X-Ray Imaging

Siemens Healthcare introduces first twin robotic X-ray system
Radiology’s answer to the Swiss army knife


The two ceiling-mounted arms on Multitom Rax can be moved into position automatically using robotic technology. While one arm moves the X-ray tube and the large touchscreen, the other carries the 43 x 43 cm flat panel detector, which can record static, dynamic and real 3D sequences.

Siemens Healthcare has introduced the world’s first twin robotic X-ray system. They call it the Multitom Rax (Robotic Advanced X-ray). The system enables a wide variety of examinations in a range of clinical areas to be performed using only a single X-ray system. In addition to conventional 2D X-rays, the system also makes it possible to perform fluoroscopy examinations, angiography applications and 3D imaging.

An operator controls of the system’s movement. With the push of a button, both robotic arms are positioned automatically around the patient, improving both safety and convenience. There is no need to move the patient or to change rooms for further imaging procedures, which improved work processes in hospitals and increases economic efficiency.

The system was demonstrated for the first time late last year at the University Hospital Erlangen in the Netherlands.

“We see the Multitom Rax as a universal device that covers all aspects of X-ray diagnostics. You could call it radiology’s answer to the Swiss army knife,” says Professor Michael Lell, Senior Physician at the Imaging Science Institute of the University Hospital Erlangen.

The new system can be used in a wide range of applications, from emergency medicine to orthopaedics, angiography or fluoroscopy, and can thus help optimize clinical work processes. The detector can be freely positioned enabling quite different X-ray images, both static and dynamic, which can be taken in a single room using a single system.

Precision X-ray
The two ceiling-mounted arms on Multitom Rax can be moved into position automatically using robotic technology, and they can also be moved manually, servo motor supported, when required – to make fine adjustments, for example. While one arm moves the X-ray tube and the large touchscreen, the other carries the 43 x 43 cm flat panel detector.

“The robotic technology ensures a new level of precision and automation, enabling a new level of standardization and throughput”, explains Francois Nolte, head of the X-ray Products Business Line at Siemens Healthcare. “The precise positioning of the arms in all three planes makes the examinations so much easier: regardless of whether the patient is standing, sitting or lying down, the robotic arms move with perfect accuracy using robotic technology. Our strategy is based on the principle that the system moves, not the patient, which reduces risk of additional injuries and pain.”

With conventional radiography systems, the detector often has to be placed in an external holder. In addition to the extra time required, this also involves the challenge of positioning the tube at exactly 90 degrees. Multitom Rax does this at the push of a button for free exams. This also prevents any risk of having to repeat image processes because the tube was not precisely positioned.

The system also offers wireless, portable detectors in two different sizes that can be positioned directly between the wheelchairor mattress and the patient’s back, which avoids the need to sit the patient up. The automatic control of the robotic arms ensures that they will always take the shortest and safest route to reach the next programmed position. Pre-programmed safety zones and an automatic stop in response to contact also improve safety.

3D imaging
3D computed tomography (CT) images are often used in situations such as orthopaedic examinations involving the implantation of prosthetic joints, for example, to ensure that the artificial joint is best adapted to fit the patient’s anatomy. The Multitom Rax makes it possible to take 3D images under the patient’s natural weight bearing condition. 3D images can be made of all areas of the body with the patient seated, lying down or standing. Images taken while the patient is standing are essential because for example knees, pelvis and spinal column appear differently under the influence of the patient’s body weight compared to when the patient is lying down. As a result, 3D images acquired by Multitom Rax offer better diagnostic and planning certainty compared to those that do not reflect a natural weight bearing condition. Conventional 2D x-rays, for example, do not always reveal fine hairline fractures in the bone. If a bone fracture is suspected, it has previously been necessary to take a 3D image using a CT system to be sure of the diagnosis. With Multitom Rax, however, a 3D image can be taken with the same system, and so the patient does not have to wait for a further appointment or to be transferred to the CT unit.

Easy access
A free-standing patient table and fully mobile system elements with Multitom Rax provide a more comfortable examination atmosphere. The system is designed for all patient types, from children to the elderly, mobile, immobile and obese individuals. The fact that the table can be adjusted to a very low 50 centimetre table height means that children can get onto it by themselves. It can also be positioned at the most convenient working height. The result is an improvement in both safety for the patient and the examining physician.

Future treatment trends
Care (Combined Applications to Reduce Exposure) applications support treatment standardization using Multitom Rax and aim to keep the radiation dose as low as possible for both patients and hospital staff. Removable scatter grids and a copper filter, combined with the sensitive detector, help to minimize dose. Precisely focusing on the area of the body to be X-rayed and avoiding the need to repeat examinations using Xrays helps protect patients from unnecessary exposure to radiation. In the case of fluoroscopy examinations, such as gastrointestinal or swallow exams, several Care features keep the dose low. A preliminary examination using an especially low radiation dose to fine-tune the tube and detector helps to correctly position even in very challenging exams. For all examinations, in addition, the dose used is automatically reviewed and recorded.

As a part of the Max system family from Siemens Healthcare, Multitom Rax stands out by providing the same image impression and thus making it easier to compare X-ray images. The controls and user interfaces on the Max systems are identical, which means the operators have no need to familiarize themselves over again with new equipment. The wireless detectors in the Max family can also be used equally with all the systems in the family, improving the level of flexibility. Multitom Rax is also configured to accommodate future trends in treatment with functions that can be adapted at a later time. And lastly, its closed surfaces are easy to keep clean, which contributes to the long service life of the system.

Hip osteoarthritis may not appear on x-ray

In the majority of cases, hip x-rays are not reliable for diagnosing hip osteoarthritis (OA), and can delay the treatment of this debilitating disease.

These findings are the first to evaluate the diagnostic performance of an x-ray in patients with clinical signs and symptoms of classic OA. The study appears in the British Medical Journal.

Hip osteoarthritis (OA) is a significant source of morbidity causing pain, difficulty walking, and disability.

Researchers looked at the Framingham Osteoarthritis and Osteoarthritis Initiative studies, with nearly 4,500 participants. In the Framingham study, only 16% of patients with hip pain had radiographic hip OA, and only 21% of hips with radiographic OA had hip pain. Results of the Osteoarthritis Initiative were similar with nine percent and 24%, respectively. In both study populations, hip pain was not present in many patients with radiographic OA, and many with hip pain did not have imaging evidence of hip OA.

“The majority of older subjects with high suspicion for clinical hip osteoarthritis did not have radiographic hip osteoarthritis, suggesting that many older persons with hip osteoarthritis might be missed if diagnosticians relied on hip radiographs to determine if hip pain was due to osteoarthritis,” explained corresponding author Chan Kim, MD, instructor of medicine at Boston University School of Medicine.

Missing the diagnosis of hip OA has consequences. According to Kim, up to 10% of patients with OA do not meet adequate physical activity recommendations, and are associated with having higher risk of developing heart or lung disease, diabetes, obesity and falls. “Given these findings, patients with suspected hip OA should be treated regardless of x-ray confirmation.”

Advanced 3D imaging technique applied for the first time to lung disease

Doctors and scientists at the University of Southampton have used advanced 3D Xray imaging technology to give new insight into the way an aggressive form of lung disease develops in the body.

Originally designed for the analysis of substantial engineering parts, such as jet turbine blades, the powerful scanning equipment at Southampton’s ì-VIS Centre for Computed Tomography, has been used to image Idiopathic Pulmonary Fibrosis (IPF) lung tissue samples for the first time.

IPF is usually diagnosed via a hospital CT scan or by using a microscope to view a lung biopsy sample however Southampton researchers have now successfully applied Microfocus CT to image biopsy samples. This allowed them to view each lung sample with a level of detail similar to an optical microscope but now in 3D.

It had been thought that active scarring in IPF progressed like a large ‘wave’ from the outside to the inside of the lung. Instead, the study, published in JCI Insight, found that there are large numbers of individual sites of active disease scarring. The research team, from the National Institute for Health Research Southampton Respiratory Biomedical Research Unit, believes this finding will help to ensure doctors develop targeted therapies focussing on these areas.

In the UK alone there are over 5,000 new cases of IPF are diagnosed each year, and the number of cases is increasing by around 5% every year. The condition, one of a group of disorders known collectively as interstitial lung diseases, causes inflammation and scarring of the lung tissue. This makes it increasingly difficult to breathe, and it leaves sufferers with a life expectancy of only three to five years.

The study’s lead author Dr Mark Jones, a Wellcome Trust fellow from the University of Southampton and University Hospital Southampton, comments: “Whilst accurate diagnosis of IPF is essential to start the correct treatment, in certain cases this can be extremely challenging to do using the tools currently available. This technology advance is very exciting as for the first time it gives us the chance to view lung biopsy samples in 3D. We think that the new information gained from seeing the lung in 3D has the potential to transform how diseases such as IPF are diagnosed. It will also help to increase our understanding of how these scarring lung diseases develop which we hope will ultimately mean better targeted treatments are developed for every patient.”

Microfocus CT can scan inside objects in great detail – rotating 360 degrees whilst taking thousands of 2D images, which are then used to build detailed 3D images.

Professor Ian Sinclair, Director of the ì-VIS Centre for Computed Tomography, says: “Our centre examines a wide variety of objects from the layup of individual carbon fibres in aircraft wing components, to the delicate roots of growing plants, and now parts of the body. By being a multidisciplinary centre we have a wealth of expertise that have allowed us to apply this technology in a way that has not been done before. This work is of great significance to us, with the long-term potential to translate our research from the bench to the bedside of patients.” The Southampton team are now studying how this technique can help doctors improve the way we diagnose such diseases more accurately, to ensure every patient will receive the correct treatment.

  • doi:10.1172/jci.insight.86375

Xbox gaming technology may improve X-ray precision

With the aim of producing high-quality X-rays with minimal radiation exposure, particularly in children, researchers have developed a new approach to imaging patients. Surprisingly, the new technology isn’t a high-tech, high-dollar piece of machinery. Rather, it’s based on the Xbox gaming system.

Using proprietary software developed for the Microsoft Kinect system, researchers at Washington University School of Medicine in St. Louis have adapted hands-free technology used for the popular Xbox system to aid radiographers when taking X-rays.

The software coupled with the Kinect system can measure thickness of body parts and check for motion, positioning and the X-ray field of view immediately before imaging, said Steven Don, MD, associate professor of radiology at the university’s Mallinckrodt Institute of Radiology. Realtime monitoring alerts technologists to factors that could compromise image quality. For example, “movement during an X-ray requires retakes, thereby increasing radiation exposure,” Dr Don said.

“The goal is to produce high-quality X-ray images at a low radiation dose without repeating images,” Dr Don said. “It sounds surprising to say that the Xbox gaming system could help us to improve medical imaging, but our study suggests that this is possible.” The technology could benefit all patients but particularly children because of their sensitivity to radiation and greater variation in body sizes, which can range from premature infants to adult-sized teenagers. Setting appropriate X-ray techniques to minimize radiation exposure depends on the thick-ness of the body part being imaged. Highquality X-rays are critical in determining diagnoses and treatment plans.

Traditionally steel callipers have been used to measure body-part thickness for X-rays. However, callipers are a “time-consuming, intrusive and often scary to kids, especially those who are sick or injured,” said Dr Don, a paediatric radiologist who treats patients at St. Louis Children’s Hospital.

“To achieve the best image quality while minimizing radiation exposure, Xray technique needs to be based on bodypart thickness,” Dr Don said. The gaming software has an infrared sensor to measure body-part thickness automatically without patient contact.

“Additionally, we use the optical camera to confirm the patient is properly positioned,” he explained.

Originally developed as a motion sensor and voice and facial recognition device for the Xbox gaming system, Microsoft Kinect software allows individuals to play games hands-free, or without a standard controller. Scientists, computer specialists and other inventors have since adapted the Xbox technology for nongaming applications.

Dr Don and his colleagues, for example, combined the Microsoft Kinect 1.0 technology with proprietary software to improve X-ray imaging. With help from Washington University’s Office of Technology Management, the team has applied for a patent.

Dr Don developed the technology with William Clayton, a former computer programmer at the School of Medicine, and Robert MacDougall, a clinical medical physicist at Boston Children’s Hospital.

Dr Don and his colleagues are continuing the research with the updated Microsoft Kinect 2.0 and seek feedback from radiological technologists to improve the software.

While further research and development are needed, the eventual goal is to apply the technology to new X-ray machines as well as retrofitting older equipment.

“Patients, technologists and radiologists want the best quality X-rays at the lowest dose possible without repeating images,” Dr Don said. “This technology is a tool to help achieve that goal.”

Does this ankle need an X-ray? There’s an app for that

The Ottawa Rules, a set of rules used around the world to help health professionals decide when to order x-rays and CT scans, are now available as a free mobile health app.

The Ottawa Rules app can be downloaded from the Apple App store on any device compatible with iOS or the Google Play Store for Android operating systems.

Developed by emergency department physicians at The Ottawa Hospital and the University of Ottawa, the Ottawa Rules are evidence-based decision trees that help physicians determine whether a scan is needed for injured bones, cutting down on unnecessary radiation and wait times. The existing rules for ankle, knee and spine injuries have been bundled together in a mobile app to appeal to a new generation of wired doctors, nurses and paramedics.

“Studies have repeatedly shown that the Ottawa Rules reduce unnecessary use of x-rays and CT scans, reduce wait times and save money for the health-care system,” said Dr Ian Stiell, an emergency physician and research chair at The Ottawa Hospital, distinguished professor at the University of Ottawa and creator of the Ottawa Rules. “I am excited to be able to make the Ottawa Rules more accessible to clinicians around the globe.”

The app includes the Ottawa Knee Rule, the Ottawa Ankle Rules and the Canadian C-spine Rule, which were previously only available as posters or online. The Ottawa Rules have been validated by more than 20 studies, translated into several languages and adopted worldwide. For example, two of Dr Stiell’s rules made a list of the top five ways doctors in the United States can reduce unnecessary procedures, published in the prestigious journal JAMA Internal Medicine.

Seeing the potential of mobile technology to put the Ottawa Rules into the hands of health-care professionals, Dr Stiell joined forces with The Ottawa Hospital mHealth Research team led by Dr Kumanan Wilson, a specialist in general internal medicine and senior scientist at The Ottawa Hospital and professor at the University of Ottawa.

“I think it is great how a group of creative young people can take a world-class discovery like the Ottawa Rules and make it accessible to a new generation of physicians,” said Dr Wilson, who also holds a chair in public health innovation. “This is a great model for innovation in medical care.”

Studies have repeatedly shown that the Ottawa Rules reduce unnecessary imaging and emergency room wait times, which allows patients to feel more comfortable while waiting to be seen by a clinician. The Rules also lead to significant savings for hospitals. However, the creators of the Rules still face the challenge of dissemination. The team hopes the new mobile and web formats, with images of bone structures and YouTube videos, will help the Rules become more widespread in emergency departments around the world.


 Date of upload: 8th July 2016


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