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X-ray Shifting Into A Higher Gear

X-ray Shifting Into A Higher Gear

With continued growth and development in the field of radiography, the segment has progressed from conventional wet radiography to computed radiography, and further to digital radiography in the last century.

Today X-ray technology has advanced to new horizons and is breaking newer barriers. From conventional to computerized radiography (CR) and now direct radiography (DR) there has been a tremendous refinement in the processes for viewing the images of the human body from inside out.

In CR and digital radiography newer trends are being witnessed. The digital X-ray systems have made rapid strides as the integration of latest technologies has made it easy-to-use, safe, fast, and less expensive. Technological advances in tubes, sources, imaging, detectors, hardware, have improved the user-friendliness and efficiency of digital X-ray systems.  These technological advancements have helped vendors to improve their software capabilities and offerings.

Radiology technology has advanced by leaps and bounds to a stage where the manufacturers too understand the impact of the development toward patient advantage and therefore cost-effective solutions are being offered. This will go a long way in helping to promote technology and provide its benefits to tier II and tier III townships of countries like ours and other developing counterparts.

Indian market

X-ray machines are finding increasing popularity in the Indian market, albeit intense competition is pushing pressure on margins for the DR sellers. All the segments, analog, DR, and CR saw increasing numbers being procured in 2017. Analog continues to be in demand as procurement increases in tier II, and III cities, while the tier 1 cities transition to their digital counterparts. Fluoroscopy, part of DR is finding increased application in the Indian facilities. 3D mammography is also being sought by the discerning customer.

The Indian market in 2017 was 12,140 units, with value estimated as Rs 697.8 crore. While Siemens, Philips, and GE continue to be the dominant brands, Fujifilm and
Agfa have a combined share of about 70 percent in the CR market, other players being Konica and Carestream. Many other players are aggressive in the X-ray equipment segment including Allengers, Samsung, Canon (Prognosys), Skanray, BPL, RMS, Erbis and FX Rays.  2017 saw the entry of some new brands including iRAY, China; Cura marketing some Korean brands; Rayence, USA;  and CareRay, China.

Global market

The global X-ray market size is projected to surpass USD 15 billion by 2024, according to Global Market Insights, Inc. Rising prevalence of chronic diseases, favorable reimbursement scenario in developed nations, growing number of diagnostic imaging procedures, and increased funding on research and development activities by the government will serve as major driving factors for the medical X-ray market growth.

Technological advancement in medical imaging, particularly in CT, has led to the rapid growth in performance of X-ray examinations. Demand for imaging procedure is high among females as compared to males owing to increasing number of breast cancer patients. However, high risk associated with exposure to radiation among patients and high installation cost of medical imaging modalities may restrain industry growth.

Line scans detectors are expected to contribute to significant growth over the forecast timeframe, owing to factors such as being ideal for in-line X-ray photography and enabling high-resolution capture for X-ray. It provides imaging function within a single scan, which will further drive industry growth.

DR could witness lucrative growth over the next 6 years. The growth is attributed to availability of mobile digital X-ray systems. It is used in various applications such as chest imaging, dental, mammography, and orthopedic. Moreover, increased demand for portable systems from the geriatric population will drive medical X-ray market growth.

CR accounted for highest revenue share in 2017. Rising geriatric population, continuous advancement in digital imaging modalities, and introduction of new equipment by industry players are the key factors, which will drive segment growth.

The medical X-ray market, by portability is categorized into portable and fixed systems. The fixed segment held major revenue share in 2017, due to increasing government investment for installation of advanced diagnostic equipment. Moreover, it is mostly used to address imaging demand in all clinical settings. Portable systems should contribute witness lucrative growth. The rising geriatric population with mobility problems and increasing R&D funding by companies and government for portable systems should drive business growth.

Diagnostic centers accounted for major revenue share in 2017 and will continue to dominate. Diagnostic centers provide treatment at low cost as compared to hospitals due to high operational efficiency, which will propel industry growth. Moreover, rate of hospital-acquired infections in diagnostic centers is far less than hospitals.

New hospitals are expected to be set up at a rapid pace in the coming years. Most of the procedures performed in hospitals with mobile C-arm X-ray equipment require flat panel technology. Hospitals can relatively afford expensive equipment. Factors such as these will drive growth.

The United States of America accounted for the highest revenue share in the medical X-ray market in the coming years owing to presence of sophisticated healthcare facilities, growing number of medical imaging procedures coupled with development, and increased use of computer technology. Moreover, implementation of digital radiography, reduction in payments for examination performed on analog X-ray systems in 2017 would further drive business growth over the next 6 years.

The Asia-Pacific region is expected to witness lucrative growth in coming years. Rising prevalence of chronic diseases such as, cardiovascular diseases (CVDs), asthma, lung, and breast cancer that need diagnosis and treatment should fuel the demand for medical X-ray. Moreover, growing incidence of bone injuries will further drive industry growth.

A growing geriatric population, increasing focus on research and development activities to advance medical technologies by the German government will propel industry growth in Germany. Furthermore, the rising need for sophisticated healthcare, homecare services, and recent health reforms for accident or illness will propel business growth.

Technological advancements

History has seen many notable innovations in the field of medical X-ray imaging, from Wilhelm Conrad Röntgen’s discovery of X-rays in 1895 and Godfrey Hounsfield’s development of CT in 1967, both of which led to the award of Nobel prizes, through to the introduction of dual-energy X-ray absorptiometry in 1971. But 1971 is a long time ago; perhaps we are overdue for the next disruptive innovation? Here are the five exciting new technologies that could lead to disruptive new medical imaging modalities.

Time-of-flight (TOF) range imaging. This is the technology employed in driverless cars to sense distances to nearby objects, and can also be found in many smartphones for proximity sensing. TOF range sensing uses the travel time of reflected light to measure distances, and requires nanosecond pulse generation and detection. For optical systems, this is enabled by the use of vertical-cavity surface-emitting laservertical-cavity surface-emitting lasers (VCSELs) and single-photon avalanche diode (SPAD) photodetectors. But can this be achieved using X-rays?

X-rays are conventionally created using a radioactive element or an X-ray tube. The former requires a shutter to create pulses and cannot provide nanosecond switching. X-ray tubes, meanwhile, can only be switched at 100 ms speeds. Peter Seitz, from Hamamatsu Photonics Europe, suggested a third option: cold-catheter electron emitters. These miniaturized X-ray tubes are based on carbon nanotubes and can switch at rates of less than 10 ps, creating ultrashort X-ray pulses. He noted that fast detectors with 100 ps resolution also exist.

TOF X-ray imaging may be around the corner; we have the sources and they are not expensive. Perhaps TOF imaging is not only for cars, but also for clinical applications.

Direct photon detection. Next is the use of perovskite semiconductors for direct detection of visible photons. Perovskites, materials with the same crystal structure as the perovskite mineral CaTiO3, have recently been used to create quantum dots (QDs). Such perovskite QDs can be used to create high-quantum-efficiency light emitters and detectors with tailorable wavelengths. Direct detection of X-rays remains challenging, however. Silicon detectors are not suitable for X-ray detection, while the more optimal detector – cadmium telluride – is very expensive. So, can one use perovskites for direct X-ray photo-sensing? It is possible to grow high-quality X-ray detectors based on lead-halide perovskite crystals. Detector crystals with dimensions of 2–10 mm exhibit almost identical absorption properties to cadmium telluride, but at a cost of approximately one Euro per crystal.

The problem is that everything works but it is not stable, something migrates in the perovskite. We need to fix this… then there will be sleepless nights for the cadmium telluride guys!

Phase contrast imaging. Detecting cancer using X-ray absorption imaging is hindered by the fact that the tumor has the same absorption properties as the surrounding tissue. The two tissues do, however, have different refractive indices. Inspired by dark-field optical imaging using phase contrast techniques, the third suggestion was X-ray phase contrast imaging. In optical phase contrast techniques, a small difference in refractive index causes light to be slightly deflected. By imaging this refracted light, it is possible to distinguish structures of similar transparency and visualize far more detail. This same approach can be applied for X-ray imaging.

Phase-contrast X-ray imaging exploits refraction and interference effects to create images with significantly higher contrast than in conventional X-ray radiography, and can reveal boundaries between materials with differing refractive indices. Using a standard X-ray source, phase-contrast X-ray imaging allows simultaneous detection of a conventional absorption radiograph, a differential phase image, and a scattering image.

This is here – not yet in production, but it has been demonstrated, it is possible, and it may come soon.

Content-sensitive spectroscopy. Another recent development in smartphone technology is the incorporation of optical spectroscopy. Phones with built-in spectrometers could be used to sense the environment, to test air quality, for example. Spectroscopy is the next big thing in smartphones. Can we have this for X-rays?

X-rays used in medical applications interact with tissue via either the photoelectric effect or the Compton effect. Does this mean that it is only possible to create two different images? Not if you can detect individual X-ray photons, Seitz explained. Then it should be possible to measure the energy of each photon and deduce the elemental composition of a target from its absorption spectrum. It is possible to do X-ray spectroscopy, provided you have detectors and stable sources and can reliably detect each photon when it arrives at the detector.

Triboluminescence. The last inspiration on list is triboluminescence – light generated when chemical bonds are broken in a material subjected to friction, impact, or breakage. For example, flashes of blue light are produced when crushing a sugar cube, or unrolling adhesive tape. It has also been shown that, in a vacuum, X-ray flashes with energies of upto 100 keV can be produced simply by unrolling Scotch tape. What is more, researchers have already demonstrated that such triboluminescence can be used to create X-ray images of a finger, using a dental detector.

The way forward

With continued growth and development in the field of radiography, the industry has progressed from conventional wet radiography to CR to DR in the last one century. Despite all of the innovations the DR sector has seen as of late, even more progress is slated for the future. For one, the industry envisions a future with even more advanced software applications. Technicians will continue to see the physical characteristics of the flat panels evolve and may also see different sizes and shapes of DR panels made available, along with fused or hybrid imaging like it has been seen within the modalities of CT, MRI, and PET. The industry will also see the potential for exploring new options in how DR panels are manufactured. Manufacturers are considering how to make things lighter, more water-resistant, sturdier, less costly, and anti-microbial, since infection control is an important issue in hospitals today. X-ray is often the start of a patient’s care journey and supports critical clinical decisions from prevention through treatment across the care continuum. It affects productivity, workflow, and care team satisfaction. It is more than equipment and more than an image. X-ray is an imperative. There is yet untapped opportunity in digital radiography. No one yet knows where this will take the market, but it is believed that X-ray will find new avenues of clinical usefulness in the future.

Industry Speak
Optimizing Patient Dose

Patient safety and using the lowest possible radiation dose is a high priority for everyone. When it comes to the radiography of children dose reduction requires special attention since they are more sensitive to radiation and its cumulative effects.

Many factors can affect the amount of exposure required for a given examination. These include examination type, patient thickness, exposure technique used, beam filtration, anti-scatter grid specifications, image processing algorithms, and noise reduction methods used. Another significant factor is the performance of the image capturing device, e.g. of the detector type used and, in particular, of the phosphor or scintillator used to convert the X-ray image to light. For many years Barium Fluoro-Bromide (BaFBr:Eu) phosphor plates were used in conventional computed radiography (CR) systems. These image plates offer diagnostic quality at a reasonable dose.

Later, Cesium Bromide (CsBr:Eu) storage phosphors, popularly known as Needle Image Plates (NIP) were introduced for CR. Caesium Iodide (CsI) scintillators have been used for much longer in digital radiography flat panel (DR) detectors. CsBr and CsI offer improved X-Ray absorption and lead to increased detail visibility, thereby offering the opportunity to reduce patient exposure and dose. Cesium needle phosphors helps to reduce radiation dose to extend of 60% compared conventional CR systems.

In developed countries, due to the strong focus on dose reduction in radiographic imaging, increasing numbers of radiographic images are taken at a lower dose resulting in higher noise content and lower contrast. On the contrary, in some other geographies higher dose is given to reduce noise and increase contrast. So, image de-noising (noise suppression and removal) is a major concern in the image enhancement of radiographic images. Studies have demonstrated that image processing can significantly affect perceived image quality at reduced dose. Multi-scale image processing can improve usable diagnostic information at lower doses. Common denoising algorithms can make assumptions about the noise model that may not be applicable under some conditions; this can lead to loss of image quality especially in areas with low signal intensity and/or fine detail. The new generation multi scale image processing, helps in more efficient image denoising with preservation of the fine and subtle image structures. Radiographers can use more dose efficient exposure parameters and use image processing to compensate for the loss of contrast or reduce noise resulting from the adapted exposure technique.

Samith Kakkadan
Marketing Manager, Asia-Pacific South,
AGFA Healthcare India Pvt. Ltd.

Industry Speak
Committed Toward A Healthier Tomorrow

The healthcare sector is witnessing a sharp growth in many segments today, one of which is radiology. With emerging technology, it is interesting to see the tremendous scope that this segment can offer. The world of imaging and technology is constantly evolving which will lead to an exciting world of innovations in the time to come. Radiology has gained its relevance in the context of diagnosis, the first step toward patients’ treatment.

Tapping to this opportunity of advanced diagnostics at an affordable cost, radiology industry is witnessing a boost by launching cost-effective imaging equipment in the Indian market.

The pace of advancement in the diagnostics industry will only accelerate further. The devices will get faster, smarter and accurate, and connected leading to quick and precise diagnostic thereby improving overall patient care.

And that is where with innovation at its core, BPL Medical Technologies has its imaging range, which includes ultrasound, C-arms, fixed and mobile X-rays, and flat panel detectors. Built on world-class technologies, our systems conform to international standards of safety and manufacturing to make sure we equip you with utmost confidence for your clinical decisions.

We had associated with Alpinion to offer innovative solutions in the ultrasound segment. Brand E-Cube offers extreme clarity, efficient workflow, ergonomic design that provides customers with uniform image quality throughout the product lifetime. Alpinion has focused on acoustic engineering and front-end technology since we initiated our ultrasound business. There has traditionally been a strong focus on back-end processing in ultrasound; however, they shifted attention to the front-end with a focus on the signal quality sent to system processors. The company focuses on continuous innovation in acoustic technology. Alpinion has developed a range of transducer array types and applied them to innovative E-Cube series of ultrasound systems.

The fundamental and superb image quality, durability of our product, and ergonomics are the core value proposition to our customers. Under this principle, Alpinion continuously realizes technological innovation through development of core and fundamental ultrasound technologies that ranges from the leading-edge acoustic technology and advanced ultrasound platform to sophisticated image processing and application software technology.

We have also designed our X-ray systems keeping the modern day needs in mind. BPL’s range of fixed and mobile X-rays comes with superior design which are easy to manoeuvre and comes with smaller footprint with options to control exposure time, dose, and safety parameters.

Sunil Khurana
CEO & MD,
BPL Medical Technologies

 Industry Speak
Safety Standards For Users From Radiation Emissions

All X-ray based systems involve some potential risk of radiation exposure. There are many studies going on this subject; which are highlighting the bad effects of the ionized radiations. Statisticians predict that an effective dose of 10 mSv (1 rem) given to a population of one million would result in 400 additional cancer deaths! The national and international regulatory bodies have laid down norms for radiation protection. These are the International Commission for Radiation Protection (ICRP) the National Commission for Radiation Protection (NCRP) in America, and the Atomic Energy Regulatory Board (AERB) in India. These bodies recommend norms for permissible doses of radiation from X-ray from time to time.

The authorities in India have also started putting their focus on the judicious use of X-ray and have started taking actions against the institutions/diagnostic centers for not adhering to the guidelines. In this changing scenario it becomes more important for the manufactures to ensure the products being sold are designed to minimize leakage/scattered radiation, the user and patient should have adequate protection from the harmful effects of soft radiations.

It is essential for radiological protection that ionizing radiation is only used when there is a clear justification. The current radiation protection standards are based on the general principles of ALARA (as low as reasonably permissible). The ALARA principle demands that, every reasonable effort should be made to minimize patient exposure, even below the dose limits. In spite of the obligation to comply with the ALARA principle, the precept of optimizing patient protection during medical exposure should be adhered. We assure comprehensive radiation safety at lowest scattered dose.

We, at Allengers understand all these concerns. The company is fully committed toward radiation safety and care of its customers. In this regard the company has introduced A.S.S.U.R.E protocols, which is a step in the direction of delivering best possible image quality at lowest possible dose. Our products with A.S.S.U.R.E protocols are carefully crafted to protect users and patients from   unwanted leakages in the X-ray equipment.

As per the AERB the permissible limits for safe radiation produced by equipment producing X-rays varies from product to product. Allengers has been able to maintain very high standards by keeping the radiation levels almost 10 times lesser than the prescribed AERB limits for its radiographic products. For C-arms where fluoroscopy procedure is the main application and the radiation to the user/ operator is of prime concern, we have reduced the radiation by almost 20 times lower than the prescribed limits of AERB.

A.S.S.U.R.E is a protocol for not only keeping record of our pursuit toward achieving optimum radiation safety but it is also our endeavor for continuous improvement in radiation safety.

Suresh Sharma
Chairman cum Managing Director,
Allengers Medical Systems Ltd.

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