ICUS Weekly News Monitor 10-8-2008

1. MarketWatch, Oct 8, 2008, Toshiba Installs Vantage Titan MR System at Health Scan Imaging 2. The Heart.org, Oct 7, 2008, Ultrasound-based strategies comparable for DVT diagnosis, treatment guidance By Steve Stiles MarketWatch Oct 8, 2008 Toshiba Installs Vantage Titan MR System at Health Scan Imaging Significant Noise Reduction and High Image Quality Led to Purchase of the Titan The quietness and open design of the Toshiba Vantage Titan(TM) is dramatically improving the MR experience for patients. Health Scan Imaging has installed the Vantage Titan as the flagship MR machine at its new 5,000-square-foot location in Temecula, Calif. The system boasts a 71-centimeter opening, the largest in the industry, and patented noise reduction technology. The Vantage Titan's patient-focused features significantly improve patient comfort and increase the range of patients who can undergo a MR exam. Claustrophobic and obese patients are now able to be imaged with MR because the open bore provides a greater feeling of openness. Toshiba's patented Pianissimo(TM) technology dramatically reduces acoustic noise, the most significant cause of patient discomfort during a MR exam. Finally, patients sensitive to contrast agents now have an option for a contrast-free MRA exam. "The quietness of the Vantage Titan is dramatic when compared to other MRI systems on the market," said Dr. Bill Kelly, founder and medical director of Health Scan Imaging, a medical imaging network with nine locations throughout Southern California. "Our radiologists, employees and especially patients have all noticed the distinct reduction in noise. Additionally, our patients really appreciate the more comfortable, wider bore. In fact, both of these features have led referring physicians and patients to recommend our site." The open bore of the 1.5T Vantage Titan MRI system is 18 percent larger than other 1.5T systems on the market and features a large 71-centimeter patient aperture, outstanding homogeneity, and the largest available clinical field-of-view (FOV) of 55 x 55 x 50 cm, providing the highest level of patient care and diagnostic capability available. The 30/130 gradient platform of the Vantage Titan provides unparalleled power. It also has a guaranteed homogeneity specification of two parts per million over a 50 x 50 x 50 cm DSV and a 1.4-meter magnet length, producing exceptional image quality. "Maintaining our reputation for high levels of patient care due to outstanding image quality was paramount in our purchasing decision," explained Dr. Kelly. "Alternative short bore systems on the market did not meet our needs because of limitations in z-axis field-of-view and excessive noise. The Titan's 50 cm z-axis field-of-view for abdominal, pelvic and spine studies was a main factor in acquiring the system." The Vantage Titan MR system also takes advantage of Toshiba's proprietary contrast-free MRA techniques -- Fresh Blood Imaging (FBI), Contrast-free Improved Angiography (CIA), Time-Spatial Labeling Inversion Pulse (Time-SLIP) and Time and Space Angiography (TSA). Contrast-free imaging is particularly important because gadolinium, the most common contrast agent used for MR exams, has been directly linked to a potentially fatal disease that has occurred in patients with renal insufficiency, called Nephrogenic Systemic Fibrosis (NSF) or Nephrogenic Fibrosing Dermopathy (NFD). These contrast-free protocols allow physicians to perform scans on patients with known renal compromise and diabetes. "Health Scan Imaging's purchase of the Titan is a testament to the system's patient-friendly features," said Bob Giegerich, director, MR Business Unit, Toshiba. "The large, wide bore and significant reduction in noise create a better imaging experience for all patients. Also, the Vantage Titan's large clinical FOV is unique for this bore size and produces high-quality images without compromising homogeneity or overall imaging performance." About Health Scan Imaging Health Scan Imaging is an out patient imaging center network with nine locations throughout Southern California. Established in 1998, Health Scan Imaging has propelled its growth and has rapidly gained market share at each location by steadfastly maintaining its founding principles of quality, professional expertise and service. Health Scan Imaging provides its customers access to the industry's most advanced technology, including high-resolution multislice 3D CT, high-field open concept multichannel MRI, ultrasound and digital X-ray. All locations are linked by a wide-band-width T1 PACS network that provides instant distribution of imaging examinations to appropriate sub-specialists among its team of fellowship-trained radiologists. Health Scan Imaging especially caters to the needs of patients with complex and challenging conditions referred by specialty physicians in the fields of neuroscience, orthopedics, sports medicine, oncology, ENT and pain management. For more information visit www.healthscanimaging.com. The Heart.org Oct 7, 2008 Ultrasound-based strategies comparable for DVT diagnosis, treatment guidance By Steve Stiles Two ultrasound-based evaluations, both with their advantages and disadvantages, are about equally effective at guiding the management of patients with suspected lower-extremity deep-vein thrombosis (DVT), conclude the authors of a randomized trial reported in the October 8, 2008 issue of Journal of the American Medical Association [ HYPERLINK "http://www.theheart.org/article/909721.do" \l "bib_1" 1]. But the writer of an accompanying editorial [ HYPERLINK "http://www.theheart.org/article/909721.do" \l "bib_2" 2] gives the edge to one of the techniques, the one that's been around longer and is simpler and probably more widely available, and notes that a clinical prediction rule not evaluated in the study can also play a role in the initial evaluation of DVT. The study of more than 2000 patients with suspected DVT found comparably low three-month rates of confirmed venous thromboembolism (VTE) among those who were spared the burdens of anticoagulation therapy based on the results of either two-point compression ultrasonography with provisional D-dimer testing or whole-leg color-coded Doppler ultrasonography. Compression ultrasonography, typically performed on proximal leg veins, plus D-dimer testing "is simple, convenient, and widely available but requires repeat testing in one-fourth of the patients," according to the authors, led by Dr Enrico Bernardi (Civic Hospital, Conegliano, Italy). The Doppler method "offers a one-day answer [and is] desirable for patients with severe calf complaints, for travelers, and for those living far from the diagnostic service but is cumbersome, possibly more expensive, and may expose patients to the risk of (unnecessary) anticoagulation," they write. Whole-leg color-coded Doppler ultrasonography, unlike the other method, will disclose DVT of the calf, they explain; its clinical importance, and therefore the value of anticoagulation directed at it, has been questioned. Still, both methods are "reliable diagnostic options," Bernardi et al conclude. "Either strategy may be chosen based on the clinical context, on the patients' needs, and on the available resources." The study was very well done and sheds light on a common clinical problem, according to Dr C Seth Landefeld (University of California, San Francisco), who wrote the accompanying editorial. "It finds, basically, that the nice, standard test we've been using for 20 years, compression ultrasonography, works very well compared with the newer, more bells-and-whistles, color-coded Doppler ultrasound," he told heartwire. The Doppler method, Landefeld said, is at least noninvasive and, unlike the gold standard, venography, doesn't involve the use of contrast agents. But he echoed Bernardi et al in observing that the Doppler method, compared with compression ultrasonography, "is probably more expensive and less widely available and takes more expertise, and it will diagnose DVT that's limited to the calf and distal leg, which may lead to unnecessary treatment." The trial's patients had been referred to one of 14 ultrasound laboratories in Italy with a first episode of suspected symptomatic DVT. Of the 1045 randomized to the two-point ultrasonography strategy, 217 had abnormal findings at the initial workup and were classified as having proximal DVT; 828 had normal findings and underwent D-dimer testing. That test was abnormal in 256, who were scheduled for repeat ultrasonography a week later. Repeat ultrasound yielded abnormal findings in 14 patients. So, 814 patients were spared anticoagulation therapy and were followed for the prespecified three months; they included the 572 with normal findings at ultrasonography and D-dimer testing plus 242 with repeatedly normal ultrasonography despite a positive D-dimer result. Whole-leg color-Doppler ultrasonography yielded abnormal findings in 278 of the 1053 assigned to it. Those patients received anticoagulation therapy while the 775 with a negative test were followed. Venous thromboembolism was confirmed in seven of the 801 patients in the two-point ultrasonography group (0.9%) and in nine of the 763 in the whole-leg ultrasonography group (1.2%) who hadn't been anticoagulated and were available for the three-month follow-up. The difference met the trial's criteria for equivalence, the authors write. In his editorial, Landefeld recommends that patients with a suspected first instance of DVT be initially evaluated using two of three methods: the clinical prediction rule, two-point ultrasonography, and D-dimer testing. "If both tests are negative, DVT is effectively ruled out, and anticoagulation can be withheld safely," he said. "If the clinical evaluation using the Wells criteria [ HYPERLINK "http://www.theheart.org/article/909721.do" \l "bib_3" 3] suggests low [DVT] probability, and if the [two-point] ultrasound or the D-dimer test is negative, you've essentially ruled out DVT," Landefeld explained to heartwire. "If the compression ultrasound is positive for proximal DVT, you've made the diagnosis. If the clinical evaluation suggests intermediate or high [DVT probability] and the compression ultrasound is negative, then you have to do something more. And that could be to do another test in a week or a more definitive one right then, which would be venography or color-coded Doppler." That's not a strategy tested by Bernardi et al, he observed, "but it would be a reasonable way to go."

ICUS Weekly News Monitor 10-3-2008

1. HealthImaging & IT, Sep 26, 2008, Ultrasound contrast gains a champion with new society HealthImaging & IT Sep 26, 2008 Ultrasound contrast gains a champion with new society A new international and cross-disciplinary professional society, the International Contrast Ultrasound Society (ICUS), has been formed, devoted to overcoming challenges in field of contrast ultrasound and increasing its role in improving patient care worldwide.

The society was formed last week at the Advances in Contrast Ultrasound: Enhanced Atherosclerotic Imaging and Intervention conference in Chicago. 

Its formation follows the controversial decision by the FDA to impose new limitations on the use of contrast ultrasound - a decision that was largely reversed in May following opposition from contrast ultrasound experts, who marshaled new scientific data relating to the life-saving potential of improved contrast ultrasound diagnoses.

Contrast agents are approved in more than 70 countries for use in diagnosing a wide variety of medical abnormalities; however, only four contrast agents are available for approved indications in various countries: Definity (Lantheus Medical Imaging), Levovist (Schering AG), Optison (GE Healthcare), and Sonovue (Bracco Diagnostics). 

While usage of the agents in echocardiograms has declined in the last two years, ongoing clinical trials and pending regulatory applications are aimed at expanding the uses of ultrasound contrast agents.

“There is growing interest worldwide in expanding the approved uses of contrast ultrasound – not just for imaging the heart, but also for diagnosing abnormalities of the liver, carotid arteries, gastro-intestinal system, kidneys, and other organ systems throughout the body,” according to according to Steven Feinstein, MD, co-president of ICUS and director of echocardiography at Rush University Medical Center in Chicago.

Barry Goldberg, MD, co-president of ICUS and past president of the American Institute of Ultrasound in Medicine and the World Federation of Ultrasound in Medicine and Biology, added that the organization will provide a forum for cross-specialty communication and collaboration among contrast ultrasound professionals worldwide. “Collaboration and inclusiveness are key to the growth of the field and, ultimately, will significantly improve patient care,” he said.

Founding ICUS board members include contrast ultrasound experts from North America, Europe, Asia and Latin America. 

The recent FDA controversy has helped cardiologists appreciate “the vital importance of our colleagues in radiology, vascular imaging, and related imaging fields who also are working to develop contrast ultrasound applications -- for the liver, gynecological uses, whole body scans,” according to Feinstein. “The more we learned of their parallel universe, the more we became convinced that we need to foster more cross-specialty dialogue and collaboration.”

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