungmedicalsolution.com


RADIATION ONCOLOGY Focused Ultrasound Therapy

Focused ultrasound (FUS), also called high-intensity focused ultrasound (HIFU), has gained a lot of interest in recent years as noninvasive cancer therapy that does not require radiation, chemotherapy or surgery, resulting in less collateral damage to the patient. FUS is performed as an outpatient procedure, so it can eliminate the usual two weeks of

recovery needed from most types of surgery.

In the U.S., the U.S. Food and Drug Administration (FDA) has cleared FUS to treat bone metastases, uterine fi broids, prostate cancer, benign prostatic hyperplasia and essential tremor. Only bone metastases currently has reimbursement. Outside the U.S., there are additional regulatory approvals for breast cancer, kidney cancer, liver cancer, pancreatic cancer, soft tissue tumors, Parkinson’s disease, thyroid nodules, back pain, osteoid osteoma,

breast fi broadenomas, uterine adenomyosis and neuropathic pain.1

Currently, use of FUS is generally considered only if it will have a greater impact on the patient than surgical outcomes, said Pejman Ghanouni, M.D., Ph.D., assistant professor of radiology at the Stanford University Medical Center. He is an expert in FUS and involved in research for the use of FUS in the treatment of various conditions, including

essential tremors, soft tissue tumors and localized low-intermediate risk prostate cancer. He spoke on the topic at sessions at the Radiological Society of North America (RSNA) 2016 annual meeting.

As more providers begin off ering FUS treatment programs, Ghanouni said it is important to have a radiologist champion the project. Patient recruitment from referrals also needs to be considered, so it is important to build relationships with referring physicians. For example, at Stanford he said they have a fi broid center, and one in 10 of the patients with uterine fi broids will qualify for FUS treatment. He said this is how his center primed the pump for initial referrals. He also now works with Stanford’s prostate cancer center, radiation therapy and desmoid tumor clinic. He said one of the keys to fi nding patients has been defi ning unmet needs and defi ning how FUS can serve as a niche treatment option.

The Basics of High-intensity Focused UltrasoundAccording to the Focused Ultrasound Foundation, the principle of FUS is analogous to using a magnifying glass to focus beams of sunlight on a single point to burn a hole in a leaf. With focused ultrasound, an acoustic lens is used to concentrate multiple intersecting beams of ultrasound on a target deep in the body with extreme precision. Depending on the design of the lens and the ultrasound parameters, the target can be as small as 1 x 1.5 mm or as large as 10 x 16 mm in diameter. Where each of the individual beams passes through the tissue, there is no eff ect. But, at the focal point where these multiple beams converge, the focused ultrasound energy results in tissue ablation.2

FUS uses thermal ablation to denature proteins and cause cell death. The thermal dose required to produce irreversible damage and coagulative necrosis depends on the cell type, temperature

High-intensity

The emerging technology of focused ultrasound expands into many treatment areas as a noninvasive alternative to surgery, radiation therapy or chemotherapyBy Dave Fornell

O ers New

Brain FUS uses an array of about 1,000 elements designed to over-come attenuation issues presented by the skull and to diff use the heating over a large area of the brain to prevent damaging healthly tissue.

PHO

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ARE


and duration of exposure. This ranges from one second at 130°F, to 240 seconds at 107°F. FUS also uses mechanical tissue destruction to disrupt cells through cavitation, in which bubbles of gas oscillate in an ultrasonic fi eld and collapse, which can generate enough force to allow for the targeted destruction of tissue.3

FUS works in conjunction with magnetic resonance imaging (MRI), which is used to identify and target tissue to be treated, for real-time image guidance and control during treatment, and to confi rm the eff ectiveness of the therapy. MRI is used to create a treatment plan similar to radiation therapy. A post-procedure MRI also is performed to confi rm the eff ectiveness

of the treatment. For this reason, hospitals interested in creating FUS programs need staff that is comfortable working in the MRI suite. The close integration with MRI often has lead to the therapy being referred to as magnetic resonance-guided focused ultrasound (MRgFUS).

The treatment plan for FUS uses the anatomical MR imaging with an overlay of the zones of treatment. These are shown as strips, each representing a pass of the FUS beam. These strips are usually stacked on top of each other and the length of each varies to match the contours of the tumor target. Operators need to watch the real-time MR imaging for the formation of bubbles in the tissue being ablated, which can defl ect the FUS beams.

FUS of Uterine Fibroids, Avoiding ComplicationsMRI anatomical assessment is used at the start of patient evaluation to determine if the target is reachable by FUS, said Young-Sun Kim, M.D., assistant professor, Department of Radiology and Center for Imaging Science, Samsung Medical Center, Seoul, South Korea. He is an expert in FUS and spoke at RSNA 2016 sessions. In the case of uterine fi broids, he showed an example where the treatment window to access the fi broid might be blocked by cysts in the path of the ultrasound beam. He said thick subcutaneous fat is another ultrasound beam attenuation factor. Edema caused by fl uid back up in a fi broid may also lead to poor outcomes with FUS. He also suggests

avoiding resistant fi broids. Additionally, Kim said radiologists

need to assess MR imaging along the planned trajectory of the beams to look for foreign bodies, which often present as surgical procedure leftovers like staples. He said these could superheat during the procedure and injure the patient.

MRI off ers real-time thermography during the FUS treatment, to ensure healthy tissue is not damaged. Kim said complications from FUS could include skin burns, fat burns, sciatic

nerve injury and bowel injury. Like radiation therapy, Kim said the focused ultrasound beams also could cause damage to critical structures, such as nerves and the spine. This is why he suggests using conscious sedation with IV fentanyl so patients can off er feedback during the procedure.

Critical structures like the bowel and spine can often be avoided by manipulating the bladder or bowel. Kim said this can be done by fi lling or emptying the bladder, or fi lling the bowel with ultrasound gel to move the bowel out of the way, or to eliminate bowel loops.

Treatment of Bone Tumors, MetastasisAs tumors grow inside bones, they slowly destroy and

“ The U.S. Food and Drug Administration (FDA)

has cleared FUS to treat bone metastases,

uterine fi broids, prostate cancer, benign prostatic

hyperplasia and essential tremor. Only bone

metastases currently has reimbursement.”

Focused Ultrasound

Opportunities


break apart the bone as the tumor expands. With osteoid osteoma (benign bone tumors), HIFU could both reduce the pain and stop the tumor growth. However, with bone metastasis it is best to limit treatment to the palliation of pain, said Alessandro Napoli, M.D., Ph.D., Department of Radiological and Oncological Sciences, Sapiens University, Rome, who spoke on FUS at RSNA 2016.

“It is totally noninvasive, there is no radiation and we have low complication rates compared to other therapies. This is because it is totally image guided,” Napoli explained. “The quality of life is improved greatly with the reduction of pain.”

During the procedure, he uses an epidural nerve block or deep sedation because of the pain involved in the procedure. His center also uses gel pads to act as a coupler between the FUS and the body. He uses perfusion MRI with contrast both before and after procedures so he can see reductions in tumor vascularity.

Napoli said FUS beams can be directed through nerves if the beam is wide to reduce damage. The bone also absorbs a lot of the FUS so the treatment time will depend on the density of the bone and amount of bone that needs to be penetrated.

FUS does not hamper the bone growth, which Napoli said has been proven in several studies. Imaging from these studies has shown new bone growth months or years later with restored bone. (Editor’s note: See the article “Researchers Investigate Using Focused Ultrasound To Take Away Cancer Pain” at http://bit.ly/2l53TU5.)

FUS of the BrainA growing area of HIFU is in treatment of essential tremor by applying FUS for thalamic ablations. In this application, a special spherical FUS transducer system has been developed that fi ts over the patient’s head. Ghanouni showed before and after videos of patients he treated who could not hold a glass of water without spilling it, or use a spoon. After treatment they were able to drink from the glass or use the spoon normally. (Editor’s note: Read the article “FDA Approves First MRI-guided Focused Ultrasound Device to Treat Essential Tremor” at http://bit.ly/2l1sOer.)

Brain FUS uses an array of about 1,000 elements designed to overcome attenuation issues presented by the skull and to diff use the heating over a large area of the brain to prevent damaging healthly tissue.

“Bone is very effi cient at absorbing ultrasound energy,” Ghanouni said, explaining why so many ultrasound elements are needed to treat the brain and avoid overheating. Additionally, a silicon pad surrounding the head that circulates chilled water is used to transfer the ultrasound beams into the skull and to cool the skin and head surface. Peri-procedural MR thermography is used to monitor temperatures and ensure areas outside of the target are not being heated. The patient’s head also is shaved to permit the transference of ultrasound waves.

In the case of the brain, he said computed tomography (CT) is used for registration in the treatment planning system. Planning includes avoiding any calcifi cations inside the brain, because they will heat up during treatment, Ghanouni said. The procedure is performed with conscious sedation so the patient can off er intraoperative physiologic feedback. When the operators isolate the target area, they fi rst perform sublethal sonifi cations to confi rm their positioning before delivering lethal sonifi cations.

These brain ablations can cause edema, but Ghanouni said this usually resolves over time, and as they reduce in size, there usually is dramatic improvement in the patients. “The fi rst week is not representative of what the fi nal result will be,” he explained, adding there can be some bad side eff ects, but these often resolve or change after about three months. “The fi nal result is often not seen until after the three-month recovery period, so patients need to be told this upfront. What they have after three months is usually what they will keep.”

He said the FDA recently approved FUS for essential tremor and there is an expectation that CMS may begin reimbursing for the FUS sometime in 2017. Ghanouni said a next step will be FUS treatment of Parkinson’s disease, which is already an approved indication overseas.

Another use of FUS in the brain may be to improve targeted drug delivery to specifi c tumors. Ghanouni said FUS can help break down the blood-brain barrier

with the use of microbubbles. Early studies show this breakdown of the barrier only lasts a couple hours before it disappears.

HIFU to Treat Prostate CancerNapoli said HIFU can be used as a primary treatment for prostate cancer, or as a salvage treatment when there is recurrence after surgery or radiation therapy. He said it is important to target the individual lesions, not to use FUS for whole gland treatment, which can lead to urinary incontinence and erectile dysfunction.

He said a special FUS transrectal transducer has been created so it can be placed against the rectal wall, next to the prostate. This helps focus on the prostate without worry of causing collateral damage to surrounding critical structures.

“The primary argument against targeted treatment for the prostate is that the disease is multifocal,” Napoli explained. He said this often requires the excision of the whole gland. “However, in most cases, a single index or dominant lesion drives prostate cancer risk. The optimal candidates for targeted ablation need to be clearly identifi ed.”

Unlike surgery or brachytherapy, HIFU is signifi cantly less invasive, which may be much more appealing to patients. “It does not require incisions or punctures, it is bloodless, can be carried out on an outpatient basis, and it is repeatable,” Napoli said. (Editor’s note: For more information, see the article “Leading HIFU Expert Begins U.S.-Based Program with Treatment of First Prostate Cancer Patients” at http://bit.ly/2kzbp9V.)

Future Directions for HIFUThe use of FUS is still relatively new, and there are many preclinical and early stage pilot clinical programs investigating its expanded use for other conditions. Expansion in oncology may include several new cancers in the coming years. Pilot trials have started for pediatric neuroblastoma, melanoma, brain, head and neck, lung, ovarian and cervical cancers.

In neurology there are pilot clinical studies for brain tumors, depression and obsessive-compulsive disorder (OCD). Preclinical studies are underway for Alzheimer’s disease, epilepsy, multiple sclerosis, stroke, traumatic brain injury and trigeminal neuralgia. (Editor’s note: For more information, see the article “Pre-Clinical Research Validates Potential for Focused Ultrasound in Alzheimer’s” at http://bit.ly/2kJYXGo.)

In cardiovascular medicine, there are pilot trials testing FUS to treat hypertension. There also are numerous preclinical studies looking at the use of FUS to treat arteriovenous malformations, atherosclerosis, atrial fi brillation, deep vein thrombosis, heart block, peripheral artery disease (PAD), septal perforation and heart failure. itn

References:1. Focused Ultrasound Foundation. “Diseases and Conditions.”

www.fusfoundation.org/diseases-and-conditions/overview.

Accessed Feb. 2, 2017.

2. Focused Ultrasound Foundation. “Technology Overview.”

www.fusfoundation.org/the-technology/overview.


3. Focused Ultrasound Foundation. “Mechanisms of Action.”

www.fusfoundation.org/the-technology/mechanisms-of-action.


RADIATION ONCOLOGY Focused Ultrasound Therapy

An example of pre- and post-treatment MRIs showing the eff ectiveness of HIFU therapy on breast cancer.


Radiation Oncology | PRODUCTS |

Tomotherapy Treatment PlanningRayStation 6, the latest release of RaySearch’s radiation therapy treatment planning system, adds signifi cant new functionality and a wide range of general improvements. Major additions include forthcoming support for Accuray TomoTherapy systems. The new release enables planning for both conventional linacs (linear accelerators) and tomotherapy systems, giving clinics one point of control for all treatment planning needs. All contouring work can be done in one workspace. It is also possible to plan combined treatments and accurately calculate combined dose. Clinical support for tomotherapy systems is pending fi nal validation and will be included in a service pack to be released in the near future. Other highlights include: Monte Carlo dose calculation for proton pencil-beam scanning (PBS); PBS planning with block apertures; simultaneous co-optimization of multiple beamsets; magnetic resonance (MR)-based planning, using MR-image as planning image; and auto-recovery.RaySearch | www.raysearchlabs.com

Online Educational Resource for Healthcare ProfessionalsVarian Medical Systems launched a website for the exchange of clinical information, scientifi c research and expert opinion around the management of cancers and other conditions, with an emphasis on applications utilizing radiotherapy. The site off ers video- and audio-taped symposia that Varian has supported or sponsored in the recent past, including a recent self-assessment continuing medical education (SA-CME) accredited webinar, and a selection of bibliographies organized by disease site. In the future the site will house additional resources including webinars with educational credits, information about sponsored/translational research and clinical trials, case studies and FAQs for the medical professional.Varian Medical Systems | www.medicala airs.varian.com

MR-guided Focused UltrasoundInsightec Ltd’s Exablate Prostate system received CE mark for treating locally confi ned prostate cancer with MR-guided focused ultrasound (MRgFUS). One in six men will be diagnosed with prostate cancer during their lifetime. Many patients are diagnosed with locally confi ned disease with low or intermediate risk for progression. In these cases, patients may choose active surveillance or an intervention. Currently available treatments including prostatectomy, which surgically removes the entire prostate, and radiation therapy, targeting the full prostate, demonstrate good cancer control, however there is high risk of impotency and incontinence. The Exablate Prostate system is based on Insightec’s proprietary MRgFUS. It uses focused ultrasound waves to precisely target and ablate (destroy) the targeted tissue in the prostate, while minimizing damage to adjacent structures. The treatment is done under magnetic resonance imaging (MRI) guidance for high resolution visualization of the patient’s anatomy as well as real-time temperature monitoring. The treatment does not require incisions and is performed in a single session, allowing patients to quickly return to normal activity. The Exablate Prostate system features an endorectal probe integrated into a treatment bed which is compatible with GE 1.5 and 3T MRI. Ultrasound energy is delivered by a high-frequency, 1,000-element phased array transducer which delivers focal therapy under MRI guidance and real-time thermal feedback. This enables the physician to control and personalize the therapy.Insightec Ltd | www.insightec.com.

Helical Tomotherapy SupportMobius Medical Systems’ DoseLab, the complete TG-142 solution, fully supports American Association of Physicists in Medicine (AAPM) TG-148: QA for Helical TomoTherapy. DoseLab provides comprehensive support for all tests outlined in TG-148, including: Y-jaw divergence/beam centering, Y-jaw/gantry rotation plane alignment, treatment fi eld centering, MLC alignment, gantry angle consistency, couch speed uniformity, couch translation/gantry rotation, interrupted treatment, laser localization and cheese phantom image quality. Trend analysis of TG-148 results can be performed in DoseLab’s web-based database viewer alongside all daily, monthly and annual quality assurance (QA) results for linear accelerators.Mobius Medical Systems | www.mobiusmed.com


INFORMATION TECHNOLOGY Technology Report

I n the days before picture archiving and communication systems (PACS), collaboration between various hospital departments was extremely diffi cult, as clinicians could only consult with each other in person. Today, enterprise imaging allows providers to interact from wherever they are with all of the relevant clinical data stored in one place.

ITN Contributing Editor Greg Freiherr spoke with numerous enterprise imaging vendors at the 2016 Radiological Society of North America (RSNA) annual meeting for a feature video, available on itnTV, to fi nd out how they are working together with clinicians to enable this enhanced level of care.

Combining Technology and Clinical ExperienceThe goal of enterprise imaging is to ensure all members of the patient management team have the information necessary to make the best decisions about patient care. While technology is an important part of any enterprise imaging (EI) strategy, the tools are only helpful if they are wielded with the proper clinical experience.

With Conserus Imaging Fellow, its newest EI off ering at RSNA 2016, McKesson looks to assist radiologists with both aspects of their enterprise imaging strategy. “You need to work with each institution to understand how are they going to diff erentiate on value-based medicine. What is important to them?” said Scott Galbari, McKesson vice president of marketing and portfolio, in the itnTV video.

Conserus Imaging Fellow collects all relevant patient data — including surgical history, medications, lab results and admission/discharge notes — and consolidates it into one easy-to-navigate interface. According to Galbari, the goal is to fi nd “the needle in the haystack” — the information that is most important for the radiologist to make a decision about that patient and that particular clinical disease state.

The system off ers full electronic health record (EHR) integration; a vendor neutral design and fl exible confi guration options allow it to be used in any hospital setting. “They don’t have to search for it, they don’t have to make phone calls to other departments. It’s all right there,” Galbari told Freiherr.

24/7 EHR IntegrationThe electronic health record provides another common area for all departments to contribute their expertise to patient care by creating a patient-centric view of the information. And with radiology no longer the sole executor of medical imaging, the EHR acts as an archive of its own for all image types.

Sectra believes that clinicians should have access to these repositories anywhere at any time of day or

night in order to be the most effi cient. “With all our customers growing and the consolidation in the market, having IT systems available 24/7, 365 days a year is of key importance,” said Mats Bjornemo, VP of product management for Sectra. “It’s both for driving effi ciency — because if it’s not available, all the other tools you have won’t make a diff erence — and also for patient safety.” The company prides itself on maintaining high uptime percentages, showing 99-100 percent uptime at fi ve large hospitals in fi ve diff erent countries over a three-year period.

Ultimately, Sectra believes that its PACS can be used to bring together a care team that has previously been fragmented into separate technological silos. “By helping each other out and by divvying up the work across the entire health system,

RSNA Technology Report 2016:

In an itnTV video, Contributing Editor Greg Freiherr describes enterprise imaging advances shown at RSNA 2016.

By Jeff Zagoudis


rather than siloing it like before, you actually get more precise diagnosis,” Anders

Osterholm, Sectra VP of sales operations, told Freiherr in the video.

Bridging the Information Gaps

As the U.S. healthcare system shifts focus to patient-centered, value-based care, hospitals have had to get creative to maintain quality care while lowering costs to enhance patient satisfaction — a key metric under the Aff ordable Care Act and other reform eff orts. Imaging can have an impact on all three areas, something radiologists must be aware of. “Radiologists really need to look holistically at the patient and the quality of care for that patient, and not just be so focused on driving transactional reading and revenue volume,” said Frank Pecaitis, senior VP of sales for Agfa Healthcare, in the itnTV video.

Pecaitis told Freiherr that organizations often purchase new technologies, such as vendor neutral archives (VNA) as short-term solutions. “We look at it more as a medical library, and those images are an organizational asset, part of an enterprise imaging platform and strategy,” Pecaitis said. With its Enterprise Imaging Platform, Agfa can help mitigate information gaps for clinicians and develop a cross-enterprise workfl ow. Customers can opt for a best-of-breed approach or utilize the company’s platform approach to enterprise imaging.

Streamlining Workfl owOne of the biggest challenges of coordinating care across multiple departments is that each department often has its own unique workfl ow, so fi nding information can be diffi cult for people outside their own group. An enterprise imaging system can help solve this problem by off ering one unifi ed workfl ow that all -ologies can follow.

“When you talk about enterprise imaging, it’s no longer radiology looking out, but rather, coming from a CIO perspective, how is this helping me? How is this integrated into my ecosystem?” Cristine Kao, global marketing and growth operations director for Carestream, told Freiherr in the itnTV video.

Carestream has made this principle the bedrock of all of its enterprise imaging/viewing technologies, powered by what it calls the Unifi ed Core. The zero-footprint technology aims to consolidate all clinical content to a single point of access, supporting four workfl ow pillars:

• Acquisition — Images can be acquired anywhere with any device, including at the point of care with mobile devices.

• Management — The Unifi ed Core allows care team members to access relevant information at the point of care or anywhere else via zero-footprint worklists.

• Archiving — The system creates an enterprise repository for all clinical images, whether from radiology or visible light photos at the point of care.

• Viewing — Zero-footprint technology also allows both providers and patients to quickly and easily access medical records. In addition to medical image viewing, however, solutions like Carestream’s Clinical Collaboration Platform allow clinicians and administrators to take a wider view of performance analytics to ensure they are delivering the highest quality of care. This includes looking at performance from both an operational (e.g., report turnaround times) and a clinical perspective (e.g., ensuring data is gathered and reported accurately).

Adaptive Intelligence in Enterprise ImagingArtifi cial intelligence, also known as deep learning and machine learning, was one of the hottest topics at RSNA 2016, with multiple vendors showing off applications in radiology and enterprise imaging. Philips Healthcare has incorporated the technology into its IntelliSpace PACS via a new feature it calls Illumeo. Ilumeo employs adaptive intelligence similar to a map application on a smartphone: If the user searches for a restaurant in the map app, the algorithm will

Enterprise Sectra believes that its PACS can be used to bring together a care team that has previously been fragmented into separate technological silos.

Imaging


drop a locating pin on the map, and then provide information on the hours and menu in anticipation of what the customer needs. Illumeo behaves similarly, isolating the clinical focus of an image and providing any relevant information the radiologist will need to interpret the image.

“Rather than just opening a study, scrolling through and having to fi gure out what the radiologist was referring to in the report, we can actually guide them to the right locations and show them what is relevant,” said Eran Rubens, chief technology offi cer, enterprise imaging, Philips Healthcare IT in the itnTV video.

Lifecycle ManagementPhilips also introduced the Universal Data Manager for its IntelliSpace PACS that allows diff ering lifecycle management rules for diff erent types of images (e.g., ordered vs. non-ordered) as they are archived. This can be extremely helpful in a modern environment where newly integrated hospital systems often bring with them diff erent, complex infrastructures and rules for image storage. For example, a hand X-ray may be archived for a year while a pediatric image might have to be held for decades. The Universal Data Manager sits on top of all existing infrastructures to create its own rulesets.

Effi cient Data ExchangeAs previously discussed, any enterprise imaging system must fi t into the workfl ows of the various departments it serves to best facilitate effi cient data exchange. At RSNA 2016, Mach7 Technologies showcased its best-of-breed hybrid approach that combines platform and VNA approaches.

“What is diff erent is how we’ve simplifi ed it, how we’ve made the data workfl ow behind the scenes much easier to implement and much

easier to execute on those standards, and therefore consumable by IT teams and PACS administrators,” said Eric Rice, Mach7 chief technology offi cer. Recent updates have been driven by considerations like what steps does a wound care physician have to take to associate a picture or video captured at the point of care with an encounter or a patient in the EHR. The goal is to improve workfl ow so clinicians can access all of the relevant data needed for treatment.

“As much as we are a VNA company, we’re

a medical imaging company that delivers a complete solution across workfl ow to better exchange, manage and share medical imaging data,” Rice told Freiherr.

Expanding the Enterprise ReachAmong EI vendors at RSNA 2016, Lexmark is one of the newest, having entered the market less than three years ago via acquisition of VNA companies and others focused on the capture and sharing of photos and videos. Most recently, Lexmark purchased Claron Technology, adding the NilRead viewer to its product portfolio. Since then, Lexmark has expanded

the viewer’s capabilities, enabling it to perform both image-enabled EHR functionality and a fully diagnostic workfl ow — a rarity, according to Lexmark Chief Technology Offi cer Claudio Gatti, who told Freiherr that most zero-footprint solutions are only capable of basic viewing functionality.

“We started with radiology, and we can now essentially perform all the functions of a traditional PACS in a zero-footprint manner. Then as a strategy we started specializing in other specialties,” Gatti said in the itnTV video.

This year, according to Gatti, NilRead’s capabilities expanded to include digital pathology and light-based specialties. The digital pathology functionality has been cleared for use in Europe, and the company hopes to have U.S. clearance within the next 12 months.

For light-based imaging, such as surgery and gastroenterology, Lexmark added video functionality, and clinicians can even select smaller portions of a larger video to be archived into the EHR.

If there was a common theme among enterprise imaging vendors at RSNA 2016, it was that medical practices must break out of their individual silos to form truly collaborative patient management teams. Enterprise imaging has the potential to break these patterns, change the decision-making environment and may even change the way decisions are made. itn

Editor’s note: Watch the video “Technology Report: Enterprise Imaging 2016” for additional information at http://bit.ly/214upMZ.

INFORMATION TECHNOLOGY Technology Report

“ The goal of enterprise imaging is to ensure all

members of the patient management team have

all of the information necessary to make the best

decisions about patient care.”

Conserus Imaging Fellow from McKesson collects all relevant patient data — including surgical history, medica-tions, lab results and admission/discharge notes — and consolidates it into one easy-to-navigate interface.


Information Technology | PRODUCTS |

Medical Imaging MonitorLG Electronics USA Business Solutions is introducing clinical and surgical monitors, marking its entry into the growing global medical imaging devices market. The LG 8 MP Clinical Review Monitor is a 27-inch IPS monitor driving 3,840 x 2,160 pixels, specifi cally designed to increase hospital staff effi ciency by enabling streamlined workfl ows and multitasking. In addition to enhanced brightness levels, this monitor provides healthcare professionals with wide viewing angles, minimal color shift and accurate images. The monitor is Digital Imaging and Communications in Medicine (DICOM)-compliant, which means that grayscale tones are corrected to maintain image accuracy. Finely calibrated to ensure consistency across multiple devices, the monitor is equipped with backlight stabilization technology to guarantee stable luminance levels. Dynamic Sync Mode reduces input lag, while Flicker Safe and Reader Mode settings help reduce eye strain experienced by doctors and nurses working long shifts.LG Electronics | www.lg.com/us

Medical Image SharingNexGenic LLC, the developer of the image sharing solution ImageInbox, announced that its latest release includes cloud-based features for clinical specialists and hospital customers to provide comprehensive image tele-consultation services, which can be rapidly integrated into existing clinical operations and workfl ows. The latest version also includes options for cloud image viewing and supports EEG and non-DICOM image formats. Developed for more than a decade in support of millions of diagnostic image transfers, ImageInbox provides a turnkey image capture and utilization platform for individual physicians, healthcare organizations, clinical trial sponsors and patients that need to send essential images securely at a moment’s notice.NexGenic | www.nexgenic.com

4-D Advanced Vis MRI SoftwareArterys received 510(k) clearance from the FDA for its Arterys Software in November, paving the way for use in clinical settings for the quantifi cation of cardiac fl ow. This includes 4-D Flow and 2-D Phase Contrast workfl ows, and cardiac function measurements. Arterys plans on launching the product in the United States through a partnership with GE Healthcare’s ViosWorks product. Powered by the Arterys software, ViosWorks will be the fi rst clinically available cardiovascular solution that delivers cloud-based, real-time processing of images with resolutions previously unattainable, according to the company.Arterys | www.arterys.com

Expanded Clinical GuidelinesNational Decision Support Company (NDSC) recently announced expanded CareSelect solutions that cover a wide variety of care settings and healthcare services including the ABIM Foundation’s Choosing Wisely Campaign. NDSC’s CareSelect helps to accurately render clinical guidelines for electronic medical record (EMR) delivery, leveraging existing clinical documentation and creating a seamless user experience within the EMR workfl ow. The expanded solution now includes clinical and business logic covering medication, lab and blood management, as well as a complete set of advisories based on the Choosing Wisely Campaign. The CareSelect platform exchanges data with the EMR in real time to perform clinical calculations against evidence-based guidelines and pathways. This enables the caregiver to choose alternate tests or clinical pathways based on the guideline. This advanced functionality can be coupled with the CareSelect benchmarking and reporting tools to ensure success.National Decision Support Companywww.nationaldecisionsupport.com

Enterprise Viewing PlatformCalgary Scientifi c Inc. announced version 6.0 of its enterprise image-viewing platform, ResolutionMD. The platform continues to expand interoperability capability across the healthcare enterprise, off ering institutions a better way to connect clinicians and patients to each other and their data. ResolutionMD provides a scalable pathway and seamless integration between picture archiving and communication systems (PACS), vendor neutral archives (VNAs), cloud archives, electronic medical records (EMRs), patient portals and hospital-developed apps. The new version includes multi-monitor support, expanded DICOM modalities in departments outside radiology, extended image sharing with third-party providers, FHIR data integration, expanded HTML5 capabilities and mobile measurements. Scalability improvements include both virtualized and physical server deployments with CPU or GPU options.Calgary Scienti c | www.calgaryscienti c.com


BUSINESS Patient-centered Care

While patient welfare has always been the guiding principle of the healthcare system, patient satisfaction has only become a priority recently. Reform eff orts of the last several years have focused on fi xing aspects of the system that have been headaches for patients — namely high costs and care process ineffi ciencies. As the healthcare system

continues to change, the importance of patient satisfaction will continue being a guiding metric for progress — a reality that could have a major impact on healthcare providers.

Those at the leading edge of change have stressed the importance of practicing patient-centered care. What this means and how it is done are driving discussions, including during the 2016 annual meeting of the Radiological Society of North America (RSNA) last November in Chicago. Several presenters there addressed why patient satisfaction is important, how the system is changing to accommodate it and what it means for the future of radiology.

Why Patient Satisfaction is ImportantAt fi rst thought, one might believe patient satisfaction and patient welfare are interchangeable concepts, as improved health is the primary reason patients seek out medical care. The reality, however, is that patient health is just one part of a larger picture. Practicing patient-centered care and prioritizing patient satisfaction requires providers to look beyond health outcomes and other clinical benchmarks to the overall patient experience.

“Imagine you don’t know anything about healthcare; how would you want to interact with the

healthcare system? Would you want to be 50th in a queue at the on-call center to schedule a radiology test?” said Ella Kazerooni, M.D., professor of radiology, associate chair for clinical aff airs and director of cardiothoracic radiology, University of Michigan Health System, to an audience of healthcare professionals at RSNA 2016.

This traditional radiology experience (dubbed “Radiology 1.0” by Kazerooni), from scheduling an exam all the way through to results communication and billing, has placed little emphasis on patient involvement, with patients being shepherded from one place to the next with little to no explanation. This has slowly given way to what Kazerooni calls “Radiology 2.0,” where more patients are coming into the radiology department via referrals from other physicians. Patient portals emerged in this era, allowing online scheduling of appointments, and viewing of imaging and lab results.

Through both phases of the radiology experience there have been various metrics to measure

performance and guide improvement eff orts. Kazerooni pointed out, however, that the majority of these metrics have focused on clinical quality.

“We’ve always thought quality was a CT with the lowest radiation exposure for the question being asked, or the fastest report turnaround time and access to a test this afternoon,” she said. “But in the value world, you see that quality as perceived by the patient includes a lot of the patient experience. This disconnect is very real.”

Financial Incentives for QualityBridging this divide has been one of the driving forces in the transformation of the healthcare industry the last several years from a volume-based culture to a value-based one. Perhaps the most signifi cant legislation in this arena has been the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which will provide fi nancial incentive for hospitals and healthcare providers to practice quality and value in medicine.

Under the guidelines of MACRA, the Centers for

Prioritizing

Patient Satisfaction

As the healthcare system begins placing greater emphasis on value, providers should make patient satisfaction a high priority throughout the whole patient experienceBy Jeff Zagoudis


Medicare and Medicaid Services (CMS) announced in 2016 it would be creating a Quality Payment Program to develop new incentives to focus on quality care and patient satisfaction. One of the primary mechanisms of the program will be the Merit-Based Incentive Payment System (MIPS), which will provide fi nancial incentives for Medicare physicians based on four performance categories: Quality, Advancing Care Information, Clinical Practice Improvement Activities and Cost. There will be an option for physicians to include patient experience data in their annual reporting for additional incentive pay. While MIPS reimbursements are not scheduled to begin until 2019, performance evaluation under the new criteria does begin this year.

Reaching Radiology 3.0With MACRA, MIPS and other changes yet unknown in the future, radiology is poised to enter yet another phase, which Kazerooni calls Radiology 3.0. This next evolution will center on the healthcare “team,” on which patients will play an integral role. “People demand a lot and radiology costs a lot, so we need to reassociate with our patient base,” she said.

To establish a philosophy of patient- and family-centered care, Kazerooni told the audience there are four core concepts that must be practiced:

• Respect and dignity;• Information sharing;• Participation; and• Collaboration.

Most importantly, these tenets must be integrated throughout all parts of the patient experience. For example, if a department wants to optimize its CT operations, the project team should start by speaking to the patient check-in desk and ask questions about those procedures — i.e., are the exam request processes easy to access, understand and navigate? Do the people working the call center have good customer service skills?

Kazerooni emphasized that it is important to collect data — be it through surveys, patient satisfaction scores or other metrics — throughout the process. Then, as changes are implemented, the same metrics should be used to remeasure the eff ects of the changes.

Remembering the diff erence between professionally centered metrics and patient-centered metrics is key. For example, a provider may believe that if a patient needs multiple tests, it would be best to schedule them all in one day so the patient does not have to come back multiple times. This type of schedule can be exhausting for patients, though, and they may actually prefer to come back and do one test at a time.

Five Keys to Quality Improvement SuccessWhile the idea of a quality improvement project as described may be exciting, it is important for the project team and its leaders to come in with a solid plan, said David B. Larson, M.D., MBA, associate professor of radiology and associate chair of performance improvement, Department of Radiology, at Stanford University School of Medicine. “If you’ve made no preparations and you just start into it, you’re probably going to fail,” Larson told his RSNA audience, “and that’s OK. You can learn from that failure and move on.”

To minimize the chances of failure, however, Larson noted that every successful quality improvement (QI) project considers fi ve factors:

1. Leadership: In order for change to fully set in, the team must understand the leadership hierarchy of their organization to know who is best suited to help facilitate the change(s). The leader’s role is not to solve the problem, Larson stressed, but rather enable their team to solve the problem.

2. Method: Knowing how the team is going to approach the project is critical to ensure everyone is on the same page. While those with a healthcare/science background may be more familiar with

the scientifi c method (centered on answering a question), Larson said QI projects are more suited to an engineering-design approach (centered on solving a problem). “You should be developing solutions to a problem and refi ning them as you go,” he told the audience.

3. Resources: The project team must have a strong knowledge of all of the resources at their disposal before they begin, or they will be unable to overcome obstacles along the way. Larson gave the example of calling a team meeting, but attendance is sparse because people are unable to break away from their other work. “Ask leadership up front, ‘What resources are we going to have available to us?’ and ‘If we need more personnel/equipment/other resources along the way, are you willing to make that commitment?’ ” he said.

4. Culture: Every organization has its own unique culture — the way people interact, what informal procedures are in place and who talks to whom. “You have to ask yourself: Who will be impacted by the change and is everyone who will be impacted included in the process?” Larson said.

5. Execution: Ultimately, the project team must have the ability, desire and perseverance to execute the improvement plan. The key, according to Larson, is choosing the projects and project roles wisely.

The Future of Quality in RadiologyAs healthcare reform continues forward in the future, providers must ask themselves, “How can we think more like patients, what information will they want to know, and what measures can we use?” said James Duncan, M.D, Ph.D., professor of radiology in the Division of Interventional Radiology at Washington University School of Medicine in St. Louis. Duncan wrapped up the RSNA session by considering these questions and off ering two predictions:

1. Patients will want “more” and “better” from all aspects of healthcare. Maintaining patient satisfaction, in Duncan’s mind, will require more predictable processes and outcomes throughout the healthcare system — as well as more transparency on pricing and expertise. The ultimate goal, he said, should be better integration across the system and care better tailored to individual patient needs.

2. Providers will be working with more data. In order to provide the level of care patients will expect, Duncan warned providers will need to rely on traditional sources — speaking with and observing patients — as well as newer ones like patient monitors and patient-entered data. “Other industries have fi gured out how to get around it and maybe we should too,” Duncan said of allowing patients to contribute their own information.

The ultimate goal will be to use all of this data and information to reduce uncertainty in the process of patient care. Duncan said patients are more aware of how much data is collected but that they are often frustrated with how it does not seem to be used. By prioritizing patient satisfaction throughout their entire experience, providers can begin to build the relationships that will be key to successful outcomes moving forward. itn

Passion can’t be trademarked.GE Mammography is driven by a singular passion: perfecting 3D Mammography. So while some may be focused on trademarking 3D Mammography, we’ve been busy perfecting it. The result: our technology provides images of outstanding detail and superior diagnostic accuracy, which helps clinicians provide exceptional care and puts patients’ minds at ease. And it does it all with the same low dose as a 2D exam, the lowest patient dose of all FDA approved DBT systems.1

gehealthcare.com/mammography

1. GE screening protocol consists of 3D CC/MLO + V-Preview CC/MLO, V-Preview is the 2D synthesized image generated by GE Seno Iris mammography software from GE DBT images. FDA PMA P130020/S001 http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm?id=P130020S001, Data on file. Average glandular dose in digital mammography and digital breast tomosynthesis: comparison of phantom and patient data. Bouwman, R. W. and al., et. 2015, Physics in Medicine & Biology, pp. 7893-7907.


Comparison chart compiled by Imaging Technology NewsScranton Gillette Communications assumes no responsibility or liability for any errors or omissions in this chart.

COMPARISON CHART BREAST TOMOSYNTHESIS

New research presented by Stephen Rose, M.D., chief medical offi cer of Solis Mammography and president of Rose Imaging Physicians Group, Houston, at the 2016 Radiological

Society of North America (RSNA) annual meeting found recall rates, cancer detection and invasive cancer detection for women under age 50 were signifi cantly improved with the addition of digital breast tomosynthesis (DBT) to mammography.1

However in January 2016, the U.S. Preventive Services Task Force (USPSTF) sparked controversy when it changed its recommendations, advising women to start their mammograms at age 50. This reversed the previous standard set by the American Cancer Society (ACS) in October 2015 in its “Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update” that advised women to be screened by age 45 and then every two years after age 55.2 It also seemed to ignore the fact that the men and women who were key in making these policy changes were not peer-reviewed radiologists, used 2-D mammography research and did not consider the benefi ts of DBT. They also did not take into account that according to the American Cancer Society’s Breast Cancer Facts & Figures Report,3 in 2015, 20 percent of women diagnosed with invasive breast cancer were under the age of 50 when diagnosed. In addition, women under the age of 50 tend to be more likely to have dense breast tissue, which increases the potential for a false negative result.

DBT is defi ned as multiple low-dose full-fi eld projection images of the breast obtained from diff erent angles that form an arc. The images are then used to reconstruct a 3-D image of the breast, resulting in a clearer view without the distraction of overlapping tissue.

For the study, Rose and Solis Mammography collected data from Jan. 1-Dec. 31, 2015, from a network of community-based screening centers of women 40-49 to investigate if the addition of DBT to mammography could improve screening performance outcomes for women under the age of 50.

As reported at RSNA 2016, the eff ects of adding DBT in women under 50 were decreased recall rates by 6 percent; increased cancer detection rates by 67 percent; and increased positive predictive values for recall by 56 percent. Other conclusions from the study noted that the addition of DBT to mammography in women

40-49 shows improved outcomes in recall rates and cancer detection rates; that DBT addresses a primary concern regarding screening women in their 40s by reducing recall rates; and adding DBT to mammography takes about the same amount of time as digital mammography, and captures around 60 pictures (radiologists can now see cancers as early as Stage 0 with tomo).

“Our study is confi rming the benefi ts of tomosynthesis. For a disease with no known form of prevention, early detection is key and the earliest detection is with tomosynthesis, especially in women under 50 years old with dense beast tissue,” said Rose in a statement released by RSNA.

The PlayersToday there are four tomosynthesis systems on the market. Hologic’s Selenia Dimensions mammography system off ers earlier detection of breast cancers, clearer lesion images and reduction in the number of unnecessary biopsies, minimizing patient anxiety and unnecessary costs.

GE’s SenoClaire 3-D breast tomosynthesis off ers clarity at a low dose using a short X-ray sweep around the compressed breast with only nine exposures. SenoClaire is an add-on feature to existing Senographe Essential and Senographe Care platforms.

Siemens Mammomat Inspiration Prime with Tomosynthesis Option is a breast tomosynthesis add-on for its Mammomat Inspiration digital mammography platform. The premise of the technology is that it shoots multiple images and creates a 3-D dataset that produces multiple slices, between 40-140, at 2 mm each, that can be rolled through and looked at in diff erent sections.

New to the market is Fujifi lm Medical Systems U.S.A. Inc.’s DBT software upgrade for its Aspire

Cristalle digital mammography system, which recently received premarket approval (PMA) from the U.S. Food and Drug Administration (FDA). The optional DBT upgrade is now available in the United States. According to Fujifi lm, radiologists using the Aspire Cristalle full fi eld digital mammography (FFDM) system with DBT will realize enhanced clinical effi ciency compared to using FFDM alone. This includes superior diagnostic accuracy and lower recall rates for non-cancer cases. Known as Amulet Innovality outside of the United States, the optional DBT upgrade has been widely available in Europe, Asia and Latin America since May 2013.

The Aspire Cristalle FFDM system with DBT combines Fujifi lm’s hexagonal close pattern (HCP) detector design, advanced image processing and image acquisition workfl ow to optimize patient dose while maximizing image quality.

Looming on the horizon is the Planmed Clarity 3-D DBT system, which is FDA-pending and has received the CE mark and is currently available for sale in the European Union and other countries where the CE mark applies. Planmed’s new method is said to signifi cantly improve image accuracy and allows even the smallest details to be captured with great precision.

Coverage IssuesA recent report from market intelligence fi rm Infi niti Research discussed the growth of DBT in the United States, highlighting the benefi ts and acknowledging the barriers to continued adoption. The report states that despite all of the benefi ts of this technology, many have been unable to take advantage of them. In the United States, numerous health insurance companies will not cover procedures that use this new technology, despite its eff ectiveness. While Medicare and Medicaid do cover it, private insurers do not, forcing patients to settle for a 2-D mammogram even when it is not the best option.

Some states are fi ghting this, however. According to Infi niti Research, Connecticut has brought in a new law this year that requires insurers to cover 3-D mammograms if the patient asks for them. “While the state’s Insurance Department argues that this will be very costly to implement, supporters of the law disagree. Although the initial cost of acquiring new equipment will be high, the accuracy of these tests will eliminate the need for many 2-D tests. The costs should also fall as the equipment and tests become more prevalent,” according to the report. itn

References:1. Rose, S. “Tomosynthesis Impact on Screening Patients 40 to 49.”

Radiological Society of North America 2016 Scientifi c Assembly

and Annual Meeting, Nov. 27 - Dec. 2, 2016, Chicago IL. archive.rsna.

org/2016/16015111.html Accessed Feb. 7, 2016

2. Kevin C. Oeffi nger; Elizabeth T. H. Fontham,; Ruth Etzioni; et al. JAMA.

2015;314(15):1599-1614. doi:10.1001/jama.2015.1278

3. American Cancer Society. Breast Cancer Facts & Figures 2015-2016.

Atlanta: American Cancer Society, Inc. 2015.

Finding Value in Digital Breast TomosynthesisBy Melinda Taschetta-Millane

ParticipantsFujifi lm Medical Systemswww.fujifi lmusa.com

GE Healthcarewww.gehealthcare.com

Hologicwww.hologic.com

Siemens Healthcarewww.usa.siemens.com/healthcare

Scranton Gillette Communications obtained the product specifi cations fromthe manufacturers.


COMPARISON CHART Breast Tomosynthesis Systems

Company Name Fujifi lm Medical Systems U.S.A., Inc. GE Healthcare Hologic Siemens Healthineers

Product name Aspire Cristalle Senographe Essential with SenoClaire Senographe Pristina Selenia Dimensions (Avia 3000/6000/9000) and Genius 3D

Mammography exams

Mammomat Inspiration Prime with Tomosynthesis Option

FDA cleared, year Aspire Cristalle 2014, with Tomo 2017 2014 December 2016 FDA PMA for tomosynthesis February 2011 Tomo: 2015, tomo only: 2016

FDA indication of equivalent/superior to FFDM

N/S Superior diagnostic accuracy at the same dose as 2-D FFDM Tomosynthesis approval PMA pending at FDA Superior to FFDM Superior to FFDM

CE mark, year N/S 2013 2016 2008 2006

What diff erentiates your product from competitors

Innovative hexagonal close pattern (HCP) detector yields more

effi cient capture vs. conventional square pixels, resulting in lower

patient dose; iAEC intelligent auto recognition of diff erentiating

tissues, muscle & implants for optimal exposure conditions

GE Digital Breast Tomosynthesis delivers superior diagnostic

accuracy at the same dose as 2-D FFDM, the lowest patient

dose of all FDA approved DBT systems; ASIR DBT, a calcifi cation

artifact correction iterative reconstruction algorithm that delivers

off -plane images much improved in terms of both in-plan and

out-of-plane artifacts; provides improved scatter rejection, with

equal or improved image quality, especially for thicker breasts

GE Healthcare set out to reshape the mammography experience

focused on comfort for patients: improving the overall exam

experience with an inviting appearance and unique features such

as the rounded detector edges and slim profi le to allow for a

more comfortable breast examination and may help reduce com-

pression anxiety; confi dence for technologists: a fully integrated

digital platform and thoughtful ergonomic design featuring tube

head park position to improve patient positioning; clarity for

radiologists: building upon our continued development in image

quality focused on detector design, tube and fi lter combinations

and a universal grid

Selenia Dimensions system’s Genius 3D Mammography exam

off ers the following advantages over 2-D mammography: an

increase in invasive breast cancer detection; a reduction in false

positive recalls, minimizing patient anxiety and unnecessary

costs; proven superior clinical performance to 2-D mammogra-

phy, providing exceptionally sharp images, seamless transition

between imaging modes, sophisticated user tools that simplify

operation, advanced clinical applications, tomosynthesis-guided

biopsy and ergonomic design for patient comfort and ease of

operation

Prime technology using software to replace the antiscatter grid

saves up to 30% dose without compromise in image quality;

wide angle (50°) for tomosynthesis for superior depth resolution,

decreased noise and separation of overlying tissue compared to

narrower angle breast tomosynthesis images

Number of WW installs N/A N/S N/S Approximately 4,000 breast tomosynthesis systems >3,500

Scan time, 60 mm breast 4 sec N/S N/S 3.7 seconds (using C-View software) N/S

Tomo dose for ACR phantom 1.2 mGy N/S N/S 1.45 mGy N/S

Combo (Tomo + 2-D) dose for ACR phantom

1.3 mGy N/S N/S 1.45 mGy (using C-View software) N/S

Upgrade from FFDM (hardware/soft-ware required)

Aspire Cristalle software only, Aspire HD or HD+ full system

replacement

Hardware and software required to upgrade to 3-D N/S S/w upgrade SW upgrade

Tomo require add-on unit or built in Built in (software upgrade only) N/S N/S Built in Built in

Reconstruction time for 60 mm breast N/S N/S N/S <5 seconds N/S

Tomo-guided breast biopsy available Not yet avail in U.S. (in use outside of U.S.) N/S N/S Yes Yes

Size of tomo screening paddles 18 x 24 and 24 x 30 N/S N/S Various paddles available; no limit; 18 x 24 cm, 24 x 30 cm, small

breast paddle, etc.

24 x 30 cm, 30 x 36 cm

Tomo with needle localization paddles supported

No N/S N/S Yes Yes

Combo mode imaging supported Yes N/S N/S Yes Yes, with or without Prime Technology

Compression time for combo study, 60 mm breast

4 sec N/S N/S ~10 sec. (from initial compression to end of X-ray exposure) 27 sec

PACS requirements BTO N/S N/S DICOM objects: MG, DBT, SC, GSPS; DICOM functions: Q/R, DICOM

store, DICOM send, DICOM, store commit

DICOM objects: MG, CT, BTO

Generator type High frequency High frequency single-phase power supply High frequency single-phase power supply High frequency High frequency

kV range 22 - 49 in 1 kV increments 22 to 49 kV 22 to 49 kV 20 - 49 kV 23-35 kV

mAs Range 2 - 600 4 to 500 mAs (depending on track, fi lter and kV) 4 to 600 mAs (depending on track, fi lter and kV) 3 - 150 mAs 2 to 630 mAs

mA range 20 - 200 Molybdenum target: 100 mA from 25 to 30kV on large focal spot,

40 mA from 25 to 30 kV on small focal spot; Rhodium target: 62

mA from 25 to 30 kV on large focal spot, 35 mA from 25 to 30 kV

on small focal spot

Molybdenum target: 100 mA from 25 to 30kV on large focal spot,

40 mA from 25 to 30 kV on small focal spot; Rhodium target: 62

mA from 25 to 30 kV on large focal spot, 35 mA from 25 to 30 kV

on small focal spot

10- 200 mA N/S

AEC detector Automatic, semi-automatic, manual Two exposure modes: automatic optimization of parameters

(AOP) and manual mode available

Two exposure modes: automatic optimization of parameters

(AOP) and manual mode available

Yes; both AutoAEC and manually select AEC regions Inteligent AEC algirithim analyses each breast indivdally for

thickness and breast composition to optimise exposure

Parameters controlled Fully automatic: sets kV, mAs, target/fi lter, grid, AEC, dose level;

semi-automatic: sets mAs; manual: all selections manually input

i-AEC - used clinically - will perform a detailed analysis of the

pre-exposure image to determine the optimum exposure (kVp

and mAs) conditions for the view; ideal for implant cases

Track, fi lter, kVp, mAs, AOP or manual Track, fi lter, kVp, mAs, AOP or manual kVp, mAs, fi lter, AEC method, AEC location Stand: patient name, breast thickness, force in N; AWS: kVp, mAs,

fi lter, AEC, Opdose,

Breast Density and Dose Reporting

Density reporting software (list if it is optional or integrated and who is the software vendor)

Integrated, Volpara Optional; Volpara Density 3D - specifi cally designed and cleared

for 3-D/tomo mammography systems

N/S Quantra breast density assessment software option from Hologic;

no other vendor software is validated for Hologic

Compatible with Volpara and iCad breast density software

vendors

What information is recorded N/S Breast density score compliant with BI-RADS fi fth edition N/S Breast density score compliant with BI-RADS fi fth edition; scores

for each breast, temporal information, various

Vendor dependent

What density parameters are used and what is listed in the report

N/S Breast density score compliant with BI-RADS fi fth edition N/S Breast density score compliant with BI-RADS fi fth edition Vendor dependent

Dose software record dose N/S N/S N/S Advanced connectivity license Vendor dependent

How is density information stored or transferred

N/S Structured report and secondary capture N/S Structured report and secondary capture Stored with images and transfered - vendor dependent

Digital Detector

Type (CCD, CsI, aSe) aSe direct-conversion Patented needle structure CsI scintillator, single piece

construction

Patented needle structure CsI scintillator, single piece

construction

aSe aSe

Spatial resolution 50 x 50 μm pixel resolution 100 μm in both 2-D and tomo modes, no binning 100 μm no binning 70 μm; FFDM resolution: 70 μm; tomo resolution: 85 μm 85 μm in 2-D, 85 μm in tomo

Matrix, pixels 24 x 30 cm: 4,728 x 5,928 = 28,027,584 pixels 3,062 x 2,394 pixels; approx 14 MB per image 2,850 x 2,394 pixels; approx 13 MB per image 3,328 x 4,096 2,816 x 3,584

Standard size 24 x 30 Detector size 24 x 30.7 cm Detector size 24 x 29 cm 3,328 x 4,096 2,816 x 3,584

High-resolution size 24 x 30 Detector size 24 x 30.7 cm Detector size 24 x 29 cm 3,328 x 4,096 2,816 x 3,584

Imaging area: Standard size, cm 18 x 24, 24 x 30 Detector size 24 x 30.7 cm Detector size 24 x 29 cm 24 x 29 24 x 30 cm

Imaging area: High-resolution size, cm

24 x 30 Detector size 24 x 30.7 cm Detector size 24 x 29 cm 24 x 29 24 x 30 cm

Additional features Innovative hexagonal close pattern (HCP) pixel design engineered

to deliver higher acquisition effi ciency for fi ner detail, higher

DQE, higher MTF and lower dose than conventional square

pixel arrays

Senographe Essential detector, 100 μm (no binning in tomo); DQE

average values: 69% at 0 lp/mm, 61% at 2 lp/mm (average data

for 2016 production detector)

DQE at IEC 62220-2-3 equivalent spectrum, at 75 μGy: 70%

(+/-3) at 0.5 lp/mm and 64% (+/-3) at 2 lp/mm

Supports dual energy imaging; selenium based direct capture

technology

Full detector readout, no pixel binning

Acquisition Workstation

Workstation 3 MP Dual core Kontron workstation: 4 GB memory, 500 GB disk, 7,200

RPM; image storage 30,000/50,000 large/regular fi eld of view

Quad core Intel i5 workstation Yes Yes

Monitor size, inches 21.3 in 2 types of display available: 1 MP LCD monitor; 48 cm (19 in.)

medical grade; 1,280 x 1,024 pixels (landscape); high luminance

- up to 300 Cd/m²; contrast ratio: 2000:1; viewing angle: 170

degrees; mounted on a rotating arm for easy in-room access; 3

MP monitor display; high performance color TFT 3MP monitor;

54 cm (21.2 in.); 2,048 x 1,536 pixels (landscape); brightness:

1,000 Cd/m²; contrast ratio: 1,400:1; viewing angle: 170 degrees;

mounted on a rotating arm for easy in-room access

2 types of display available: 1 MP LCD monitor; 48 cm (19”)

medical grade; 1,280 x 1,024 pixels (landscape); high luminance

- up to 300 Cd/m2; contrast ratio: 2000:1; viewing angle: 170

degrees; mounted on a rotating arm for in-room access – 3 MP

monitor display: high performance color IPS 3MP monitor; 54 cm

(21.2”); 2,048 x 1,536 pixels (landscape); brightness: 1,000 Cd/

m2; contrast ratio: 1,400:1; viewing angle: 170 degrees; mounted

on a rotating arm for in-room access

Imaging monitor: 21.3 (2 MP/3 MP); control monitor: 17 in. 1 MP or 3 MP, one or two montiors (optional)

Hard disk capacity N/A 1 internal 500 GB, 7,200 RPM 1 internal 250 GB disk for the system, 1TB for image storage 1 TB (min.) 2 TB

Memory N/A 4 GB 8 GB 8 GB RAM (min): Avia 3000; 16 GB RAM (min): 6,000/9,000 12 GB


N/A = Not applicable N/S = Not specifi ed

Comparison Chart Compiled by Imaging Technology News

Scranton Gillette Communications assumes no responsibility or liability for any errors or omissions in this chart.

Editor’s Note: Additional submitted information also appears on our website at www.ITNonline.com.

Company Name Fujifi lm Medical Systems U.S.A., Inc. GE Healthcare Hologic Siemens Healthineers

Networking capabilities N/A 2 Gigabit ethernet port; DVI display; DICOM 3.0 platform:

modality worklist user; storage provider; storage commitment

user; query/retrieve user; basic grayscale print user; verifi cation

provider; DICOM-compliant CD-RW data interchange

4 Gigabit ethernet port; DVI display and port connector; DICOM

3.0 platform: modality worklist user; storage provider; storage

commitment user; query/retrieve user; basic grayscale print user;

verifi cation provider; DICOM-compliant CD, DVD-R/-RW and USB

data interchange

Ethernet Ethernet, DICOM and IHE compliance

Adjustable height N/A N/S N/S Available Yes, 28.7-43.3 in

Multiple exposure control options N/A N/S N/S Yes Yes, 3 diff erent options

Gray levels N/A N/S N/S 10 bit display 8,192 greyscales/ 13 bit

Additional features N/S Connectivity features: customizable Autopush to multiple DICOM

databases, autoprint, autodelete based on storage commitment,

modality perform procedure step user, connectivity to GE service

for remote diagnostic capability

N/S Upgrade features available for enhanced ergonomics syngo software, shared with all Siemens modalities and reading

solutions to reduce training requirements

Review Workstation

Workstation 5 MP SenoIris Diagnose SenoIris Diagnose SecurView DX syngo.Breast Care

Monitor size, Inches 21.3 in Dual 5MP 21.3” LCD display; single 12 MP 33.6” color LCD display;

19” TFT color monitor

Dual 5 MP 21.3” LCD display; single 12 MP 33.6” color LCD display;

19” TFT color monitor

Single 12 Megapixel 33.6 in. color LCD display with built-in

auto-calibration and 10 bit graphics card; high contrast dual 5

Megapixel 21.3 in. LCD display with built-in auto-calibration

and 10 bit graphics card; standard dual 5 Megapixel 21.3 in. LCD

display with 10 bit graphics card

Variable, dependent on customer requirements

Hard Disk Capacity N/A 1 x 256 GB, 2 x 1 TB SSD (additional 1TB optional) 1 x 256 GB, 2 x 1 TB SSD (additional 1TB optional) Minimum 3.5 TB, RAID 5, disk encryption Variable, dependent on customer requirements

Memory N/A 32 GB RAM 32 GB RAM 16 GB high speed RAM minimum Variable, dependent on customer requirements

Networking Capabilities N/A 10/100/1,000 base T ethernet 10/100/1,000 base T ethernet 10/100/1,000 base T ethernet Variable, dependent on customer requirements

Archive/Storage N/A Enterprise archive Enterprise archive SecurXchange archive Variable, dependent on customer requirements

Type Eizo Departmental PACS Departmental PACS Departmental PACS Variable, dependent on customer requirements

Capacity N/A N/S N/S At least 3 TB Variable, dependent on customer requirements

Gray Levels N/A N/S N/S N/S N/S

Additional Features (space permit-ting)

N/S Meets requirements of IHE radiology mammography imaging

integration profi le-imaging display actor; capable of accepting

DICOM breast tomosynthesis objects

Meets requirements of IHE radiology mammography imaging

integration profi le-imaging display actor; capable of accepting

DICOM breast tomosynthesis objects

Meets the requirements of IHE Radiology Mammography Image

Integration Profi le- Image Display Actor; capable of accepting

DICOM BTO, CT, SCO

syngo software, shared with all Siemens modalities and reading

solutions to reduce training requirements

X-Ray Tube

Anode Type Rotating Dual track anode: molybenum (Mo) enriched with vanadium

and rhodium (Rh)

Dual track anode: molybenum (Mo) enriched with vanadium

and rhodium (Rh)

Tungsten Mo/W

Heat Capacity, HU 300,000 Anode heat storage capacity: 250 kJ (340 kHU) Anode heat storage capacity: 250 kJ (340 kHU) 300,000 HU 2,430,000 HU (tube unit)

Heat Dissipation Rate, HU / Min. 60,000 N/S 500 W (40 kHU/min) 60 kHU/min 40.5

Target /Filter Combinations w/Rh N/S Mo/Mo and Rh/Ag Tungsten/aluminim Mo/Mo, W /Ro, W/Mo

Focal Spot Size, mm 0.1 mm and 0.3 mm 0.1 and 0.3 IEC on each target 0.1 and 0.3 IEC on each target 0.3 0.15 / 0.3 mm

Positioning Assembly

Collimation Yes Filters: molybenum 0.030 mm; rhodium 0.025 mm Filters: molybenum 0.030 mm; silver 0.030 mm N/S Automatic collimation to compression paddle

18 x 24 cm Yes Yes Yes Yes Yes

24 x 30 cm Yes Yes Yes Yes Yes

Movement locks Electromagnetic Gantry locked when compression force applied Gantry locked when compression force applied Electro-magnetic brakes Electromechanically

Assembly movement N/S N/S N/S N/S N/S

Rotation -190 to +190 + 185 to - 165 degrees + 180 to - 180 degrees +180 degress to -140 degrees (total rotation) + 180 to - 180 degrees

Vertical, cm (inches) 69-150 (27.2-59.1) Floor to image receptor distance: from 65 to 150 cm Floor to image receptor distance: from 65 to 150 cm 70 - 141 cm (28.3- 55 in.) 69 (27.2 in.) to 150 cm (59.1 in.) (object table)

SID, cm 65 66 66 70 65 (25.6 in.)

Scale Guide N for force and mm for thickness Yes N/S Yes, lb or N N/S

Handswitch Yes (customer option) Dual foot-pedals for column height and compression adjustments Dual foot-pedals for column height and compression adjustments No Yes

Radiation Output

mR / Sec. @ 28 kVp 540 with W/Rh tube using 50 micron fi lter N/S N/S 1,232 mR/sec @ 28 kVp (0.7 mm Al fi lter) N/S

Radiation Shield

L x W, cm (inches) 108 x 60.4 (42.5 x 24) Choice between two radiation shields: integrated to the control

console (height: 1,900 or 2,200 mm); standalone

N/S 84 W x 138 L cm 86 x 195 cm (33.9 in.) x (76.8 in.)

Thickness 0.5 mm Pb equivalent; designed to meet the relevant require-

ments of 21 CFR 1020 and IEC 60601-2-45:2001

N/S N/S 12 mm leaded acrylic, 0.5 mm Pb/ 35 kV per IEC 60601-2-45 0.5 mm lead equivalent

Compression system Auto and manual compression Motorized/manual Motorized/manual N/S Opcomp, intelligent compression

Force, Newtons 0-200 Motorized up to 20 daN; manual up to 30 daN Motorized up to 20 daN; manual up to 27 daN Manual: max 300 N; pre-compression force: 67 to 134 N; full

range compression force: 89 to 178 N

30-200 N

Grid Ratio 6:1 41 lines/cm 2D ratio 5:1 frequency 36l/cm - 3D grid for DBT acquisition Grid ratio: 11:1 N/A for tomo 5:1, 31 lines /cm

Bucky N/A 24 x 31 cm N/S N/A for tomo Reciprocating

Magnifi cation device 1.8x 1.5 and 1.8 (2-D) 1.5 and 1.8 (2-D) N/A for tomo Optional

Stereotactic device Optional Yes (2D) N/S Affi rm Optional

Film ID system N/A Digital detector, no fi lm Digital detector, no fi lm None No

Label printer N/A N/S N/S None No

Power requirements N/A Input frequency: 50Hz/60Hz; input voltage: single phase

200/208/220/240 V~, APC smart UPS 750 VA

Input frequency: 50 Hz/60 Hz; input voltage: single-phase 200-

240 V~; EATON UPS 5P650 650 VA

Gantry: 2080/208/220230/240 VAC; AWS:

100/120/200/208/220/230/240 VAC

208 V, 230 V, 240 V, 277 V, ± 10%

H x W x D, cm (inches) N/A Gantry: 1,930 x 700 x 1,270 mm; acquisition station: 1,560 x 708

x 395 mm; generator 1,330 x 640 x 436 mm

Gantry: 2,020 x 720 x 1,312 mm; acquisition station: 1,885 x

775 x 368 mm

Gantry: 66 W (26 in.) x 223 H (87.8 in.) x 138 D cm (54.25 in.);

AWS: 135.6 W (53.4 in.) x 204 H (80.3 in.) x 122 D cm (48.4 in.)

235 (92.5) x 65 (25.6) x 117.5 (46.3)

Weight, kg (lb) N/A Acquisition station: 217 kg; gantry: 420 kg; generator: 160kg Gantry: 394 kg; control station without monitors: 198 kg Gantry: 400 kg (882 lbs); AWS: 209 kg (460 lbs) 350 kg (770 Ibs)

Optional accessories N/A Options: 24 x 31 cm ergonomic paddle that conforms to the

breast, 19 x 23 cm ergonomic sliding paddle that conforms to

the breast, 1.5 and 1.8 magnifi cation stands with dedicated

paddles (19 x 23 cm, round spot, square spot), square spot sliding

compression paddle, round spot sliding compression paddle,

2-D localizer with standard and round spot biopsy paddles, X-ray

remote control hand switch, hydraulic exam chair, bar code

reader, X-ray protective shield, mobile mounting kit, stereotaxy

add-on (2-D), senoIris Review station providing technologist easy

access to prior images and reports in the exam room

Additional 24 x 29 cm paddle; additional 19 x 23 cm sliding

paddle; 24 x 29 cm fl exible compression paddle; 19 x 23 cm

fl exible and sliding compression paddle; 10 x 23 sliding implant/

small breast compression paddle; square spot sliding compres-

sion paddle; round spot sliding paddle; 2-D localization 19 x 23

Swiss cheese sliding compression paddle; 2-D localization 19 x 23

sliding standard compression paddle; 2-D crosshair device; X-ray

protective shield; bar code reader

Optional accessories for gantry include but are not limited to

biopsy add-on (Affi rm), paddles, mag stand, tomo face shield

Moodlight, mag table, biopsy unit, Prime technology

Warranty 1 year 1 year system warranty 1 year system warranty 12 months 1 year standard


WOMEN’S HEALTH | PRODUCTS |

Breast Imaging WorkstationThree Palm Software released verson 1.8.2 of its breast imaging workstation, WorkstationOne. It is a total integration of imaging and informatics for breast imaging, which provides native functionality to generate diagnostics reports and patient letters. This mechanism is integrated into the reading workfl ow, so that reporting information is captured as the case is read, and is transparently used to populate customizable templates. The reports are saved in a variety of formats, including DICOM standard mechanisms that can be archived to any picture archiving and communication system (PACS) and accompany the studies for reference in future years. Generated DICOM formats include secondary capture, encapsulated PDF and structured reports. The 1.8.2 release of WorkstationOne builds on its existing comprehensive support for mammography, which includes seamless integration of tomosynthesis and breast projection images from any vendor into the workfl ow; display of mammography computer-aided detection (CAD) reports (including 3-D tomosynthesis CAD reports with enhanced workfl ow); and simultaneous display of related modalities and reports. WorkstationOne was also shown in a number of partner booths at RSNA, including PACS and full-fi eld digital mammography (FFDM) vendors, as well as the major vendors of high-resolution mammography monitors.Three Palm Software | www.threepalmsoft.com

Breast Tomo MonitorEizo Inc.’s RadiForce GX550 is a 21.3-inch, 5 megapixel monitor for viewing detailed digital breast tomosynthesis and mammography images. It is the successor model to the RadiForce GX540 and features superior imaging capability and ease-of-use. The RadiForce GX550 features Eizo’s Sharpness Recovery technology, with which the decrease in sharpness (MTF) is restored. This allows healthcare professionals to display an image safely on the monitor that is true to the original source data, even at high brightness levels. The monitor’s new design features thinner, black front bezels, making it easier to focus on images in dark reading rooms, while the original white stripe design around the sides of the monitor presents a fresh, clean aesthetic to promote a comfortable, user-friendly environment. For keeping the workspace effi cient, the monitor’s width, height and depth were reduced by 21 mm, 36 mm and 45.5 mm respectively – a 28 percent diff erence compared to its predecessor. The width of the side bezels was reduced by approximately half to 13.5 mm – the thinnest in the industry for 5 megapixel monitors, according to Eizo. This allows users to comfortably view two monitors side by side to compare images. The company has received U.S. Food and Drug Administration (FDA) 510(k) clearance for digital breast tomosynthesis and digital mammography for the RadiForce GX550. Eizo | www.eizo.com

Personalized CompressionSigmascreening’s Sensitive Sigma Paddle enables personalized compression for better quality mammograms without unnecessary discomfort for patients. The patented Sensitive Sigma Paddle has multiple sensors that measure each breast to optimize compression for each breast. Based on breast size and tissue stiff ness, the device calculates the pressure to achieve an optimal compression of 75 mmHg and allows for a highly reproducible procedure. Investigational in the United States, the device is CE-marked and is actively being used at breast screening centers and hospitals in England, Germany, Sweden, The Netherlands, Belgium and Switzerland since receiving CE-mark last year.Sigmascreening | www.sigmascreening.com

Integrated force sensors

X-ray transparent foil

Compression Paddle (small)

Sensitive Sigma Paddle controller

LED pressure indicators

TMIST Tomosynthesis TrialResearchers from The Ottawa Hospital Breast Health Centre and the Ottawa Integrative Cancer Centre (OICC) have opened the Ottawa site of the Lead-In to the Tomosynthesis Mammographic Imaging Screening Trial (TMIST). The Breast Health Centre is one of three clinical trial sites to launch the Lead-In in Canada. It is expected that shortly this trial will be integrated into a larger U.S./Canada TMIST, managed by the ECOG-ACRIN Cooperative Clinical Trials Group. TMIST is the fi rst large randomized, multi-centre study to assess whether a novel 3-D digital tomosynthesis technology combined with 2-D digital mammography may be more eff ective at reducing the incidence of advanced breast cancers than conventional 2-D mammography alone. Previous smaller studies suggest that this new kind of mammography can increase breast cancer detection and reduce the rate of false positives and recalls for women who do not have cancer. If successful, implementation of this technology would provide greater assurance of an eff ective test, reduce patient stress and anxiety, and ultimately reduce costs to the healthcare system. The current Lead-In study aims to enroll 6,300 women in Canada, including 2,000 from Ottawa. Women attending mammographic screening at the Breast Health Centre may be approached to participate.Canadian Cancer Trials | www.canadiancancertrials.ca


Breast Screening SoftwareVolparaEnterprise 2.0 software helps breast imaging providers deliver high-quality, personalized breast screening. It delivers key performance indicators (KPIs) for hundreds of performance and quality metrics, including positioning, compression and equipment utilization. The Microsoft Azure–based solution provides continuous quality assurance and performance monitoring through dynamic, interactive dashboards. Updated with every mammography or tomosynthesis exam, the VolparaEnterprise ConstantQuality metrics may help facilities comply with the U.S. Food and Drug Administration’s (FDA’s) new EQUIP inspection program. Designed to support large or small enterprises, VolparaEnterprise software enables breast imaging providers to provide objective evidence to demonstrate compliance and quality of care. Users can perform rapid quality control checks to optimize the productivity and effi ciency of imaging resources, to help reduce costs through the reduction of retakes, and to increase staff eff ectiveness.Volpara | www.volparasolutions.com

Breast Density Category Assessment SoftwareThe FDA has granted 510(k) clearance to Statlife’s DenSeeMammo, a software solution for breast density category assessment. DenSeeMammo provides a standardized and automatic breast density evaluation that mimics radiologists’ visual assessment according to the BI-RADS 5th Edition guidelines. The images from the mammography equipment are compared to a database of images that were previously quoted by a consensus of Mammography Quality Standards Act (MQSA) radiologists specialized in breast imaging. The DenSeeMammo software can be combined with Statlife’s MammoRisk software for breast cancer risk assessment; it provides a breast density category assessment, a risk evaluation, and a patient report with a personalized screening program. DenSeeMammo is a software application intended for use with digital mammography systems. DenSeeMammo estimates BI-RADS breast density value by analyzing digitally processed 2-D mammograms using a fully automated comparison procedure. It provides a BI-RADS breast density 5th Edition category to aid radiologists in the assessment of breast density. DenSeeMammo is compatible with images obtained from GE Senographe Essentials systems.Statlife | www.mammorisk.com/us

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the last readGreg Freiherr

Beware the Invisible Gorilla

29 percent drop in payments in 2011, according to a study by Thomas Jeff erson University researchers. In 2012 and 2013, the volume of CT procedures dropped 5.5 percent annually, according to the IMV Medical Information Division.

In 2013 the Protecting Access to Medicare Act of 2014 (PAMA) directed CMS to develop an appropriate use criteria (AUC) program for advanced diagnostic imaging services, singling out magnetic resonance (MR), CT and molecular imaging. It is no coincidence that the highest profi le modalities — the ones with the costliest machines and the highest charges — continue to be lightning rods for politicians. And that brings us to the gorilla and the presidential tweets that could make it invisible.

Cognitive psychologists call this phenomenon of invisibility “inattentional blindness.” (It is also known as perceptual blindness and change blindness.) It happens when observers see only what they are looking for, even when other options are right in front of them.

This phenomenon was most famously demonstrated in a study that asked volunteers to count the times players passed a basketball. Absorbed in the counting, the volunteers did not notice a person in a gorilla suit walking right through the players.

Enter the Gorilla Radiologists are not immune. In a study at Brigham and Women’s Hospital in Boston, 24 radiologists were asked to detect lung nodules. “A gorilla, 48 times the size of the aver-age nodule, was inserted in the last case ... 83 percent of the radiologists did not see the gorilla,” the researchers wrote, even though the majority, as revealed by eye tracking, looked directly at it.

Will radiology fail to see the approaching gorilla of reimbursement cuts, if and when it comes again? There are plenty of reasons to be alert.

In his bid for the Presidency, Mr. Trump attacked ObamaCare relentlessly as Republicans voted repeatedly — and unsuccessfully — to repeal it. Both had cited this program as the cause of rising insurance premiums. Hoping to leverage the seismic shift in Washington that occurred last November, Mr. Trump and Congressional Republicans are trying to come up with a “replace/repair” plan for ObamaCare.

Assuming they succeed in the ouster of ObamaCare, if insurance premiums (or healthcare costs) rise, Congres-sional Republicans and Mr. Trump will want a scapegoat, something the President can tweet about with impunity. What branch of medicine will it likely be? (Hint: Which lacks grassroots support? Which depends on costly machines and high charges?)

Maybe it isn’t a bad idea for radiology to keep an eye out for gorillas.

Greg Freiherr has reported on developments in radiology since 1983. He runs the consulting service, The Freiherr Group. Read more of his views on his blog at www.itnonline.com.

Aslam against radiology is probably the last thing anybody would expect to see in fallout coming from the new U.S. president. And so far there has been nothing. In literally thousands of Trump tweets over the last several years, radiology has not been mentioned once. And that is exactly why radiology needs to be on the lookout. Big time!

It’s not what the tweets say but the eff ect they have — how Trump tweets distract and how they might provide cover for the gorilla that could be coming for radiology.

To see this, we fi rst must consider the phenomenon of “Trump tweeting.” In early December, the President-elect took aim at Boeing for “out of control costs” on a new Air Force One — “more than $4 billion. Cancel order!” he tweeted.

Never mind that the Air Force, according to Reuters, had previously said it planned to spend $1.65 billion for two of the jets. Never mind that the initial contract of $25.8 million had been awarded to reduce risk and lower the cost of the program, according to the Pentagon’s daily digest of arms deals.

A big company with lots of military contracts, booming sales of commercial planes and a soaring stock price, Boeing was an irresistible target for the soon to be Commander in Chief. And world media from CNBC to the BBC, The Guardian to WirtschaftsWoche quickly scrambled to report the “news.”

The tweetfest continued after Mr. Trump moved into the White House. And it wasn’t all about Boeing. In the three weeks since inaugural day (Jan. 20 to Feb. 10), more than 130 Presidential tweets were sent, according to a search on Trump Twitter Archive. Those tweets gripped the nation’s attention, appearing daily on websites and in newspapers, nightly on network news, distracting the public from the substance of what was going on.

To understand the signifi cance of this for radiology, we must consider the phenomenon of the “invisible gorilla.” But first we must look at the economic barrage that radiology has struggled against in recent years.

Hard Times More than a decade ago, as editor of the newsletter DI SCAN, I suggested in a series of commentaries that radiology launch a public awareness campaign. Radiology, I warned, was not properly appreciated by the public. And,

because radiologists are “doctors’ docs,” it has no grassroots support among patients, making it an easy target for politicians wanting to “do some-thing” about spiraling healthcare costs.

From 2006 to 2013, the Centers for Medi-care and Medicaid (CMS) repeatedly cut radiology payments. The bundling of reimbursement codes for computed tomog-raphy (CT) of the abdomen and pelvis led to a

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