Ultrasound is more accessible than ever; the utility of ultrasound extends across the entire continuum of care and has become fundamental to providing cost-effective care for patients. Due to its lower cost, best imaging quality, workflow efficiency, reliability, no requirement of same computing power, fast frame rates, or specialized transducers ultrasound scans are becoming the preferred diagnostic imaging technique. Though ultrasound originated within traditional imaging, novel point-of-care (PoC) applications are now being performed by multiple specialties and are contributing to better patient care pathways that are safer and more economical than traditional imaging.

In the last couple of years, there has been a big investment in ultrasound productivity. A lot of new software technology and changes in the way companies are analyzing ultrasound information can be seen. Systems are being redesigned to be more streamlined, lighter, have less components, be user-friendly, and most of all, have much greater mobility.  There really has been a proliferation of advancements over the last few years. Some other factors to highlight would be the creation of handheld ultrasound equipment and the adaptation of 3D and 4D ultrasound system capabilities. Also, image quality has vastly improved due to technology advances in transducer sensitivity. Previously, machines were only able to capture a single image, but now they are able to capture images through multiple planes simultaneously allowing for a more complete picture.

Furthermore, there is a progressive refinement in ultrasound technologies from trolley/cart based equipment to modern handheld miniaturized, wireless, and mobile machines with high portability, advanced computational power, workflow automation and improved quality, and networking capabilities. Over the years, the speed, efficacy, cost-effectiveness, and noninvasive nature of ultrasound imaging diagnostic capabilities have spread its usage across all clinical applications, from obstetrics and gynecology, orthopedics and cardiology to emergency medicine, prostate cancer, and breast cancer detection, and so on. TB is another sickness that can be successfully determined using ultrasound systems, additionally boosting its request. However, the industry might face little hindrances owing to the difficulty associated with the operation of these devices. Thus, researchers are focusing on making them technologically advanced enough to suit everyone’s purpose.

Indian Market

 In 2017, Indian ultrasound equipment market is estimated at Rs. 1310 crore, an 8 percent increase over Rs. 1212 crore clocked in 2016. While the premium, very expensive machines saw a decline in market share, all the other segments including high-end, mid-end, entry level, and portable machines gained market share. The B/W are gradually losing share, and are only procured by small clinics, which do the preliminary test and then if required refer the patient to a nearby diagnostic center for further investigation.

Customer preference is shifting toward high-end technology and high quality imaging for better clinical diagnosis. The market for intraoperative ultrasound (IOUS) is rapidly growing and these ultrasound machines are preferred for various clinical scenarios like robotic surgeries, oncology, surgical gastro applications etc. Hospitals prefer dedicated IOUS machines that are compatible with common disinfectant methods, for safe use in the operating room. The market for high-end portable ultrasound too is seeing rapid growth because of preferences for high technology machines with superior image quality and easy workflow features like touch screen display monitors and high end probes.

The two largest segments for ultrasound tests conducted in 2017 were OB/GYN and radiology. Radiology was the first area to use ultrasound equipment intensively. Due to the large number of important applications, cardiology has also become a traditional setting for the use of ultrasound devices.

Some customers in 2017 include the Apollo chain of hospitals; AIIMS; PGI, Chandigarh; North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGRIHMS),  Shillong; Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow; Tamil Nadu Medical Services Corporation Limited (TNMSC); Govt. of Karnataka; KIMS Hospitals, Hyderabad; Amrita Institute of Medical Sciences, Kochi; Dr Mukund Joshi, Mumbai; and RP Scans, Chennai.

GE maintains its leadership by far. Other leading brands in India continue to be Philips, Mindray, and Samsung. Also aggressive in this segment are Siemens, Trivitron (Aloka and Hitachi), Esaote, Sonosite, Toshiba, BPL, and Sonoscape. Recently, Cura Healthcare has forayed into the business of ultrasound equipment device.

The past couple of years have seen remarkable technological advancements hit the market. These innovations have not only made scanning easier for the end-users, but have taken image resolutions to the next level. With the advent of touch screens, man and machine interactions have become seamless and efficient. The new gesture control touch panels on some ultrasound systems have taken this touch interface one step further. Machines can now be controlled with gestures. Machine control becomes easier and scanning becomes more enjoyable.

Vendors have also introduced elastography, which improves ultrasound’s specificity by utilizing conventional ultrasound imaging to measure the compressibility and mechanical properties of a lesion. Since cancerous tumors tend to be stiffer than surrounding healthy tissue or cysts, a more compressible lesion on elastography is less likely to be malignant. Elastography can properly identify lesions that appear to be malignant on a biopsy, as well as lesions that are benign. Elastography also can be more accurate in gauging the size of the lesions.

Global Market

The global market for ultrasound equipment is expected to witness a CAGR of 5.8 percent between 2017 and 2023, to rise from a value of USD 7.9 billion in 2017 to USD 11 billion in 2023, projects Transparency Market Research. Rising population with chronic and lifestyle disorders; increasing public–private investments, funds, and grants; growing number of manufacturers for ultrasonic devices; and increasing adoption of ultrasound imaging in the field of cardiology, oncology, and emergency medicine are the main factors driving the growth of this market.

Moreover, technological shift from conventional to PoC ultrasound diagnosis, increasing adaptation of ultrasound systems in hospitals and diagnostic centers, and growing penetration of ultrasound equipment manufacturers in emerging nations are some of the factors that are further propelling the growth of the market. However lack of skilled sonographers, stringent regulations and legislations, high cost of medical imaging, and cost associated with the recalibration of these devices are few major aspects that are hampering the growth of the global market.

Geographical area wise, Europe is the largest market. However, the market is expected to witness a paradigm shift with Asia-Pacific taking over the market giant and replacing it to be the leading region in the global market by the end of 2023, growing at a CAGR of 6.5 percent, suggesting an array of opportunities for growth and likely to be getting into the eyes of new investors in the market.

The market is highly consolidated and all the existing players are involved in developing new and advanced products to maintain their market shares. Recently, Clarius Mobile Health has launched wireless handheld ultrasound scanners that will work as a stethoscope for doctors and help professionals to diagnose accurately.

Technological Advancements

Ultrasound systems have made several advances over the years with many more uses in the hospital setting. Enhancements in traditional ultrasound include contrast imaging, volume imaging, and elastography. These advances allow physicians to image blood perfusion and blood flow, view real-time 3D imaging of structures, and differentiate malignant tumors from benign, among other applications. Another important technological advance in ultrasound, however, is the development of mobile systems with increased functionality for the PoC market.

Mobile ultrasound probe. It is becoming an increasingly disruptive technology for the entire medical imaging industry. A wired or wireless probe can now display an ultrasound image on most off-the-shelf tablets or even smartphones. Image processing has come a long way allowing for the smaller, more mobile stand-alone probe to challenge its predecessor with the larger systems in most aspects including 3D and 4D imaging. The market has been picking up slowly as more and more skeptical providers are embracing portable systems. The technology has the potential to save the medical industry billions of dollars in healthcare cost as a portable probe is only a fraction of what the large cart-based system costs.

PoC ultrasound. Point-of-care ultrasound (PoCUS), while not exposing the patient to radiation, may facilitate early diagnosis and minimize the need for delay in management of patients with major health issues. There have been continual advances in PoCUS technology. This is helping to reduce hospital and patient expenses by decreasing costs to the health system and the time required for diagnosis and treatment. Because hand-carried POC systems are so much smaller than conventional cart-based systems – and because mountable POC machines have a zero footprint in locations where space is at a premium – PoCUS has also found its way into remote corners of the world where funds, facilities, and space are limited.

Image quality. The quality of image has improved exponentially in recent years with the addition of high definition also known as 4K resolution to monitors and LCD displays. Progressive p resolution has been proven to be faster, provide a clearer picture, and be less prone to blurring therefore allowing radiologists/cardiologists to calculate a much more defined diagnosis. The majority of advances came in miniaturization. A lot of systems became smaller and more compact and come with algorithms that help in image quality as well.

Transducer technology. There is a greater commitment to transducer innovations that allow clinicians to easily assess technically difficult patients, such as young children or individuals who are overweight. For instance, Philips’ PureWave technology is specifically designed to allow deep penetration and excellent resolution on all patients, even those who are traditionally harder to image. These portable devices improve the accessibility of ultrasound while streamlining diagnostic processes and improving quality of care for patients. This has led to wider adoption by a variety of providers who may not traditionally have used ultrasound, including nurses, midwives, and emergency medicine and critical care professionals.

Contrast media. Newer ultrasound contrast media materials facilitate higher levels of tissue absorption of therapeutic agents used in chemotherapy and the dramatic increase of handheld smartphone ultrasound devices, especially as it relates to point-of-care use on a worldwide basis. With the new materials, modalities, and techniques, as well as the creation of novel acoustic biomarkers, the blending of diagnostic ultrasound with therapeutic ultrasound is becoming more pronounced and will continue to dramatically evolve over the next 5 years.

AI and automation. The new systems feature capabilities such as precision imaging, differential tissue harmonics, and advanced dynamic flow. The systems are more intelligent than ever before, and that helps users to be more confident. Manufacturers are also introducing elements of artificial intelligence (AI) algorithms into their cardiac ultrasound systems to speed automation. It takes a 3-D echo dataset acquisition and automatically analyzes the image to identify the heart’s anatomy, labels it, and then slices the optimal standard views for presentation. Other vendors also have introduced elements of deep learning algorithms to help analyze echocardiograms or perform auto quantifications. Next-generation echo systems will incorporate more AI features to further improve workflow by auto-completing time-consuming tasks and augmenting the sonographer so they can become more efficient and consistently accurate.

Future

Most therapeutic administrative and counseling bodies, including the WHO, concur that the quantity of patients experiencing cardiovascular ailments is developing at an alarmingly high rate. The WHO states that the quantity of heart patients is relied upon to cross 23 million by 2030 and is one of the leading mortality causing NCD in India. This is all that anyone could need to demonstrate that human services associations are in grave requirement for cutting edge ultrasound technology.

As technology evolves, the basic tools clinicians use to assess patients change as well. PoCUS has the potential to improve patient management for all medical and surgical subspecialties. In routine and urgent settings, using ultrasound imaging to help in the timely assessment and diagnosis of medical conditions is going to become more commonplace among general practitioners, critical care physicians, orthopedic surgeons, and anesthesiologists. It is expected that there will be continued advancements in ultrasound toward cost-effective solutions that do not compromise high-quality imaging. Ultrasound will become even more automated, mobile, definitive, and intuitive for users, making it an indispensable everyday tool for patient diagnosis and care in near future.

 

Industry Speak

Early Detection Early Prevention

 The aim of medical technologies has always been early detection and early prevention, since time immemorial. In the year 2018 we would like to renew this vow and make a solemn promise to deliver more and more solutions that keep with the vision of Early Detection and Early Prevention.

Ultrasound researchers have been constantly striving to help clinicians gain an edge over diseases. One recent example has been shear wave elastography. Shear wave elastography has been around since 2004, but the real effects it has had on diagnostic quality have recently started to become evident. Shear Wave elastography when combined with the ZST+ platform of the Resona series solves the existing difficulties of elastography. SWE is now faster, more accurate, and more importantly has become real time on all transducers. ZST+ technology’s artificial intelligence allows users to gain assistance from reliability indices to figure out the more accurate results. This way liver diseases, malignancies, etc. can be detected earlier and then eventually managed well.

Another giant leap in technology is V-Flow. V-Flow technology is a blood flow measurement technology which is, first, angle independent, second, provides the ability to study the blood hemodynamics in the form of vectors. Moreover, the advanced measurements like Wall Shear Stress (WSS) help us study the shear stress the arterial walls face. This helps in detecting atherosclerotic changes even before blood reports of IMT measurements can. With WSS plaques can now also be quantified, which has not been possible with any imaging modality till now.

On antenatal diagnosis ultrasound systems with AI are already becoming established in the clinical community. However, systems that employ AI with cognitive learning are guaranteed to have an edge over the generic AI-based systems. A simple yet very effective example of this is AI-based fetal brain study. The Smart Planes CNS technology available on the ZST+ systems is a one of its kind technology. It not only delineates all the foetal head planes but also makes the measurements and annotations, automatically with high accuracy. This is all possible because the AI is based on cognitive learning rather than simple pattern recognition based ones. I am certain that these technologies in the very near future will improvise patient care.

Punervasu Vyas
National Application Manager,
Mindray

Industry Speak

Technological Advancements in Ultrasound Guided Procedures

There are two methods to carry out musculoskeletal procedures, in-plane and out of plane approach. The out-of plane approach is typically used for superficial injections with minimal surrounding soft tissues and is also popular for intravascular needle or catheter placement. In general, the out-of-plane approach provides less consistent needle visualization when compared to the in-plane approach. While advancing the needle during an ultrasound guided procedure, the performing clinician should maintain continuous, real-time visualization of the needle and its relationship with the target and surrounding structures. Coordinating transducer and needle positions is integral to maintaining optimal visualization. If the transducer moves or the needle trajectory drifts out from under the transducer, needle visualization will be reduced. The clinician can minimize unwanted transducer risk by firmly anchoring the hand holding the transducer onto the patient. Software like Needle Vision Plus automatically steers the waves to an angle such that the waves are orthogonal with respect to the needle and not only the needle tip but the shaft also can be clearly visualized. Needle Vision Plus gives its user three options (shallow, medium, steep) to optimize their settings to get maximum clarity of the needle and can be activated in harmonics and color mode as well.

Post Processing Imaging Suite is as important as the Needle Vision technology. It enhances the resolution and improves tissue differentiation so that the procedure can be conducted smoothly for a broad spectrum of patients. For example, in the case of technically difficult group of patients like very obese patients and patients in ICU’s, Optimal Imaging Suite along with single crystal technology makes it possible to get an optimized image with uniform sensitivity without much manoeuvring of the transducer or moving patient’s position.

Along with this state-of-art-technology, we provide our customers an entire range of linear transducers to choose from, one can go for a frequency of 3–8 MHz for vascular application, 8–17 MHz for musculoskeletal, and superficial applications, 3–12 MHz with 60 mm wide footprint for breast scans, and specialized intra-oral and hockey stick probes with frequency going up to 17 MHz. In addition, the MicroFit technology and light weight transducers with flexible cable are designed ergonomically thus reducing user fatigue and helps the clinician to carry out the procedure efficiently.

Team BPL Medical Technologies

Industry Speak

Point-of-Care Perioperative Ultrasound

 The role of the anesthesiologist is changing. With hospitals seeking innovative ways to streamline patient care and improve outcomes, anesthesiologists are increasingly expected to provide patient care beyond general anesthesia and nerve blocks. Perioperative medicine – pain management and patient care responsibilities – now extend past the operating room and well into recovery. Anesthesiologists are taking on new roles before, during, and after surgery.

Now, anesthesiologists are picking up new skills, like point-of-care perioperative ultrasound, that would have been previously relegated to another specialist. Learning how to scan perioperative patients for complications and conditions is actually a time-saving measure, and can significantly improve patient outcomes and shorten hospital stays.

How Can Point-of-Care Ultrasound Aid in Perioperative Medicine?

Point-of-care ultrasound (PoCUS) is becoming an increasingly essential component of perioperative medicine, specifically patient care. With several applications, such as aiding in local anesthetic placement, and helping determine and prevent postoperative complications, perioperativists will find PoCUS to be an invaluable tool in helping provide better patient outcomes.

Common perioperative ultrasound applications include: hemodynamic monitoring and volume status management; identification of pericardial effusion or tamponade; detection of cardiopulmonary pathology including pneumothorax; ET tube placement/airway management; focused assessment of transthoracic echocardiography (FATE exam); assessment of gastric contents; evaluation of hemodynamic instability (FAST exam); and ultrasound-guided nerve blocks.

Nowadays, physicians are well accepting the small and mobile devices that enable them to take instant diagnostic decisions and streamline all other steps in a patient care process by using bedside ultrasonography. They prefer sanitizable ultrasound equipment in operation theatre and ICU settings for infection control (patient safety) during surgeries and invasive procedures. It not only avoids the risk of infection and exposure to radiation but also creates a balanced approach between patient’s satisfaction and the clinician’s professional intellect. Dynamic imaging, precision-based clinical visualization, and real-time analysis are some of the other benefits that PoCUS offers as a bundle. It is imperative for clinicians to undergo the requisite training that can assure the best possible usage of PoCUS in a situation. It is not a qualification but a specialized skill to be acquired. It is encouraging to see manufacturers willing to provide dedicated education and reference material for a better understanding of the application during procedures. After all, ultrasound technology has been devised to be used wisely as a lifesaving tool for better patient outcomes.

Nitin Gupta
Country Manager, India,
Fujifilm SonoSite India Pvt. Ltd.

Second Opinion

Development in Ultrasound

 Ultrasound imaging has taken some dramatic steps forward since its inception three decades ago, with innovative new systems and technologies debuting across multiple market segments. The original cumbersome B-mode gantry system has evolved into a high resolution real-time imaging system. Ultrasound is more accessible than ever and has become fundamental to providing cost-effective care for patients around the world.

Developments in transducer materials and array designs have resulted in greater bandwidths with improvements in spatial and contrast resolution. Developments in digital signal processing have produced innovations in beam forming, image display and archiving. Micro bubble contrast agents have dramatically extended the clinical and research applications of ultrasound. Not only can Doppler studies be enhanced but also novel non-linear modes allow vessels down to the level of the microcirculation to be imaged. The advent of tissue-specific agents promises to improve the sensitivity and specificity of ultrasound in the detection and characterization of focal liver lesions to rival that of computed tomography (CT) and magnetic resonance imaging (MRI).

Ultrasound has recently moved into therapeutic applications with high intensity focused ultrasound (HIFU) and micro bubble assisted delivery of drugs and genes showing great promise. With the technical development of ultrasonography (US), electromagnetic tracking-based fusion imaging of real-time US and computed tomography/magnetic resonance (CT/MR) images has been used for percutaneous hepatic intervention such as biopsy and radiofrequency ablation (RFA).  Contrast-enhanced US can also be added to fusion imaging, thus decreasing false positive rates.

3D and 4D ultrasound have emerged as an excellent problem solving tool by acquiring a volume set data which combined with post processing techniques produces high quality images in three planes, thus adding important information and improving diagnosis. Ultrasound elastography, tissue harmonic imaging and spatial compound imaging are few other newer application of ultrasound that aid in improved diagnosis and obviate the need for repeated scanning.

Ultrasound gives clinicians incredible insight—the ability to look into patients’ bodies and diagnose, screen, intervene, treat, and monitor, Souquet says.

Dr BYT Arya
Consultant Radiologist,
Manipal Hospital


10 Diagnostic Imaging Trends for 2018

Best of 2017 Medical

 

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