Conventional or B-mode ultrasound has been used as a diagnostic imaging tool for over four decades. Over the last few years, however, ultrasound systems have witnessed a blizzard of developments in their underlying technology. This has catalysed a significant change in the patterns of ultrasound usage vis-a-vis other, older imaging modalities, especially in terms of concerns about the latter – for example, radiation risk in X-rays and computer tomography (CT), and cost for both CT and magnetic resonance imaging (MRI).

Technology drivers
The ultrasound market is largely driven by innovations in underlying technologies and more sophisticated software algorithms, which allow manufacturers to offer smaller, more powerful and complex systems.
Key developments include an acceleration in processing speed and enhancement in the quality of diagnostic images – coupled to advances in contrast-enhanced imaging and precision in the timing of image capture. This has been accompanied by a sharp reduction in noise-to-signal ratios in the final data to optimize spatial, contrast and temporal resolution, including rotatable views for better visualization.
GE’s cSound technology, for example, offers CT level image quality based on advanced algorithms that capture much larger amounts of data than possible previously (by some estimates, about a DVD worth of data per second). The technology also makes pixel-by-pixel selections of the most precise information to display.

Developments in transducers, beam formation
Ultrasound has also made quantum leaps in factors such as transducer sensitivity and beam formation. For example, line-by-line imaging in beamformers has been replaced in some systems by large zone acquisitions, allowing users to view examinations in greyscale and colour Doppler. Meanwhile, retrospective imaging makes it possible to process raw data multiple times, while retention of channel domain data allows for patient-specific imaging.
Because of all the above, clinicians are able to use ultrasound to image blood perfusion and blood flow in vessels with diameters of 2 mm and less, with small vessel beds displayed via Doppler flow false-colour 3-D or greyscale reconstructions. The result is better assessments of organ perfusion, which have traditionally been difficult on ultrasound.

Commodification trends
Take-up of ultrasound has also been recently boosted by a growing commodification trend. Certain categories of ultrasound have become relatively inexpensive, mobile and less demanding of power. Mobility-related innovations include portable hand-held devices, and more recently, the world’s first wireless transducer. Even some low-end machines are now enabled for full bi-directional communication with electronic medical records.
As healthcare reforms and budgetary pressures favour use of cost-effective solutions, this has led to especially sharp growth in the use of low- and mid-range ultrasound systems. It is now commonplace, for example, to see ultrasound systems in a recovery room, next to hospital beds, or equipping NGOs at health outreach projects in developing countries.

For many hospitals, this kind of product/technology mix makes sense, since not all patients require the sophisticated features offered by high end machines, while their smaller, inexpensive counterparts provide solutions for an everyday challenge faced by most hospitals – workflow bottlenecks.

High-end remains motor for new applications
At the other end, the high-end segment is leading innovation not only in ultrasound technologies, but driving the overall medical imaging market, too. Despite their cost, the advanced features of premium systems have moved ultrasound well beyond traditional applications such as ob/gyn to interventional cardiology and internal medicine. Several ER clinicians, for instance, now routinely utilize ultrasound for echocardiograms and abdominal imaging, while radiologists and surgeons use it to guide needle placement or perform bone sonometry.
Some cutting-edge areas – such as matrix transducers – remain ensconced in the premium category. Matrix transducers have direct relevance to two fast-emerging applications, namely volumetric ultrasound and 3-D/4-D applications.

Key developments
Given below is an overview of key recent developments in ultrasound systems.

Mobility and Ergonomics
Ergonomics and mobility are being addressed by vendors in order to differentiate their systems and grow user volumes. Some surveys suggest that over three out of four of ultrasound users experience work-related pain, with a fifth of these suffering a career-ending injury.
New-generation ultrasound systems stand out in terms of design. Most are noiseless to permit sonographers to minimize distraction and focus on the exam, with settings customized and organized depending on clinical preferences.
Some have slanted bodies to prevent users hitting their knees or feet on the machine, with keyboards that can be raised or lowered depending on user height, probes that are shaped to the human palm and rotatable LCD monitors for sharing the display with colleagues. Other innovations include the possibility of use in both sitting and standing positions, with memory features to accommodate different users.
Some recent ultrasound machines have tablet-sized touchscreen-based interfaces, which significantly reduces the reach and steps (in some cases by 15-20%) in order to start and complete an exam. This enables faster workflow. Touchscreens allow users to tap in order to start functions, pinch and drag to zoom in and out, and swipe to expand the image. Some vendors offer exam presets, with several enhanced functions such as continuous wave Doppler or transducers.

Miniaturization
As discussed below, there is an increase in the use of ultrasound as an alternative to CT and MRI in many point-of-care (PoC) settings. One of the reasons for the trend is mobility as well as increasing miniaturization. Smaller ultrasound machines provide solutions to concerns about cables or wheeling bulky machines around patient rooms, and address tight space demands in key hospital settings such as the operating room. Compact models can be transported by being wheeled or atop a cart.
In some cases, smaller portable machines can also be moved between departments within a hospital or clinic – on a user’s back.

Enhanced quality drives ultrasound to point of care
Ultrasound images today are available with far-higher resolutions than in the early 2000s, when most physicians were used to pictures being fuzzy. One of the key reasons is enhancement in real-time computer processing of images.
Superior image quality has also driven ultrasound to the point-of-care (PoC) setting – both for diagnostic and interventional procedures. PoC ultrasound is now widely available in operating theatres and emergency rooms. Between 2010 and 2013, anesthesiologists are reported to have doubled the use of ultrasound procedures, and ultrasound is also far more common today in certain interventional procedures such as image-guided biopsies and ablations, previously dominated by CT and MRI.

Volumetric ultrasound development
Volumetric ultrasound allows superior characterizing of tissue and the performance of procedures with far greater accuracy.
Ultrasound was previously only able to capture a single imaging plane, but it can currently acquire volumes. This is because transducers which enable the acquisition of real-time volumes of tissue and allow imaging in multiple planes such as the transverse and sagittal have recently become available. For instance, transducers can detect the altered speed of high-frequency sound waves through adipose layers versus other tissue, and make the system aware of increased adipose content.
Though several new-generation transducers remain expensive, in areas where they make a difference, the added price tag is becoming justified. For instance, high-resolution matrix transducers are finding use in interventional cardiology applications such as trans-esophageal echocardiogram (TEE) and 4D imaging.

3-D/4-D imaging
While 2-D continues to be widely used in clinical applications, recent technological advances such as matrix transducers have been enabling factors and triggered interest in 3-D and 4-D ultrasound.
3-D/4-D ultrasound has a more rapid acquisition rate of datasets and subsequent improved image visualization.
4-D imaging consists of the three spatial dimensions as well as the element of time. It projects a cinematographic, motion picture view of an organ or a specific part of an organ, and is emerging as the next generation in advanced imaging. 

In combination with advanced visualization functions, 4-D ultrasound aids complex surgical applications and interventional procedures. Multiplanar reconstructed (MPR) images are now available for review in the same manner as CT and MR scans.
Leading imaging vendors already offer 4-D imaging products – across all modalities, PET/CT, MRI and ultrasound. However, 4-D ultrasound is capturing a great deal of interest in applications where ultrasound has already made a case for itself, due to cost, mobility or radiation concerns.

The close connection between 4-D and ultrasound dates back to cutting edge efforts in the early 1980s, when a Duke University team determined that although MRI was faster, ultrasound was the closest to “achieving 3D real time acquisition.” The researchers, led by Dr. Olaf von Ramm, developed a single-transmit, multiple-receive ultrasound scanner called Explosocan to increase data bandwidth.

Elastography
One of the most revolutionary technologies in ultrasound consists of elastography, which utilizes B-mode ultrasound to measure the mechanical characteristics of tissues, which are then overlaid on the ultrasound image. This provides physicians the ability to view stiffer and softer areas inside of tissue, with image quality and clinical outcomes equivalent to X-Ray, MRI, and CT.
Elastography techniques include strain elastography and shear wave elastography (SWE). It has begun proving its use in the characterization of thyroid nodules, lymph nodes and indeterminate breast lumps as well as the detection of prostate cancer. None of these were achievable via conventional ultrasound.
The application which has generated maximum attention is liver fibrosis staging. Biopsies are not only invasive but carry bleeding and infection risks. Elastography, which can be repeated as often as required, is being seen as a way to get the data needed by clinicians to diagnose and stage liver diseases without the associated complications. Elastography is also used to predict complications in patients with cirrhosis.
SWE in particular is also seen as a tool to assist in earlier detection of conditions such as Hepatitis C, and both fatty liver and alcoholic liver disease. Alongside lab studies, it offers a means to closely monitor the impact of treatment and assess if the liver will normalize. For many hepatologists, fighting a liver condition before Stage 4 cirrhosis provides a good chance of reversibility.
SWE can also provide information on which Hepatitis C patients might benefit from viral therapy.

From smartphone apps to AI: the future
App-based ultrasound have recently been showcased. These use transducers connecting via a USB port to a mobile device and a downloadable app. The transducer performs data acquisition, processing and image reconstruction. The result is an ultrasound feature in a consumer-grade smartphone.
Some vendors have launched artificial intelligence systems to enhance speed and automatically take image volume data from 3-D echo to recreate optimized diagnostic views. In cardiac echo in particular, the result offers major potential by permitting reproducibility of imaging.
Nevertheless, such cutting edge technologies are still in their infancy. Only time and user experience will determine their eventual success.

Visiting hours for hospitalized patients have traditionally been restricted to set periods during the day and limited in duration. However, the situation is slowly changing towards a more open approach to family visits, even in wards where visits are often most restricted, such as intensive care units (ICUs). As just a few examples of this general change in attitudes towards visiting, many American hospitals have now completely removed restricted visiting hours; a campaign of extended visiting hours was launched in France a few months ago; and a bill is currently being discussed in Italy to expand hospital visits.

by Prof Jean-Louis Vincent

Why restrict hospital visiting?
The reasons behind restrictive visiting are not very clear or, in today’s context, very credible. The fear of transmission of infection was perhaps the earliest reason for restricting visits, but with improved infection control measures, this concern is generally unfounded. Other suggested reasons include the need for patient to have adequate rest periods and the belief that visitors interfere negatively with medical and nursing care.

Because sick patients need rest?
It was widely believed that having periods of the day without visiting would ensure that patients had sufficient periods of rest, without disturbance from visitors. However, the need for sick patients to rest is often exaggerated. Indeed, this idea is now rather out-of-date, even for the sickest of patients. Although patients must clearly not be exhausted by their visitors, too much rest can encourage muscle weakness and prolong convalescence. When a family member says “doesn’t he/she need to rest Doctor?”, I often reply “certainly not; in fact you should wake him/her up!”. The current trend is to encourage physical and intellectual stimulation for all patients.
Of course patients need some time to sleep and rest, as we all do, but this can be determined on an individual basis, preferably after discussion with the patient, rather than being enforced at fixed times by restricted visiting hours. Moreover, the presence of a loved one in the room does not necessarily prevent restorative sleep. Rest is also important for family members and it is sometimes necessary to remind them to take a break, particularly at night. In any case, access to hospitals is generally limited during the night, for security reasons.
Because visitors interfere with patient care?
The presence of visitors was often believed to interfere negatively with medical care. Visiting hours were therefore concentrated on periods of the day during which patients were least likely to be undergoing medical consults or examinations. However, hospitals of today function almost continuously or at least with considerably more extensive hours than in the past, notably for laboratory and radiological investigations, making it difficult to predict when examinations and rounds are most likely to take place.
The presence of visitors was also often believed to hinder good nursing care, and perhaps much restricted visiting was devised for the benefit of nurses, rather than  the patient. Nurses often complained that they were unable to perform the necessary care in the best possible way, because they were bothered by the presence of relatives, sometimes numerous and noisy, who asked a lot of questions, and were even critical of the care being provided!
However, it is now widely believed that extended visiting hours can be beneficial not only for the patient and visitors, but also for the staff. Staff members, especially nurses, are often initially reluctant to the proposed change to more extensive or unlimited visiting, concerned that it will increase their workload. But this is not necessarily true, and is in fact often the reverse. Allowing visitors to be present at different times during the day enables them to understand better the work of the nurses, doctors and other healthcare personnel. When visiting hours are restricted, nurses often make use of the visiting periods to have a small break, to catch up or even have a joke with their colleagues. This can sometimes give visitors the impression that nurses have nothing to do, or are not really concerned about looking after the patients under their care. By arriving at different times of the day and staying for longer periods, family members can better appreciate hospital life and realize that nurses also need some time for relaxation and distraction, thus reducing the risk of conflicts between family members and staff. Extending visiting hours also reduces the number of telephone calls from relatives asking after their loved one, thus freeing up nursing time.

Let’s welcome visitors
Importantly, fixed visiting hours can discourage relatives from visiting a patient. For example, it can be difficult for family members who are working to request time off during the day to be able to observe the fixed visiting hours; sometimes family members simply forget (or are unaware of) the specified times, especially when units have different hours on different days of the week, and have to go home having missed the allocated slot; similarly, visitors who have to travel some distance to visit their loved one may be put off by the risk of being late and missing the fixed visiting period. Finally it is sometimes just easier to say, “I’ll visit when they’re better and out of hospital…”
Rather than being made to feel that they are the enemy and not welcome, relatives should be encouraged to visit and be involved. We must not talk about “them” and “us”. The patient must be at the centre of our preoccupations at all times and we must all work together to ensure he/she has the best possible chances of a good recovery without complications. Family members and loved ones form part of the patient’s immediate supportive environment and can form a useful bridge between the patient and hospital staff. They can also play an active role in patient surveillance, for example by indicating to staff if there is a problem that has not been noticed or that the patient may not want to report. In certain American hospitals, pamphlets are now available to explain how relatives can identify and report important signs of deterioration, for example, confusion that wasn’t there before or a small change in respiration that has gone unnoticed. 
Family members can even sometimes contribute directly to some aspects of patient care, for example helping with feeding, washing or dressing. Indeed, these practices are commonplace in countries with limited resources, where family members never leave the bedside. In western society, however, patient care has been completely transferred from the family to professional carers, which can sometimes lead to the patient feeling patronized or being treated like a child.
The hospital structure is also changing to be more welcoming for visitors. Instead of a few folding seats at the end of the corridor for relatives waiting while the patient is examined or comes back from an examination, many hospitals have now introduced reception rooms where relatives can stay as long as they wish, in comfortable conditions. In the United States in particular, hospitals have set up small kitchen-lounges where families can rest, prepare a meal in the microwave or watch television… and why not socialize, chat, share experiences with relatives of other patients.
Indeed, the hospital is no longer a detached world, which we are somewhat hesitant or even scared to enter. Hospitals are increasingly user friendly and should be seen as somewhere positive and welcoming. After all, many hospitals now have a cafeteria (if not a restaurant), small shops, a bank, a post-office, pleasant gardens… creating the idea that hospitals can be part of everyday life, and indeed are for the many patients and visitors that pass through the doors daily. Visitors can make use of these areas when their relative is undergoing an examination or receiving nursing care.

Family presence during interventions?
As families spend more time visiting their loved ones in hospital, the chances that they will be present when an intervention is needed are increasing, perhaps particularly on high acuity wards. But should they be allowed to stay in the room? Perhaps yes for a simple blood test or changing of a dressing, but what about during cardiopulmonary resuscitation (CPR)? This issue continues to raise considerable debate, not least because the patient needing CPR cannot be asked if they mind. Although some staff members find having family members present adds stress to an already complex situation, studies have suggested that the presence of a relative can help a surviving patient understand what has happened and, if the patient dies, having been present can reassure the family member that everything possible was done. This is an area where attitudes are changing and, if a family member wishes to be present during CPR, this request should not be refused.

The rights and responsibilities of visitors ….
Clearly, although visitors have the right to see their loved ones in hospital, they must also abide by certain rules. They must leave the room when asked to do so by the hospital staff and should not interfere with patient care. They should not slow the work of the nursing or medical staff by asking repetitive, unnecessary questions or by engaging in prolonged conversation. Importantly, too, visitors are there to visit only their relative/loved one and must not look, even surreptitiously, into the rooms of other patients!

… and the rights of the patient
On reflection, rather than asking whether visiting the sick patient is allowed, the question should rather be the reverse, whether the patient is allowed to see his/her relatives? Limiting hospital visits is generally harmful for the patient and opening up visiting is reported to improve patient satisfaction. By bringing news from the outside world, family, friends, pets, … visitors can stimulate a patient’s intellect and interest, helping promote a quick recovery. There is nothing worse than lying in bed all day just looking at the ceiling… But, it is important to consider the patient’s viewpoint when considering visitor access. For example, some patients may prefer to have only close family members visit, feeling embarrassed about less well-known friends and relatives seeing them unwell, and others may prefer not to discuss their condition when family members are present for fear of upsetting them. Patients have the right to see visitors whenever they wish, but should not have visiting forced upon them.

Conclusion
It is not so long ago that, when visiting a patient in hospital, an often rather officious nurse would announce the end of visiting hours and insist you leave your loved one. Such strict practices have become less common and there is much more flexibility, particularly on general hospital wards. We need to go further and extend open visiting to all areas of the hospital, including ICUs, where visiting still remains, in general, more restricted. In many cases, we should be actively inviting relatives to visit more and to stay longer, especially when the patient has few visitors and feels isolated. Visiting is humane and good for the patient.
If you still have restricted visiting hours at your hospital, I am sure this will change in the near future. I am not convinced that there should be a law on this subject, whether in Belgium, Italy or elsewhere, but rather a collective effort needs to be made to change our mentality related to visiting hours and thus improve the quality of care for our patients.

Suggested reading
Giannini A, et al. What’s new in ICU visiting policies: can we continue to keep the doors closed? Intensive Care Med 2014; 40: 730-33
Jabre P, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med 2013; 368: 1008–18.
McAdam JL & Puntillo KA. Open visitation policies and practices in US ICUs: can we ever get there? Crit Care 2013; 17: 171
Shulkin D, et al. Eliminating visiting hour restrictions in hospitals. J Healthc Qual 2014; 36: 54-7

The author
Jean-Louis Vincent, MD, PhD
Dept of Intensive Care, Erasme University Hospital, Université libre de Bruxelles,
Route de Lennik 808, 1070 Brussels,
Belgium
jlvincent@intensive.org

The Health Industry Summit (tHIS) 2017 hosted by China and organized by Reed Sinopharm, was held in Shanghai at the National Exhibition and Convention Center from May 15th to 18th with well over 200,000 healthcare industry professionals from more than 150 countries and regions in attendance.

Now in its third edition, tHIS has been firmly established as the world’s largest health industry event with over 350,000 square meters of exhibition space and 160 individual events and conferences.  It comes at a crucial time as China drives forward its “Healthy China 2030 Plan” initiative to realize among other goals an industry growth target of RMB 16 trillion (USD 2.3 trillion, Euro 1.9 trillion) by 2030 and an increase of average citizen lifespan by 3 years to 79 years.

Key events at tHIS 2017 included China’s three top medical equipment and pharmaceutical exhibitions (CMEF, PHARMCHINA and API China) and the leading healthcare investment forum – Healthcare China 2017. This year’s investment forum was co-organized by Reed Sinopharm, JP Morgan Asset management, CICC and Sinopharm Capital and was attended by more than 1000 CEOs, investors and institutions.

The exhibition featured the entire industry value chain and showcased tens of thousands of the latest technologies and products. Emerging technologies such as VR, AR, wearables and AI featured strongly on the show floor as well as in the key forums. During tHIS 2017, the World Medical Robots Innovation and Development Summit was held to reflect the growing trend for robotics and AI applications.

Over 7000 exhibiting companies from 30 countries were at the show including medical device giants like GE, United Imaging, Siemens, Philips and Mindray as well as major pharmaceutical groups in China including Sinopharm, Shanghai Pharma and CR Pharmaceuticals.  The majority of the most innovative companies in the medical field choose CMEF as their global or Asia Pacific new product launch platform and more than 600 new product launches took place during the 4 days of the show. Among the new products released, United imaging launched its uVR 4D vision explorer platform, enabling more detailed dissect structure and spatial information, while GE launched its first cloud-based digital application for medical equipment management APM (asset performance management), which was developed by their China team. BGI also attended with their gene sequencer BGISEQ-500, a benchtop high-throughput open sequencing platform that provides end-to-end solutions.
Natural Health and Nutrition Expo were among the fastest growing segments in the portfolio, helped by the expected population boom in light of the reversal of the single child policy last year as well as a growing health-conscious middle class in China. Popular international brands like Blackmores, Nature Made and Garden of Life made their debut at the show along with 700 suppliers of health food and supplements, bringing with them popular product lines tailored to the Chinese market.

The Health Industry Summit is organized by Reed Sinopharm, a joint venture between the world’s leading event organizer Reed Exhibitions and China’s leading state-owned medical & pharmaceutical group Sinopharm, ranked number 199 on the latest Fortune 500 list released in July. Its next edition will be held in April 2018 in Shanghai while the 78th China International Medical Equipment Fair (CMEF Autumn 2017) is to take place in Yunnan at the Kunming Dianchi Convention & Exhibition Centre from October 29 to November 1.

Visitor profile
The vast majority of visitors naturally came from China, covering all regions and healthcare sectors. However, there was also a growing segment of international visitors. Topping the list of foreign countries was India with a 20% share of international attendees followed by Korea (15%), Pakistan, Japan, USA, Russia and Germany.

Overall, CMEF visitors spanned the entire medical area – both healthcare and medical device industry. Distributors of medical devices constituted the largest single visitor group with 45% of the total followed by hospital build and design (26%) and rehabilitation centre professionals (see detailed visitor composition chart on previous page).

National pavilions
The international participation is increasing, reflecting the growing importance of China’s healthcare industry. Further adding to the show’s attraction, a large number of national pavilions were featured in a dedicated hall where a constant stream of visitors could view the latest products and technology of companies from countries as diverse as Switzerland, Canada, Taiwan or Germany. For the first time the US and Pakistan had country group exhibits while the Spanish Medical Technology Association (FENIN) led some Spanish companies to make their appearance at the CMEF Spanish pavilion and the German Land of Thuringia organized a regional exhibit for the first time.