Advances in ultrasound technology and its non-invasive nature enable better clinical applications from neo-natal imaging to cardiology and comprehensive cancer imaging.

A significant landmark in the evolution of ultrasound technology has been a transition from the cumbersome static B-mode imaging into real-time imaging systems with improved resolution. Innovations in hardware with a short learning curve, addressing shortcomings of this modality, have revolutionized the use of ultrasound with emergence of a variety of new clinical applications. Ultrasound has undergone dramatic changes since its inception with ever-expanding applications. Technological advances and developments in digital signal processing have produced innovations in image display, archiving, novel imaging modes, functional, and quantitative studies. Ultrasound has recently moved to therapeutic applications with high-frequency ultrasound (HIFU), ARFI, micro-bubbles-assisted delivery of drugs and genes. With recent advances like color-coded elastography, perineal ultrasound obtained in multiple planes and 3D images shows tremendous opportunity to exactly locate, define, quantify, and treat the pathology, which is most useful in cancer patients. With ever-increasing concern about radiation dose and cost effectiveness, doctors are continuously looking for better imaging ways. Advances in ultrasound and newer technology and its non-invasive nature enable better clinical applications from neonatal imaging to cardiology and comprehensive cancer imaging. With innovations like portable hand-held devices and wireless transducers, there is an effective change in terms of medical imaging, surgical, and therapeutic applications like cancer therapy.

Indian Market Dynamics

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The Indian ultrasound systems market in 2014 is estimated at Rs.966 crore. In 2015, an 8-10 percent increase over 2014 is seen in all four segments: premium, high-end, mid-end, and entry level. Black-and-white systems continue to show a steady decline. {mosimage}

The major players are GE Healthcare, Philips, Siemens, and Toshiba. Other major brands aggressive in this segment are Mindray, Samsung, Carestream, Trivitron, Skanray, BPL, Hitachi, Konica Minolta, Blue Star, and Analogic Ultrasound (BK Medical). The portable segment is dominated by Sonosite, GE, Philips, Mindray and Esaote.

Some customers in 2015 include corporate chains as Fortis, Apollo, Medanta, Care Hospitals, Global Hospitals and YMC (Yashwantrao Mohite college of Arts, Science and Commerce) in Pune; large diagnostic centers as Amrita Institute of Medical Sciences, Kochi; and Dr Boopathy Vijayaraghavan, Coimbatore.

It seems that the high-end systems are finding greater use in applications as cardiology and OB/GYN, whereas the mid-level systems are being used more for radiology. 3D and 4D imaging is increasingly getting popular. Sound elastography, especially for whole body, is gaining traction. The use of ultrasound in other areas such as emergency medicine (EM), anesthesiology, and musculoskeletal applications has shown increasing use of this modality.

Wi-Fi connectivity, touch screen, battery backup for not just portable but also premium systems, are features increasingly being offered by most brands.

The strict implementation of the Prenatal Diagnostic Tests Act, which prevents deliberate abortion of female fetuses after determining the gender of the baby, is restraining the growth of this segment in India.

Central schemes such as Janani Suraksha Yojna and ASHA (accredited social health activist) have been launched to promote antenatal checkups and institutional deliveries for pregnant women living below poverty line in India where infant mortality is high. The central government spent Rs.1300 crore under the scheme JSY by sponsoring 100 percent maternal expenditure of women under certain conditions. More ultrasound machines have been instrumental in ensuring good maternal health in such programs, although the utilization has been a meager 20 percent in public hospitals.

The steady influx of low-cost ultrasound machines due to reduced import duties and increased local production due to surge in demand and easily available technology has heightened competition pushing down the procurement cost in India, thus forcing major players to reduce their margins.{mosimage}

Global Market Dynamics

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The global market for ultrasound devices has been estimated to grow at a CAGR of 6.4 percent during the forecast period 2015 to 2019. The growth of ultrasound devices market is expected to increase with rising incidences of various diseases such as cardiovascular diseases and cancer. Technological advancements in ultrasound devices is further expected to propel the uptake of ultrasound devices market since new technologies that are revolutionizing the ultrasound industry are efficient enough to diagnose complex diseases with high precision and less time consumption. For instance, unlike CT scanners, 3D and 4D ultrasound imaging technology is efficient enough in producing real-time images of anatomical structure of organs. Likewise, increasing government initiatives will also accentuate the growth of this market during the forecast period.

Ultrasound devices market has been segmented based on product type as cart/trolley-based ultrasound devices and compact ultrasound devices. Owing to rising number of surgeries, compact ultrasound devices market is projected to grow at the highest CAGR of 11.5 percent by value during the forecast period 2015 to 2019. Unlike cart/trolley-based ultrasound devices, compact ultrasound devices are small in size that enable their easy movement while performing surgeries, hence are preferred in operating rooms. In addition, increasing government funding for compact ultrasound devices will further expedite the growth of this market.

Geographically, North America accounted for the largest share in terms of revenue of the total ultrasound devices market. This is majorly due to the presence of a large number of key players such as GE Healthcare and Siemens Healthcare in the region. Owing to rising geriatric population, it has been projected that Asia-Pacific and rest of the world (RoW) will grow at the highest and second highest CAGR respectively during the forecast period. Improving government initiatives will further augment the growth of this market in aforementioned regions.

Technology Trends

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Advent of elastography in ultrasound. New advances in elastography are leading to improvements in surgical procedures and enhancing the doctor's ability to navigate around the body during operations. Elastography, being the medical imaging technique that maps the elastic properties of soft tissue to provide diagnostic information, determines the stiffness of tissue and can be adapted to measure the level of muscle contraction. Cancerous cells, for example, will often be profoundly stiffer than the surrounding tissue and diseased livers are stiffer than healthy ones. Elastography's strength lies in its ability to image tissues and organs that ultrasound cannot reach. It also has the advantage of being more uniform across operators and less dependent on operator's skill than most methods of ultrasound elastography. Acoustic radiation force impulse imaging (ARFI) uses ultrasound to create a 2D map of tissue stiffness. It creates a push inside the tissue using the acoustic radiation force from a focused ultrasound beam. By pushing into the tissue masses, a map of varying tissue densities is created. On the other hand, supersonic shear imaging gives a quantitative, real-time two-dimensional map for a stiff tissue. It is often called shear wave elastography (SWE), though it is not the only method to use shear waves. Like ARFI and shear wave elastography imaging (SWEI), supersonic shear imaging uses acoustic radiation force to induce a "push" inside the tissue of interest, and like SWEI, the tissue's stiffness is computed from how fast the resulting shear wave travels through the tissue. By using many near-simultaneous pushes, and by using an advanced ultrafast imaging technique to track the wave, supersonic shear imaging can make a two-dimensional quantitative map of the tissue's stiffness, and create one every second.

Point-of-care in ultrasound. The use of ultrasound to aid diagnosis and guide management has expanded rapidly beyond the darkened rooms of the radiology department. Point-of-care ultrasound (POCUS) on the ICU has the distinct advantage of rapidly providing relevant information at the bedside rather than transferring a critically ill patient or risking exposure to radiation. Multiple studies have shown that ultrasound modalities such as echocardiography and lung ultrasound have significantly impacted patient management. The use of ultrasound for procedures such as intravenous access has been incorporated into various national guidelines. Pulmonary aspiration of gastric contents is a major cause of anesthesia morbidity and mortality. Point-of-care (POC) gastric ultrasound provides information regarding the type and volume of gastric content. The addition of POC gastric ultrasound to standard patient assessment results in changes in anesthetic management in at least 30 percent of elective surgical patients who do not follow fasting instructions. Smaller ultrasound machines, acceptance of ultrasound procedural guidance, and increasing exposure in medical school, and graduate training programs are driving the increasing use of procedural and diagnostic ultrasound at the bedside. Machines capable of rendering high-quality images are smaller and less expensive, making it feasible for hospitals and clinics to purchase more units, and for providers to fit the machines into their inpatient and clinic rooms. Both competence and ongoing quality assessment are hampered by the fact that unlike chest radiographs and CT scans, which have standard protocols such that they can be interpreted widely by providers who did not perform the examination themselves, POC ultrasound is by its nature individualized and brief. There are traditional cardiac views, and some anatomical structures are readily identified by their sonographic appearance, but some images will be difficult to interpret by someone who was not present at the time of the examination.

Smart fusion technology gaining traction. Despite limitations considering the presence, staging, and aggressiveness of prostate cancer, ultrasound-guided systematic biopsies are still the gold standard for the diagnosis of prostate cancer. Promising results have been witnessed for targeted prostate biopsies using MRI and ultrasound fusion platforms. Fusion or hybrid ultrasound is now being used as a real-time, 3D visualization, and navigation tool. The previously recorded CT, MRI, or positron emission tomography (PET)/CT dataset is transferred to the ultrasound system and a co-registration from external or internal markers is performed either static or real time. It improves diagnostic accuracy and guidance in prostatic biopsy procedures. Here, the real-time capability of ultrasound is retained while biopsying the targets that are better seen on MRI. Targeted biopsies using fusion imaging are more accurate than systematic biopsies using ultrasound alone in diagnosing prostate cancer.

Making way for spatial compound imaging. Spatial compound ultrasound uses the electronic steering of ultrasound beams from a transducer array to obtain overlapping scans of a target tissue from different angles. The given tissue is imaged multiple times from different directions using parallel beams. The resulting echoes from these multiple acquisitions are then frame averaged to produce a single compound image of improved quality due to a reduction in image speckle. It achieves an improved visualization of details compared to what is available with the conventional B-mode image. Spatial compound ultrasound demonstrates a low level of noise, refraction, reduced shadowing, speckle and enhancement artifacts, and improved contrast and margin definition, thus improving visualization of tissue details, including lesion margins. Compound imaging allows an excellent definition of kidney profiles, detection of renal calculi, and more accurate evaluation of parenchymal echotexture and calcifications. It is subjectively superior to conventional ultrasound in evaluating patients with Peyronie's disease, as microcalcifications are better detected.

Road Blocks

Ultrasound system has rapidly advanced in the past decade from 1D M-mode imaging to 2D cut plane imaging, then to 3D reconstructions and now on to 4D, which are 3D images in motion in real time. While the technology has advanced, providers have been slow to adopt it, partly due to the lifespan of their current systems, the cost of 3D and 4D systems, and the need for more data to establish a benefit for the increased costs for the newer technology. Clinical studies of the newer technology have found that the gold standard of 2D is not an exact science when it comes to quantification. This further means, measurements for a 3D structure are being made only at single points on a single plane, whereas 3D echo allows the measurement of the entire volume of anatomy, such as the right or left ventricle. An example of this is 3D speckle tracking, which enables better measurements than 2D, since the anatomy attempted to measure in 2D often comes in and out of plane, whereas 3D is always in plane.

Road Ahead

Innovative advances in high-resolution ultrasound now enable detailed anatomical characterization and accurate differentiation of benign from malignant disease. Ultrasound has become the core component of thyroid nodule guidelines, but it is important that the key technological aspects of the modality are understood and that challenges and limitations remain with the technique. The large evidence base for ultrasound elastography indicates that the assessment of nodule stiffness can improve the imaging evaluation of thyroid lesions and potentially avoid unnecessary FNAC/surgery for benign nodules, particularly if integrated with ultrasound classification. The potential for 3D and CEUS in thyroid nodule ultrasound has not yet been realized, but the emergence of these novel approaches is an illustration of the huge strides that have been made in the underlying ultrasound technology. Elastography shows promise for improving clinical outcomes in numerous applications. The technology has seen strong investment over the last 18 months as suppliers strived to develop a reproducible methodology. Whilst advances have been made, the technology still requires further refining for widespread use. Nevertheless, elastography has been shown to improve clinical outcomes in obstetrics and gynecology, breast imaging, and imaging of the liver.

Fusion ultrasound systems are also gaining interest. The use of ultrasound in conjunction with MRI and CT images improves diagnostic outcomes. Furthermore, growing interest in minimally invasive procedures has resulted in strong growth in the interventional ultrasound market. Advances in new software and connectivity to advanced visualization tools have streamlined fusion technology for radiologist's further driving adoption. This technology is projected to be one of the most important advances in premium ultrasound equipment over the next five years. Despite the high cost of premium ultrasound systems, the advanced features in these systems are important not only for some traditional applications such as obstetrics and gynecology, and cardiology, but perhaps also for the newer applications of breast imaging, interventional cardiology, and internal medicine. Commoditization is starting to occur in the core of the ultrasound market with many traditional specialties using midrange and high-end systems as a valuable standard in many disciplines.

Niranjan Kumar, CEO and MD, India, Niranjan Ultrasound India Private Limited

The year 2015 has occupied a very special place in the successful journey of Niranjan Ultrasound in India since 1999. The company has become a name to be reckoned with in the refurbished ultrasound systems in India, especially with increasing awareness of refurbished medical equipment across varied new clinical segments throughout the country, and introduction of refurbished products making it the most sought-after products to line-up in the refurbished segment. Our wide product range has caught the attention and imagination of our esteemed customers and hospitals alike. Our range with its exciting buyback offers and competitive prices has opened up new horizons. {mosimage}

To capitalize on all this, we have worked out aggressive plans for 2016-17 to register unprecedented growth not only in the refurbished segment but also in other services in terms of medical hospitality. The overall business environment in the healthcare delivery system looks conducive to help us grow and achieve our ambitious targets for the coming financial year 2016-17.

We bear testimonial for our continuous and unprecedented growth to all our employees and team members who have contributed equally and judiciously to stand high at present since a decade long journey.

We are also indebted to our esteemed customers and well-wishers for their continuous support and motivation to stand by us all through our journey toward success.

Niranjan Kumar
CEO and MD, India,
Niranjan Ultrasound India Private Limited

Dr Jayalatha, Proffesor-Radiology & Imaging, MNJ Institute of Oncology & Regional Cancer Centre, Hyderabad
Second Opinion
Beside Equipment Will be the Future

Over the past 15 years, there has been tremendous improvement within the equipment as well as development of new trends which allowed ultrasound to become more widely adopted equipment among the physicians. It has become more and more user friendly and power efficient.{mosimage}

There is enhancement in usage contrast improvement and finer delineation of tissues with advanced technique. Ultrasound has become a routine investigation in emergency room, at bedside, and also in obstetrics practice.

Today, ultrasound images are available with higher resolution with the availability of high-frequency probes with less weight, which allow radiologists and physicians to diagnose superficial things with more clarity. Radiologists are able to see small vessels as thin as 2 mm in diameter in organs like kidney bowel and lymph nodes.

Ultrasound is now widely used in image-guided biopsies and interventions - the field which was earlier dominated by CT and MRI. Now ultrasound guided tumor ablations are done avoiding radiation. Ultrasound is able to capture volumetric images in sagittal and transverse dimensions simultaneously. Volumetric images are very helpful in characterization of tissues with three-dimensional clarity.

New technologies like sono-elastography to measure tissue stiffness in organs like breast and liver thyroid prostate and lymph node make it easy to diagnose malignancies.

Contrast usage in ultrasound gives much more sensitivity in imaging tumors. The improvement in technology and cost effectiveness has put ultrasound ahead of CT and MRI in the present revolution. We can look forward to see more and more light-weight small user-friendly bedside equipment in future.

Dr Jayalatha
Proffesor-Radiology & Imaging,
MNJ Institute of Oncology & Regional Cancer Centre, Hyderabad


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