Carestream DRX Evolution Plus

Radiographic and fluoroscopic: what's new?

November 22, 2016
by Lisa Chamoff, Contributing Reporter
The new releases in radiography and fluoroscopy over the last year have lined up with key trends in health care. All-in-one systems are meant to increase utilization, while automation and in-room displays are part of an effort to improve workflow and allow technologists to have more face time with patients.

At the same time, OEMs continue to release larger flat-panel detectors and create budget-friendly products for the growing market of outpatient clinics and urgent care centers, while also keeping their eye on the growth of tomosynthesis for general radiography, not just for breast imaging. The following are products from several OEMs that are new to the market.

Siemens Healthineers
Siemens Healthineers launched a highly automated robotic X-ray scanner called the Multitom Rax, which is designed to move around the patient. The multimodality system also allows for fluoroscopy as well as angiography applications. One area the product is meant for is in the emergency and trauma environment, where it can be difficult for the patient to move, says Viola Fernandes, the X-ray product manager for Siemens Healthineers.

The Multitom Rax also allows for X-rays while sitting and standing, so imaging can be done on the ankles, knees, hips and spine when the patient feels pain in certain positions. “The joints and the cavities look very different in their natural weight-bearing position,” Fernandes says. University of Utah Hospital, the first facility in the U.S. to install the Multitom Rax, takes advantage of the ability to do a multitude of exams in the room, and its automation.

“The room in there before didn’t have a wireless detector,” says Matt Harris, supervising technologist at the hospital, which is part of University of Utah Health Care. “This limited what you could do in the room. Without the wireless digital detector, you couldn’t really do extremity work like hands and feet. You could do some body parts and not others. In this one, you can do any possible X-ray that is ordered for any patient, plus most of our fluoroscopy examinations. “With the previous system we also couldn’t move the system in a way to accommodate the limited mobility of trauma patients. In the current room, the machine can move around them.” The company is also marketing the Multitom Rax for the value-based reimbursement era.

“The focus was a system with a high degree of utilization as the health care environment is moving to do more with less, and toward quality-based reimbursement,” says Joe D’Antonio, director of radiography, fluoroscopy, mobile and twin robotic X-ray products for Siemens Healthineers. “Now you’re going to get greater utilization out of that room, rather than have a patient go in a dedicated CT or angiography suite for certain procedures. That’s not to say we’re replacing CT, but there are a multitude of exams we can do within the Multitom Rax that are basic procedures for CT. Why tie up [the] angiography suite’s schedule when you can do PICC lines and injections in this room?”

Carestream Health
The company expanded its premium category of radiography products with the DRX-Evolution Plus digital X-ray room, which Sarah Verna, Carestream’s worldwide marketing manager for X-ray solutions, says builds on its previous release, the DRX-Evolution. “We really listened to our customers about what the next generation of room design needed to be,” Verna says.

The DRX-Evolution Plus has a table with a higher weight capacity, accommodating patients up to 705 pounds, and enhanced pediatric capabilities, including a table that adjusts low enough for small children, as well as a new tube column designed to reach feet and ankles more easily. The new room also has the capability to eventually accommodate advanced applications under development at Carestream, such as dual-energy radiography and tomosynthesis.

SSM Health St. Joseph Hospital in Lake Saint Louis, Missouri, replaced a 15-year-old radiography room with a DRX-Evolution Plus last November, after using Carestream’s portable X-ray units. Jamie Rapp, the hospital’s leader of diagnostic imaging, says the technologists like the ability to transfer Carestream’s digital detectors between the portable units and the room. They also use the room’s long-bone image capture and stitching technology. “Long-length imaging is fast and very simple for the technologist, compared to the old way of doing it,” Rapp says. “You don’t need a separate room, and stitching the separate images together is handled by the software.”

Carestream’s large format DRX Plus 4343 detector, which is 17 inches by 17 inches, is ideal for imaging on a stretcher and for larger patients, Rapp says. “The idea behind using this is that we have to do more with less, and our patients are getting heavier,” Rapp says. Carestream also released the DRX-Excel Plus radiography/fluoroscopy (R/F) system, which is the company’s first move into fluoroscopy. “Fluoroscopy is a need within Europe and we see the demand increasing within the U.S.,” Verna said. “But it’s very expensive to have a standalone fluoroscopy room that may not be utilized seven days a week. Combining fluoroscopy with general radiography makes sense since a facility can easily leverage the fluoro room for general X-ray and achieve maximum utilization while reducing patient wait times. It’s really improving the overall investment for the facility that’s using it.”

Carestream also expanded its detector portfolio in 2016. Its large-format DRX Plus 4343 is available with gadolinium (GOS) or cesium (CsI) scintillators, for use with Carestream’s DRX-Evolution Plus, DRX-Excel and DRX-Ascend systems, as well as the DRXRevolution Mobile X–ray system. Verna says the larger wireless detector is ideal for patients in the ICU who need daily chest X-rays. In addition, Carestream released its DRX Core family of detectors for radiology customers who require high-quality imaging, but need a detector that is affordable, Verna says.
Agfa HealthCare
Agfa is currently implementing its DR 600 X-ray suites, with the first one installed at the Sunnybrook Health Sciences Centre in Toronto, Canada. The DR 600 is a ceiling-suspended DR room designed for a hospital environment with both tabletop and chest imaging. The machine uses what the company calls Zero Force Technology to move the overhead tube in a lightweight way.

“For large hospitals and busy radiology centers, the speed of the positioning is very important,” says Jared Houk, vice president of the imaging business unit for Agfa. “We developed the Zero Force Technology to help with that positioning.” The company is anticipating FDA clearance next year for its DR800 model, which will combine radiography and fluoroscopy. The equipment will use Agfa’s MUSICA (Multi-Scale Image Contrast Amplification) software, and it will be the first time the software will be used for fluoroscopy.

“Digital fluoroscopy has been around for almost 30 years with very little improvement,” says George Curley, Agfa’s senior marketing manager. “Most of the improvement has been focused, rightfully so, on lowering patient and operator dose. Typically, lowering dose on any digital image also means reducing image quality. With MUSICA, users can lower radiation dose and still improve image quality. With our patented fractional multi-frequency processing, MUSICA helps visualize fine details throughout the entire image automatically and consistently provides images at a brightness and sharpness that the radiologists prefer, regardless of the patient size, body part or exposure parameters. This virtually eliminates the need for time-consuming post-processing, and provides increased productivity for technologists and radiologists.”

Agfa has also expanded its DR panel line with new 10-inch-by- 12-inch and 14-inch-by-17-inch detectors in both GOS scintillator and CsI scintillator. The detectors are lighter weight, have sharing options and an in-bucky charging option and optional full-field automatic exposure detection, Houk says.

Del Medical
Del Medical’s newest release is the OTC15-T, an overhead suspension system with synchronized auto-tracking to Del’s EV800 elevating four-way, float-top table and VS300 wall stand.

“Tracking systems in general are becoming more popular in the U.S. market,” says Tony Galles, senior vice president of sales at Del Medical. “The U.S. market has been slower to accept auto-tracking systems, primarily due to [the] technologist’s ability in the past to complete radiographic procedures more quickly with manual movement systems. As technology has improved we’re excited to see this trend is changing and showing growth, specifically in the more demanding sectors such as hospitals, imaging centers and busy orthopedic practices.”

The OTC15-T can shift between tracking and manual modes, giving technologists the flexibility to image however they prefer for an exam, Galles says. “When configured with a DelWorks E-Series DR System and optional Patient Side software, clinical workflow efficiency improves greatly, especially in busier environments,” Galles says. “The OTC15-T provides touchscreen APR control at the tube mount, allowing the technologist to remain closer to the patient for a longer period of time, also improving patient safety.” The patient’s images can then be previewed at either the Del-Works DR console or at the OTC15-T tube mount’s integrated touchscreen display.

“Once the exposure has been taken, the technologist can return to the patient’s side to view, accept or reject images taken, and set the generator parameters or APR for the next image or study to be completed, improving patient care,” Galles says.

Medical Imaging Innovations
The Florida-based company, which focuses on more budget-friendly imaging systems and upgrades, and is led by Chief Executive Officer Tim Martinson, released two models in the last couple of years: the FluoroSight ONE, a universal R/F system; and the FluoroSight ECO, a flat-panel DR retrofit for a GE classic R/F table.

The FluoroSight ONE is an R/F system that can perform barium and contrast studies at a source-to-image distance (SID) of up to 80 inches, giving the radiologist more room to work, and the patient more space for positioning, says Boris Geyzer, general manager of Medical Imaging Innovations. Radiographic exams of the chest, spine and extremities, along with orthopedic exams, can also be performed. Technologists can perform cross-table lateral X-ray and fluoroscopy without an overhead suspension, with one flat-panel RF detector.

“The FluoroSight ONE gives hospitals the ability to perform their routine fluoroscopic exams in the morning, then do any radiographic work that may need to be done, and keep the room busy throughout the day,” Geyzer says. “The system has the flexibility to be used for some special procedures as well, giving the hospital redundancy and the ability to achieve return on investment of their purchase.” The FluoroSight ECO allows facilities with R/F systems from GE to upgrade their technology in a low-cost way. There’s no need to change the room, so customers have minimal outlay in room renovations.

“In states like California, where new equipment planning has to meet earthquake regulations, fluoroscopy systems can take time to be approved by the state regulators, with additional funds needed to make the room ready for the new equipment, plus the new equipment itself,” Geyzer says. “Just the state approvals can add as much as 20 percent additional to the cost of the system, plus an additional year of waiting for approvals. The FluoroSight ECO, being a retrofit where we don’t change any of the mechanical components, alleviates that issue, and costs considerably less than replacing with a full new system.

“At the end of the day, most facilities don’t really want to purchase fluoroscopy, but it’s necessary. Generally, people are replacing rooms every 15 years. You have to be able to give them the ability to either keep the asset they already have and upgrade it to existing technology, or give them an option for new equipment that covers the gamut of exams that a department has, so the system doesn’t stay idle.”

The company is awaiting 510(k) clearance for its CombiDiagnost R90 cross-functional DRF system, a remote-controlled, high-end combination room designed to increase room utilization. “Instead of two separate rooms for dedicated fluoroscopy and radiography exams, they can use fluoroscopy in the morning and for the rest of the day use it for radiography,” says Richard Moessel, sales and business development specialist for diagnostic X-ray at Philips. “Fluoroscopy is really important and this is where we still want to position ourselves.”

The system comes with the option of a vertical stand and ceiling-mounted tube, along with Philips SkyPlate wireless detectors. It comes with Grid Controlled Fluoroscopy — a Philips technology of pulsed fluoroscopy that uses a grid-switched X-ray tube, and the control of X-ray parameters, such as the X-ray tube voltage, current and time, within each single pulse to provide a high-quality image at low dose — and other features to manage dose capabilities.

Especially for pediatric patients, CombiDiagnost R90's smart beam management reduces patient movement blur and blooming effect while at the same time managing the X-ray dose. Sharply defined X-ray pulses eliminate ramps and trails so there is no soft radiation emitted. With In-Pulse Control, very low pulse frequencies are possible. The image is adapted immediately to the density of the current region of interest.
The CombiDiagnost R90 employs Philips' Eleva user interface to provide all the tools and controls necessary for seamless procedures. This one common platform is easy to learn and easy to use, and is highly suitable for streamlining the radiography department. It is the same harmonized user interface found across Philips' radiography portfolio.

FUJIFILM Medical Systems
Before RSNA 2015, the company released the second generation of its Virtual Grid capability, a new software that simulates the use of a physical grid used to eliminate scatter radiation in images. The software simulates what a lead line grid would do, estimating the scatter in the image and compensating for it.

“Grid covers are bulky and heavy,” says Rob Fabrizio, Fujifilm’s director of strategic marketing for digital X-ray. “A lot of hospitals have stopped using them. If the grid angle or source to image-receptor distance is misaligned, you’ll get a bad image. But then also, if [the technologist] is not using them, they get bad images from scatter.”

The second generation of Virtual Grid includes the ability to use the software for all body parts (the first generation was chest and abdomen only), the ability to lower dose and the ability to use it with both CR and DR. Eliminating the real grid has the potential to lower the dose by as much as 50 percent compared to the dose of a grid exam, Fabrizio says.

The company also released a new detector, the FDR D-EVO GL, which Fabrizio says is the first long-length, single-exposure DR detector. The detector is designed for long leg X-rays as well as scoliosis exams, which are commonly done on children, where dose is a critical factor.

“Long-length imaging has been one of the last holdout areas in the transition from CR to DR,” Fabrizio says. “Before this new detector, the only way to perform long-length X-ray exams was either CR with multiple imaging plates, or DR with multiple exposures. Acquiring multiple images with DR can be fast, but it’s not as fast as one exposure, resulting in less pain for the patient in terms of time to stand still, and less patient dose.”

Fujifilm has also released two new X-ray rooms. The FDR Visionary Suite is a high-end automated room with auto stitching, dual-energy subtraction and tomosynthesis for general radiography. It comes with removable detectors for cross-table exams. The company expects to start shipping the model in early November. The company’s new FDR Clinica is a series of X-ray components to build a scalable X-ray room system, designed for the urgent care and outpatient market.

“You can build a system based on your budgetary and clinical needs,” Fabrizio says. “You would purchase a generator based on power requirements and clinical penetration needs, pick different tables based on patient sizes, or choose no table for chest X-rays. It’s a great way to customize to your needs.”

Shimadzu Medical Systems
At RSNA 2015, the company debuted its RADspeed Pro series of fixed radiographic table systems, which received 510(k) clearance in July. The RADspeed Pro also offers optional advanced applications known as the “EDGE” package, including tomosynthesis, dual-energy subtraction and speed stitching.

The company also recently released the MobileDaRt Evolution MX7 mobile X-ray system, which has an optional port to connect to a second external monitor, says Frank Serrao, marketing manager for Shimadzu. He says customers requested the option, particularly when large teams are viewing an image in the neonatal intensive care unit or in the ER. The new mobile allows hospitals to use DR panels from other manufacturers. Shimadzu became panel neutral a few years ago.
“We found that everyone wanted our radiographic and RF equipment and everyone had different CR or DR systems in their hospitals,” says Serrao. “We said, ‘Why sell panels from only one OEM?’ “ For Shimadzu’s latest SONIALVISION G4, the R/F system offers both tomosynthesis and slot radiography as options.

Dr. David Zadvinskis, medical director of the radiology department at OhioHealth Dublin Methodist Hospital in Dublin, Ohio, says the facility is in the process of purchasing a Shimadzu G4, currently in use at Riverside Radiology and Interventional Associates, where Zadvinskis also practices. What drew them to the product was the 750-pound weight limit for the table, which can also go down to 18 inches, the ability to do exams for non-mobile patients while they’re propped up in bed and the tomosynthesis capability, Zadvinskis says. The facility will also take advantage of the slot radiography for scoliosis surveys. Tomosynthesis is a good exam for fractures and a replacement for expensive CT scans.

“Instead of having a single image, when you have tomosynthesis, you can go through a millimeter at a time and see a fracture easily,” Zadvinskis says. “I believe tomosynthesis may become an important modality in the setting of fracture evaluation.”

GE Healthcare
While GE is waiting for RSNA to release information about its new products, the company is excited about a recent development in digital X-ray tomosynthesis, which provides a stack of X-ray images reconstructed into slices, removing the hindrances in imaging of overlapping anatomical structures. Studies have shown, for example, that digital X-ray tomosynthesis can detect small-size lung nodules, 4 to 6 millimeters in diameter, at 7.5 times the sensitivity, with no loss of specificity compared to a two-view chest X-ray. GE provides it in an advanced application called VolumeRAD, available on GE’s premium fixed X-ray systems, including the current Discovery XR 656 Plus platform, which was launched last year.

Michelle Edler, general manager of the global X-ray business at GE, says that while digital X-ray tomosynthesis is gaining traction, there is a hesitancy to use it because there is no specific Current Procedural Terminology (CPT) code. GE has engaged with the American College of Radiology (ACR), which has recommended applying for a dedicated code. In the interim, the ACR recommends using the CPT 76100 code to report X-ray tomosynthesis, Edler says. CPT 76100 is for radiological exams with a single-plane body section and was used for an older technology called linear tomography. Providers who report code 76100 for tomosynthesis may be reimbursed by payers.

“It’s a step in the right direction to compensate physicians for reading the multiple slices of a typical digital tomosynthesis exam,” Edler says. “To really drive and accelerate adoption, the reimbursement has to catch up with the technology.” The technology can help visualize complex joint spaces more clearly, Edler says, and the company has been working with the orthopedic surgical community. “We’re getting a lot of traction when it comes to the orthopedic space,” Edler says.