Note, this version of the x-clometer has been replaced with the updated version 4.7 on the following 3DPX site: https://3dprint.nih.gov/discover/3DPX-015652

This marker (X-Clometer) displays the head-of-bed (HOB) angulation of a cassette and a patient during a portable chest x-ray (pCXR) providing an optimal comparison of day to day improvement in patients not able to come to the radiology department for a standing (upright) CXR. 

 

More specifically, the  X-Clometer is a left or right marker (required on every x-ray) that also quantifies the HOB angle from supine (0 degrees) to sitting perfectly upright (90 degrees, difficult to achieve in a hospital bed). The approximate angle is determined by a ball bearing that rolls freely within a curved passageway indicating angulation of the patient, cassette and x-ray tube during the CXR. The status quo for at least the last 40 or so years includes the registered x-ray technologist (RT) including a lead arrow pointed up or a lead marker that includes one of the following: supine, semi-erect, erect or upright. However, this effort is highly subjective as some may include it when only 30 degrees, others between 30 and 60, and some 80 degrees. There is also ambiguity interpreting these subjective indicators by radiologists and clinicians. There are markers available that include three tiny ball bearings that only differentiate supine (0 to 20 degrees) from not supine (20-90 degrees) in our experience and not adequate enough for radiologists to rely on to estimate HOB angle.

 

Knowing the approximate HOB angle helps radiologists interpret findings such as pneumonia (consolidative opacities) or other lung conditions such as fluid in the pleural space (pleural effusion, often seen in pCXR) shifts depending on how upright the patient is when the x-ray is taken. Ideally, RTs do their best to have the patient nearly erect or sitting up straight to have any effusion settle dependently as to not mask areas such as pneumonia or ground-glass infiltrates such as those seen in COVID pneumonia. There may be improved motivation by technologists to sit patients more upright knowing there is objective representation of the HOB angle. This may also be helpful in training programs to develop the mindset of sitting patients up as much as possible in pCXR. 

 

Not knowing the upright angle makes it more difficult to differentiate effusion that is not settling (when not upright) versus ground-glass or other opacities seen in COVID-19 patients for example. For more description, see the “Extra” tab including the following publication “UpRight: a radiographic marker that displays upright angle on portable chest and abdominal radiographs,” also attached below. 

 

This device is covered under US Patent 9541822 “Radiographic marker that displays an angle in degrees on portable X-rays" and made available for a limited time during the COVID-19 pandemic for clinical, academic, research and evaluation, and shall not be sold for profit without permission from the inventor, Les R. Folio, DO, MPH, and/or his agents.

 

Further, this device is made publically available for non-profit limited use in clinical or research purposes. Any modifications can be uploaded by reaching out to Les Folio les.folio@nih.gov  or Tom Pohida pohidat@exchange.nih.gov for tracking purposes

Instructions to technologists when using the x-clometer left or right markers. 

 

This device is used similar to everyday left or right markers or “upright” or up arrow indicators. The only difference is the inclusion of a steel ball that rests at a point aligning with a radiopaque scale indicating HOB angle (hence replacing that marker and the up arrow) better than prior markers. 

 

Since there are projectional differences, the left x-clometer is different than the right, that includes an internal quality control alignment of elements similar to a gunsight or airport runway elements to assist airplanes when landing. See figures demonstrating an example earlier version of the x-clometer taken at 15 degrees. Placement should be flush against the cassette, otherwise the indication may be inaccurate, the alignment “sights” would indicate this to interpreting radiologists. 

A few obvious challenges include device size required for the most accurate angle quantification (edges have been rounded to optimize carrying in pocket), and attaching to the cassette all technologists are well aware of (there is always our tape solution!). There are a few design options available, we encourage your feedback, including solutions you may have thought of.

 

 

Instructions to technologists when using the x-clometer left or right markers. 

 

This device is used similar to everyday left or right markers or “upright” or up arrow indicators. The only difference is the inclusion of a steel ball that rests at a point aligning with a radiopaque scale indicating HOB angle (hence replacing that marker and the up arrow) better than prior markers. 

Since there are projectional differences, the left x-clometer (currently the only one available) is different from the right. 

 

Disclaimers: This development was supported [in part] by the Intramural Research Program of the NIH Clinical Center and CIT, and cannot be held responsible for misuse in printing or implementation.